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National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

BACKGROUND: An integrated care pathway (ICP) is intended to improve the management of prevalent resource-consuming, life-threatening diseases. The purpose of this study was to determine whether the quality of patient care improved with the establishment of a dedicated unit for pulmonary embolism (PE). METHODS: A quasi-experimental pre-post study (pre: years 2010–2013; post: 2015–2020; year 2014, “washing” period) of PE patients ≥18 years (January 2010–June 2020). The intervention involved the implementation of an ICP for PE. RESULTS: The sample was composed of 1,142 patients (510 pre-intervention and 612 post-intervention) without significant differences between the two populations. In the post-intervention period, significant reductions were observed in the median length of hospital stay (LOS) (8 vs. 6 days); time to start of oral anticoagulation therapy (4.5 vs. 3.5 days; P

Introduction: Pleural effusion is a common clinical problem. Yet, in a significant proportion of patients (~20%), the cause of pleural effusion remains unknown. Understanding the diagnostic value of pleural fluid tests is crucial for the development of accurate diagnostic models.Areas covered: This paper provides an overview of latest advances in the diagnosis of pleural effusion based on the best evidence available.Expert opinion: For pleural fluid tests to have a good diagnostic value, it is necessary that data obtained from clinical history, physical examination, and radiological studies are correctly interpreted. Thoracentesis and pleural biopsy should always be performed under image guidance to improve its diagnostic sensitivity and prevent complications. Nucleic acid amplification tests, pleural tissue cultures, and collection of pleural fluid in blood culture bottles improve the diagnostic yield of pleural fluid cultures. Although undiagnosed pleural effusions generally have a favorable prognosis, follow-up is recommended to prevent the development of a malignant pleural effusion.

Resumen Introduccion Predecir cuando un derrame pleural infeccioso puede evolucionar hacia una infeccion complicada/empiema es dificil de establecer. Nuestro proposito es analizar si un modelo predictivo construido con parametros bioquimicos del liquido pleural puede ayudar a identificar estos derrames. Metodos Se estudio de forma prospectiva a todos los pacientes diagnosticados de derrame pleural infeccioso y se clasificaron en no complicados y complicados/empiemas. Se realizo un analisis de regresion logistica para estimar la probabilidad de infeccion pleural complicada/empiema. Con base en parametros bioquimicos del liquido pleural, se construyo un modelo predictivo y se determinaron su discriminacion (areas bajo la curva ROC), calibracion y precision diagnostica. Resultados Se incluyo a 177 pacientes (74 infecciones pleurales no complicadas y 103 complicadas/empiemas). El area bajo la curva del modelo construido (pH, lactato deshidrogenasa e interleucina 6) fue 0,9783, significativamente mejor que cualquiera de las variables bioquimicas utilizadas de forma individual (0,921, 0,949 y 0,837, respectivamente; p Conclusion El modelo predictivo analizado tiene una buena rentabilidad para el diagnostico de las infecciones pleurales complicadas/empiemas, superior a la de cualquiera de las variables individuales que lo componen.

Thoracentesis is a simple test with few complications that provides relevant information in the diagnosis of a pleural effusion, through a correct interpretation of the pleural fluid analysis. An interesting initiative would be to incorporate this technique by those Primary Care teams that treat serious and complex patients, with difficulties in moving to specialised centres far from their homes. In this context, a good knowledge of the diagnostic possibilities offered by the pleural fluid analysis could be very useful in the hands of well trained staff to establish the aetiology of a pleural effusion and be able to initiate, as quickly as possible, its treatment. This article aims to contribute to this, by suggesting guidelines on how a simple technique can provide relevant information in order to determine the aetiology of pleural effusion, and which could be implemented within a given Primary Care framework.

Background: The nature of pulmonary embolism (PE) without identifiable risk factor (IRF) remains unclear. The objective of this study is to investigate the potential relationship between cardiovascular risk factors (CVRFs) and PE without IRF (unprovoked) and assess their role as markers of disease severity and prognosis. Methods: A case-control study was performed of patients with PE admitted to our hospital [2010-2019]. Subjects with PE without IRF were included in the cohort of cases, whereas patients with PE with IRF were allocated to the control group. Variables of interest included age, active smoking, obesity, and diagnosis of arterial hypertension, dyslipidemia or diabetes mellitus. Results: A total of 1,166 patients were included in the study, of whom 64.2% had PE without IRF. The risk for PE without IRF increased with age [odds ratio (OR): 2.68; 95% confidence interval (CI): 1.95-3.68], arterial hypertension (OR: 1.63; 95% CI: 1.27-2.07), and dyslipidemia (OR: 1.63; 95% CI: 1.24-2.15). The risk for PE without IRF was higher as the number of CVRF increased, being 3.99 (95% CI: 2.02-7.90) for subjects with ≥3 CVRF. The percentage of high-risk unprovoked PE increased significantly as the number of CVRF rose [0.6% for no CVRF; 23.8% for a CRF, P

Introduction: Determining the risk of recurrence of primary spontaneous pneumothorax is challenging. The objective of this study was to develop a risk assessment model to predict the probability of recurrence in patients with spontaneous pneumothorax. Methods: A retrospective study was performed of all episodes of pneumothorax diagnosed in the last 12 years in a hospital, in patients not initially submitted to surgery. Logistic regression was used to estimate the probability of recurrence. Based on a set of variables, a predictive model was built with its corresponding ROC curve to determine its discrimination power and diagnostic precision. Results: Of the 253 patients included, 128 (50.6%) experienced recurrence (37% within the first year). Recurrence was detected within 110 days in 25% of patients. The median of time to recurrence for the whole population was 1120 days. The presence of blebs/bullae was found to be a risk factor of recurrence (OR: 5.34; 95% CI: 2.81–10.23; p = 0.000), whereas chest drainage exerted protective effect (OR: 0.19; 95% CI: 0.08–0.40; p = 0.000). The variables included in the regression model constructed were hemoglobin and leukocyte count in blood, treatment received, and presence of blebs/bullae, with a fair discriminative power to predict recurrence [AUC = 0.778 (95% CI: 0.721–0.835)]. Conclusion: The overall recurrence rate was high and was associated with the presence of blebs/bullae, failure to perform an active intervention (chest drainage) and low levels of hemoglobin and leukocytes in blood. Recurrence rarely occurs later than three years after the first episode. Once validated, this precision model could be useful to guide therapeutic decisions.

The prognosis of a patient with Covid-19 pneumonia is uncertain. Our objective was to establish a predictive model of disease progression to facilitate early decision-making. A retrospective study was performed of patients admitted with Covid-19 pneumonia, classified as severe (admission to the intensive care unit, mechanic invasive ventilation, or death) or non-severe. A predictive model based on clinical, analytical, and radiological parameters was built. The probability of progression to severe disease was estimated by logistic regression analysis. Calibration and discrimination (receiver operating characteristics curves and AUC) were assessed to determine model performance. During the study period 1,152 patients presented with Covid-19 infection, of whom 229 (19.9%) were admitted for pneumonia. During hospitalization, 51 (22.3%) progressed to severe disease, of whom 26 required ICU care (11.4); 17 (7.4%) underwent invasive mechanical ventilation, and 32 (14%) died of any cause. Five predictors determined within 24 hours of admission were identified: Diabetes, Age, Lymphocyte count, SaO2, and pH (DALSH score). The prediction model showed a good clinical performance, including discrimination (AUC 0.87 CI 0.81, 0.92) and calibration (Brier score = 0.11). In total, 0%, 12%, and 50% of patients with severity risk scores ≤5%, 6-25%, and >25% exhibited disease progression, respectively. A simple risk score based on five factors predicts disease progression and facilitates early decision-making according to prognosis. Carlos III Health Institute, Spain, Ministry of Economy and Competitiveness (SPAIN) and the European Regional Development Fund (FEDER) Instituto de Salud Carlos III

Background: The prognosis of a patient with Covid-19 pneumonia is uncertain. Our objective was to establish a predictive model of disease progression to facilitate early decision-making. Methods: A retrospective study was performed of patients admitted with Covid-19 pneumonia, classified as severe (admission to the intensive care unit, mechanic invasive ventilation, or death) or non-severe. A predictive model based on clinical, analytical, and radiological parameters was built. The probability of progression to severe disease was estimated by logistic regression analysis. Calibration and discrimination (receiver operating characteristics curves and AUC) were assessed to determine model performance. Findings: During the study period 1,152 patients presented with Covid-19 infection, of whom 229 (19.9%) were admitted for pneumonia. During hospitalization, 51 (22.3%) progressed to severe disease, of whom 26 required ICU care (11.4); 17 (7.4%) underwent invasive mechanical ventilation, and 32 (14%) died of any cause. Five predictors determined within 24 hours of admission were identified: Diabetes, Age, Lymphocyte count, SaO2, and pH (DALSH score). The prediction model showed a good clinical performance, including discrimination (AUC 0.87 CI 0.81, 0.92) and calibration (Brier score = 0.11). In total, 0%, 12%, and 50% of patients with severity risk scores ≤5%, 6-25%, and >25% exhibited disease progression, respectively. Interpretation: A simple risk score based on five factors predicts disease progression and facilitates early decision-making according to prognosis. Funding Statement: This project was funded by the Carlos III Health Institute, Spain, Grant/Award Number: COV20/00404; Ministry of Economy and Competitiveness (SPAIN) and the European Regional Development Fund (FEDER). Declaration of Interests: The authors declare no conflicts of interest associated with this publication. Ethics Approval Statement: The study was conducted in accordance with the guidelines of the Declaration of Helsinki and the principles of good clinical practice and was approved by the Institutional Review Board (IRB) of the Galician Health Service on April 3, 2020 (#2020/194). Informed consent forms were waived by the IRB.

Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12 months. Studies are contributing evidence on an increasing number of therapeutic options (therapeutic thoracentesis, thoracoscopic pleurodesis or thoracic drainage, indwelling pleural catheter, surgery, or a combination of these therapies). Despite the availability of therapies, the management of malignant pleural effusion is challenging and is mainly focused on the relief of symptoms. The therapy to be administered needs to be designed on a case-by-case basis considering patient’s preferences, life expectancy, tumour type, presence of a trapped lung, resources available, and experience of the treating team. At present, the management of malignant pleural effusion has evolved towards less invasive approaches based on ambulatory care. This approach spares the patient the discomfort caused by more invasive interventions and reduces the economic burden of the disease. A review was performed of the diagnosis and the different approaches to the management of malignant pleural effusion, with special emphasis on their indications, usefulness, cost-effectiveness, and complications. Further research is needed to shed light on the current matters of controversy and help establish a standardized, more effective management of this clinical problem.

Pleuroparenchymal fibroelastosis (PPFE) is a rare, generally idiopathic form of interstitial pneumonia with unique clinical, radiological and histopathological features. It is named after the presence of upper lobe pleural and subjacent parenchymal fibrosis, with accompanying elastic fibers. Although it is usually an idiopathic disease, it has been linked to other co-existent diseases. Diagnostic suspicion of PPFE is based on the identification of typical abnormalities on chest CT scan, which are prevailingly located in the upper lobes, adjacent to the apex of the lungs. Diagnosis can be confirmed by histological analysis, although biopsy is not always feasible. The disease is generally progressive, but not uniformly. The course of the disease is frequently slow and involves a progressive loss of upper lobe volume, which results in platythorax, associated with a significant reduction of body mass. PPFE concomitant to other interstitial lung diseases is associated with a poorer prognosis. The disease occasionally progresses rapidly causing irreversible respiratory insufficiency, which leads to death. Currently, there is no effective pharmacological therapy available, and lung transplantation is the best therapeutic option. The purpose of this review is to draw the attention to PPFE, describe its clinical, radiological and histopathological features, analyze its diagnostic criteria, and provide an update on the management of the disease.

Introduction To know the behavior of cellular components of pleural fluid can help focus the differential diagnosis of a pleural effusion. Our objective was to assess their composition in different types of pleural effusions and assess whether it provides relevant clinical information. Patients and methods Observational, cross-sectional and retrospective study in which the cellular components of pleural effusions of different etiology were analyzed. Pleural effusions were classified as neutrophilic, lymphocytic (≥50% of each one of them), eosinophilic (≥10%) or mesothelial (>5%) and were grouped into six diagnostic categories. Results 1467 patients were studied (354 heart failure, 59 other transudates, 349 paraneumonic, 133 tuberculous, 397 malignant and 175 other exudates). The predominance cell was lymphocytic in heart failure (44.4%), uncomplicated parapneumonic (29.2%), tuberculosis (88%) and malignant (49.6%); neutrophilic in parapneumonic (57%) and malignant (9.6%); eosinophilic in malignant (6.3%) and mesotelial in tuberculosis (12%). The most frequent etiologies with lymphocyte count ≥80% were tuberculosis (35.1%) and malignant (23.3%). Parameters with higher discriminating accuracy were: leukocytes (transudates: AUC 0.835) and percentage of neutrophils (empyemas: AUC 0.906 and complicated parapneumonic + empyemas: AUC 0.907). Conclusions Nucleated cell counts will help focus the etiology of pleural effusions, since each etiology often have a characteristic cell predominance. The percentage of nucleated cells in pleural fluid not ruled out tuberculosis if there is a high count of mesothelial cells, nor a parapneumonic effusion with lymphocytic predominance, or malignancy with ≥80% lymphocytes.

Resumen Introduccion El conocimiento del comportamiento de los componentes celulares del liquido pleural puede ayudar a enfocar el diagnostico diferencial de un derrame pleural. El objetivo es evaluar su composicion en los distintos tipos de derrames y valorar si proporciona informacion clinica relevante Pacientes y metodos Estudio observacional, transversal y retrospectivo en el que se analiza el componente celular de derrames pleurales de diversa etiologia. Los derrames se clasificaron como neutrofilicos, linfociticos (≥50% de cada uno de ellos), eosinofilicos (≥10%) o mesoteliales (>5%) y se agruparon en 6 categorias diagnosticas. Resultados Se estudiaron 1.467 pacientes (354 insuficiencia cardiaca; 59 otros trasudados; 349 paraneumonicos; 133 tuberculosos; 397 neoplasicos y 175 otros exudados). El predominio celular fue linfocitico en la insuficiencia cardiaca (44,4%), paraneumonicos no complicados (29,2%), tuberculosis (88%) y neoplasias (49,6%); neutrofilico en los paraneumonicos (57%) y neoplasicos (9,6%); eosinofilico en las neoplasias (6,3%) y mesotelial en las tuberculosis (12%). Las etiologias mas frecuentes con un recuento linfocitario ≥80% fueron tuberculosis (35,1%) y neoplasias (23,3%). Los parametros con mayor capacidad discriminante fueron: leucocitos (trasudados: AUC 0,835) y porcentaje de neutrofilos (empiemas: AUC 0,906 y paraneumonicos complicados + empiemas: AUC 0,907) Conclusiones Los recuentos de celulas nucleadas ayudan a enfocar la etiologia del derrame pleural, ya que cada etiologia suele tener un predominio celular caracteristico. El porcentaje de celulas nucleadas en el liquido pleural no puede descartar tuberculosis si existe un recuento elevado de celulas mesoteliales, ni un derrame paraneumonico ante un predominio linfocitico, o malignidad con un recuento de linfocitos ≥80%

Background: There are no firm recommendations when cytology should be performed in pleural transudates, since some malignant pleural effusions (MPEs) behave biochemically as transudates. The objective was to assess when would be justified to perform cytology on pleural transudates. Methods: Consecutive patients with transudative pleural effusion (PE) were enrolled and divided in two groups: malignant and non-MPE. Logistic regression analysis was used to estimate the probability of malignancy. Two prognostic models were considered: (I) clinical-radiological variables; and (II) combination of clinical-radiological and analytical variables. Calibration and discrimination [receiver operating characteristics (ROC) curves and area under the curve (AUC)] were performed. Results: A total of 281 pleural transudates were included: 26 malignant and 255 non-malignant. The AUC obtained with Model 1 (left PE, radiological images compatible with malignancy, absence of dyspnea, and serosanguinous appearance of the fluid), and Model 2 (the variables of Model 1 plus CEA) were 0.973 and 0.995, respectively. Although no false negatives are found in Models 1 and 2 to probabilities of 11% and 14%, respectively, by applying bootstrapping techniques to not find false negatives in 95% of other possible samples would require lowering the cut-off points for the aforementioned probabilities to 3% (Model 1) and 4% (Model 2), respectively. The false positive results are 32 (Model 1) and 18 (Model 2), with no false negatives. Conclusions: The applied models have a high discriminative ability to predict when a transudative PE may be of neoplastic origin, being superior to adding an analytical variable to the clinic-radiological variables.

INTRODUCTION: Diagnosis of pleural infection (PI) may be challenging. The purpose of this paper is to develop and validate a clinical prediction model for the diagnosis of PI based on pleural fluid (PF) biomarkers. METHODS: A prospective study was conducted on pleural effusion. Logistic regression was used to estimate the likelihood of having PI. Two models were built using PF biomarkers. The power of discrimination (area under the curve) and calibration of the two models were evaluated. RESULTS: The sample was composed of 706 pleural effusion (248 malignant; 28 tuberculous; 177 infectious; 48 miscellaneous exudates; and 212 transudates). Areas under the curve for Model 1 (leukocytes, percentage of neutrophils, and C-reactive protein) and Model 2 (the same markers plus interleukin-6 [IL-6]) were 0.896 and 0.909, respectively (not significant differences). However, both models showed higher capacity of discrimination than their biomarkers when used separately (P < 0.001 for all). Rates of correct classification for Models 1 and 2 were 88.2% (623/706: 160/177 [90.4%] with infectious pleural effusion [IPE] and 463/529 [87.5%] with non-IPE) and 89.2% (630/706: 153/177 [86.4%] of IPE and 477/529 [90.2%] of non-IPE), respectively. CONCLUSIONS: The two predictive models developed for IPE showed a good diagnostic performance, superior to that of any of the markers when used separately. Although IL-6 contributes a slight greater capacity of discrimination to the model that includes it, its routine determination does not seem justified.

Background: Pleural effusion occurs as a response of the pleura to aggressions. The pleura reacts differently according to the type of injury. However, pleural reactions have not yet been characterized. The objective of this study was to identify homogeneous clusters of patients based on the analytical characteristics of their pleural fluid and identify pleural response patterns. Methods: A prospective study was conducted of consecutive patients seen in our unit for pleural effusion. Principal component and cluster analyses were carried out to identify pleural response patterns based on a combination of pleural fluid biomarkers. Results: A total of 1613 patients were grouped into six clusters, namely: cluster 1 (10.5% of the cohort, primarily composed of patients with malignant pleural effusions); cluster 2 (17.4%, pleural effusions with inflammatory biomarkers); cluster 3 (16.1%, primarily composed of patients with infectious pleural effusions); cluster 4 (2.5%, a subcluster of cluster 3, superinfectious effusions); cluster 5 (23.4%, paucicellular pleural effusions); and cluster 6 (30.1%, miscellaneous). Significant differences were observed across clusters in terms of the analytical characteristics of PF (p < 0.001 for all), age (p < 0.001), and gender (p = 0.016). A direct relationship was found between the type of cluster and the etiology of pleural effusion. Conclusion: Pleural response is heterogeneous. The pleura may respond differently to the same etiology or similarly to different etiologies, which hinders diagnosis of pleural effusion.

Identifying infectious pleural effusions (IPE) that will progress to complicated infection or empyema is challenging. The purpose of this study was to determine whether a model based on multiple biochemical parameters in pleural fluid can predict which IPEs will produce empyema.A prospective study was performed of all cases of IPEs treated in our unit. IPEs were classified as uncomplicated or complicated (empyema). Logistic regression was used to estimate the risk for complicated pleural infection (empyema). A predictive model was developed using biochemical parameters in pleural fluid. Discriminatory power (areas under the ROC curve), calibration, and diagnostic accuracy of the model were assessed.A total of 177 patients were included in the study (74 with uncomplicated infectious pleural effusion, and 103 with complicated pleural effusion/empyema). The area under the curve (AUC) for the model (pH, lactate dehydrogenase and interleukin 6) was 0.9783, which is significantly superior to the AUC of the individual biochemical parameters alone (0.921, 0.949, and 0.837, respectively; P.001 using all parameters). The rate of correct classification of infectious pleural effusions was 96% [170/177: 72/74 (97.3%) for uncomplicated and 98/103 (95.1%) for complicated effusion (empyema)].The multiple-marker model showed better diagnostic performance for predicting complicated infectious pleural effusion (empyema) compared to individual parameters alone.

Resumen Introduccion Ante la ausencia de recomendaciones firmes, se analiza si en un derrame pleural (DP) bilateral es suficiente puncionar un unico lado o es necesario hacerlo en ambos. Material y metodos Estudio prospectivo de los pacientes atendidos de forma consecutiva por un DP bilateral durante 3 anos y 9 meses a los que se les hizo una toracocentesis bilateral simultanea. Los parametros analizados fueron los habituales en el protocolo de nuestra institucion. Tambien se valoraron el tamano del DP, la presencia de dolor toracico o fiebre, o la existencia de anormalidades pulmonares acompanantes, valores de atenuacion diferentes en la TC de torax, presencia de loculaciones pleurales y resolucion radiologica en un unico lado. Resultados Se estudiaron 36 pacientes (19 varones; edad media 68,5 ± 16,5 anos). Solamente en 2 enfermos (5,6%) la etiologia del derrame fue distinta en ambos lados. En 6/32 casos (18,8%), en cada uno de los lados, el analisis bioquimico del liquido (en terminos de trasudado/exudado) no se correspondia con el diagnostico etiologico del derrame. La correlacion entre los parametros bioquimicos analizados en el liquido de ambos lados (coeficiente de correlacion de Pearson) varia entre 0,74 (LDH) y 0,998 (NT-proBNP). Al hallar solamente 2 pacientes con distintos diagnosticos en ambos lados no fue posible evaluar en que circunstancias puede ser necesario llevar a cabo una toracocentesis diagnostica bilateral. Conclusiones No parece recomendable hacer rutinariamente una toracocentesis bilateral de forma simultanea. Se necesitan series mas amplias para establecer que factores pueden plantear la necesidad de puncionar ambos DP.

Pleural epithelioid haemangioendothelioma (EHE) is a rare tumour that originates in the vascular endothelium with an intermediate degree of malignancy between haemangioma and angiosarcoma. Smoking and asbestos exposure are unproven risk factors and diagnosis is usually confirmed by thoracoscopy, since pleural fluid (PF) cytology is often not conclusive. Immunohistochemistry can also help to confirm the diagnosis. We report an 85-year-old patient with bilateral pleural EHE diagnosed by thoracoscopy, who debuted with a spontaneous bilateral haemothorax, the second described so far, and we conducted a thorough review of the literature to describe the clinical, radiological and prognostic features, as well as the PF, of this rare tumour.

Resumen La afectacion pleural en la sarcoidosis es baja y se puede manifestar de diversas formas. Con el objetivo de documentar la frecuencia y las caracteristicas del derrame pleural en los pacientes con sarcoidosis, revisamos los casos diagnosticados en nuestro centro entre enero de 2001 y diciembre de 2012. De los 195 pacientes con sarcoidosis identificados, 3 (2 hombres y una mujer) tenian un derrame pleural unilateral (1,5%): uno derecho y 2 izquierdo; 2 en estadio ii y uno en estadio iv . El derrame de los 2 que se puncionaron era un exudado de predominio linfocitico. Uno de ellos correspondia a un quilotorax y el otro presentaba valores elevados de CA-125. Estos derrames suelen ser exudados serosos (a veces quilotorax), paucicelulares, de predominio linfocitico, con unas proteinas proporcionalmente mas elevadas que la LDH. Pueden evolucionar favorablemente de forma espontanea, si bien en la mayoria de los casos se tratan con corticoides.

Introduction: Endobronchial ultrasound (EBUS) has been a major breakthrough in the staging of lung cancer, but its usefulness in the diagnosis of other diseases is limited by the size of the needles available. Objectives: Analyze the diagnostic yield of EBUS without ROSE, and the influence of the use of the cell block in the diagnosis of sarcoidosis. Methods: From August 2010 through November 2015, 804 EBUS were performed without ROSE. Until June 2012 a smear of the material obtained in puncture was subsequently referred to the pathology department. Thereafter the samples were prepared as cell block. Results: Among the 804 EBUS performed, we found 44 (5.4%) sarcoidosis [30 men (68.2%; mean age 51.5 ± 16.2 years) and 14 women (31.8%; 55 7 ± 18.2 years)]. In 13/44 patients (29.5%) had previously undergone another diagnostic procedure with negative results. EBUS was diagnostic in 35 patients (79.5 %). In the remaining 9 patients, the diagnosis was established by mediastinoscopy (7 patients) peripheral lymph node biopsy and transbronchial biopsy. EBUS diagnostic yield increased to 88% (32/36) when cell block was used. On the other hand it fell to 37.5% (3/8) when a conventional smear was used. An average of 1.84 lymph nodes per patient were punctured. Stations most frequently punctured were 7, 4R and 11R (in 38, 16 and 11 cases, respectively). No significant differences were found in diagnostic yield in relation with the number of stations punctured (p=0.259). Conclusions: EBUS is an useful technique for the diagnosis of sarcoidosis. The use of the cell block technique for processing EBUS samples ,improves the diagnostic yield in sarcoidosis and should be the method of choice.

Introduction: In the absence of strong recommendations, analyze if in bilateral pleural effusion is enough to puncture one side or it is necessary puncture both. Material and methods: Prospective study (for 3 years and 9 months) of consecutive patients with bilateral pleural effusion who underwent simultaneous bilateral thoracentesis. In patients with suspected heart failure were punctured only those with asymmetric pleural effusion, or who had chest pain or fever. The parameters analyzed were common in the protocol of our institution. We also evaluated the pleural effusion size, the presence of chest pain or fever, the existence of lung abnormalities, the different attenuation values in chest CT, the presence of pleural loculations and the radiological resolution. Results: 36 patients (19 men; mean age 68.5 ± 16.5 years) were studied. Only 2 patients (5.6%) the etiology of the effusion was different on both sides. The final diagnosis of the pleural effusion did not correspond with the biochemical fluid analysis in 6/32 cases (18.8%). The correlation between the biochemical parameters analyzed in the pleural effusion on both sides [Pearson correlation coefficient (R2)] ranges from 0.53 (LDH) and 0.996 (NT-proBNP). There was no association between clinical-radiological features or between biochemical determinations of the pleural effusion and the different etiologies of pleural effusion or different diagnostic groups (transudate / exudates). Conclusions: It does not seem advisable perform routinely simultaneously bilateral thoracentesis. Larger studies are needed to establish what factors may suggest the need for puncturing both pleural cavities.

Introduction In the absence of firm recommendations, we analyzed whether unilateral thoracic puncture is sufficient for bilateral pleural effusion (PE), or if the procedure needs to be performed in both sides. Materials and methods Prospective study of patients seen consecutively for bilateral PE during a period of 3 years and 9 months. All patients underwent simultaneous bilateral thoracocentesis. The standard protocol variables collected in our hospital served as study parameters. Size of PE, presence of chest pain or fever, or accompanying lung abnormalities, different attenuation values on chest computed tomography, presence of loculated pleural fluid, and radiological resolution in a single side were also evaluated. Results A total of 36 patients (19 men; mean age 68.5±16.5 years) were included. The etiology of the effusion was different in each side in only 2 patients (5.6%). In 6/32 cases (18.8%), the biological analysis of the pleural fluid (in terms of transudate/exudate) from both sides did not correspond with the etiological diagnosis of the effusion. Correlation between biochemical parameters analyzed in the fluid from both sides (Pearson's correlation coefficient) ranged between 0.74 (LDH) and 0.998 (NT-proBNP). As different diagnoses in each side were found in only 2 patients, the circumstances in which bilateral diagnostic thoracocentesis would be necessary could not be determined. Conclusions Simultaneous bilateral thoracocentesis does not appear to be recommendable. Larger series are needed to establish which factors might suggest the need for simultaneous puncture of both PE.

Malignant pleural effusion (MPE) is common in clinical practice, and despite the existence of studies to guide clinical decisions, it often poses diagnostic and therapeutic dilemmas. Once it is diagnosed, median survival does not usually exceed 6 months. The management of these patients focuses on symptom relief since no treatments have been shown to increase survival to date. Conversely, poor management can shorten survival. The approach must be multidisciplinary and allow for individualized care. Initial diagnostic procedures should be minimally invasive and, according to the results and other factors, procedures of increasing complexity will be selecting. Likewise, the treatment of MPEs should be individualized according to factors such as type of tumor, patient functional status, means available, benefits of each procedure, or life expectancy. Currently, treatment seems to tend toward less interventional approaches, in which patients can be managed on an outpatient basis, thus minimizing both the discomfort that more aggressive approaches involve and the costs of care associated with this disease. This article reviews the pleural procedures employed in the management of MPEs with special emphasis on the indication for each one, its usefulness, benefits, and complications.

Primary thoracic sarcomas are very rare. The most common intrathoracic variants are synovial sarcoma, angiosarcoma, leiomyosarcoma, rhabdomyosarcoma, and sarcomatoid mesothelioma. Although thoracic Ewing sarcoma/primitive neuroectodermal tumor (PNET) usually develops on the chest wall, there have been reports of primary Ewing sarcoma/PNET of the lung. We present the case of a 22-year-old woman with Ewing sarcoma/PNET diagnosed following histologic, immunohistochemical, and in situ hybridization studies of a bronchial biopsy specimen. Radiography, ventilation-perfusion scintigraphy, and a bone marrow biopsy confirmed that the tumor was not metastatic. The patient was started on a chemotherapy regimen of vincristine, actinomycin, cyclophosphamide, doxorubicin, ifosfamide, and etoposide and responded well. She is now being seen regularly at our outpatient clinic.

Resumen Los sarcomas primarios de torax son muy poco frecuentes. Sarcoma sinovial, angiosarcomas, leiomiosarcomas, rabdomiosarcomas y mesoteliomas sarcomatoides son las variantes intratoracicas mas comunes. Aunque el sarcoma de Ewing/tumor neuroectodermico primitivo (PNET) toracico se desarrolla habitualmente en la pared toracica, se ha descrito en la literatura medica algun caso de localizacion pulmonar primaria. Presentamos el caso de una mujer de 22 anos diagnosticada de sarcoma de Ewing/PNET pulmonar mediante muestra broncoscopica por sus caracteristicas histologicas, inmunohistoquimicas y tecnicas de hibridacion in situ. Se excluyo el origen metastasico mediante radiografia, gammagrafia y biopsia de medula osea. Se inicio quimioterapia segun el esquema VACD-IE (vincristina, actinomicina D, ciclofosfamida, doxorrubicina, ifosfamida y etoposido), con buena respuesta. En la actualidad acude de forma regular a consultas ambulatorias.

a b s t r a c t Pleural involvement in sarcoidosis is uncommon and appears in several forms. To document the incidence and characteristics of pleural effusion in sarcoidosis patients, a review of the cases diagnosed in our center between January 2001 and December 2012 was carried out. One hundred and ninety-five patients with sarcoidosis were identified; three (two men and one woman) presented with unilateral pleural effusion (1.5%): one in the right side and two in the left. Two were in stage II and one was in stage IV. The pleural fluid of the two patients who underwent thoracocentesis was predominantly lymphocytic. One of these patients presented chylothorax and the other had high CA-125 levels. In general, these effusions are lymphocyte-rich, paucicellular, serous exudates (sometimes chylothorax) and contain proportionally higher levels of protein than LDH. Most cases are treated with corticosteroids, although it may resolve spontaneously.

Dasatinib is a drug for treatment of oncogene fusion protein BCR-ABL-positive chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia resistant/intolerant to imatinib. Pleural effusion (PE) is a common adverse effect, and in this context, we present four cases seen due to this cause. One of them is a chylothorax. The PE grade is variable, and the physiopathology is not well established, although a block in T-lymphocyte function or inhibition of platelet-derived growth factor receptor-β is suggested being involved. The PE is generally a lymphocyte-predominant exudate, but can also present as chylothorax. Several factors have been associated with its appearance, particularly the administration in two daily doses. Low grade (1–2) PEs usually respond well to interrupt the treatment while those of higher grade may also require therapeutic thoracentesis and corticosteroids. There are currently no firm guidelines that establish when to resort to one form of treatment or another.