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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.

Background There is little information of intensive care unit (ICU) performance when it's relocated to a totally new and equipped area. Objective To analyze the clinical performance and use of resources of a new respiratory-ICU (nRICU) in a large third-level care hospital. Method Cross-sectional, comparative study using prospective data of patients admitted from July 17, 2017 to July 17, 2018. The Rapoport adjusted method was used to obtain the standardized clinical performance index (SCPI) and the standardized resource use index (SRUI). Results Out of 354 patients, those who were readmissions or remained hospitalized and those whose treatment was withheld or withdrawn where excluded from the analysis. In 301 patients, the observed survival at hospital discharge was 63% while the expected survival was 67.7%. Values of SCPI and SRUI were -1.03 and 0.05 respectively, placing results in coordinates within two standard deviations when plotted in the Rapoport chart. There was a statistically significant difference in survival when comparing the study period with outcomes obtained in the RICU before its relocation (63% vs. 55%, p = 0.01). Conclusions In its 1st year of operation, the nRICU had better clinical performance compared to the former RICU, with no change in the use of resources.

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

Antecedents: Unhealthy lifestyles may often be linked to the consumption of both legal and illegal substances such as tobacco and alcohol. Notorious examples include several types of cancer, cardio...

Resumen Antecedentes La mucormicosis pulmonar es una infeccion oportunista rara con alta mortalidad causada por hongos Mucorales. Los mas frecuentes son Rhizopus, Mucor, Lichtheimia y Rhizomucor. Caso clinico Se presenta el caso de una mujer de 56 anos con diabetes mellitus tipo 2 y enfermedad renal cronica, receptora de un trasplante de rinon cadaverico dos anos antes de su ingreso. Por este motivo recibio tratamiento inmunomodulador con timoglobulina, micofenolato de mofetilo, tacrolimus y prednisona. La paciente ingreso por un cuadro neumonico con tos, expectoracion y disnea; una tomografia computarizada mostro una lesion cavitada en el lobulo superior derecho. Con la sospecha de una aspergilosis pulmonar invasiva se comenzo un tratamiento antifungico con voriconazol, sin mejoria. Se realizo una biopsia por aspiracion con aguja fina, y en el cultivo de la misma crecio Rhizomucor pusillus. La identificacion se confirmo por PCR. A pesar del tratamiento con anfotericina B, la paciente presento hemoptisis masiva incoercible, que provoco su fallecimiento. Conclusiones La mucormicosis pulmonar es una infeccion rara que suele ser fatal en receptores de trasplante renal con terapia antirrechazo. Los mucorales producen fenomenos tromboticos, necrosis y destruccion tisular, que provocaron en nuestra paciente una hemoptisis incoercible. Es importante un diagnostico preciso que permita instaurar un tratamiento quirurgico adecuado y la administracion de anfotericina B.

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

Malignant tumors can compress or invade the trachea or bronchi leading to varying degrees of airway narrowing. Lung cancer is the most frequent cause of airway occlusion of neoplastic origin1 and also the leading cause of death among all the malignancies in the world.2 However, distant metastatic tu

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.

SETTING Mexico City, Mexico. OBJECTIVE To identify proteins synthetised by Mycobacterium tuberculosis in hypoxic culture, which resemble more closely a granuloma environment than aerobic culture, and to determine if they are recognised by antibodies from patients with active pulmonary tuberculosis (PTB). DESIGN Soluble extracts from M. tuberculosis H37Rv cultured under aerobic or hypoxic conditions were analysed using two-dimensional polyacrylamide gel electrophoresis, and proteins over-expressed under hypoxia were identified by mass spectrometry. The presence of immunoglobulin (Ig) G, IgA and IgM antibodies against these proteins was determined in the serum of 42 patients with active PTB and 42 healthy controls. RESULTS We selected three M. tuberculosis H37Rv proteins (alpha-crystallin protein [Acr, Rv2031c], universal stress protein Rv2623 and isocitrate lyase [ICL, RV0467]) that were over-expressed under hypoxia. Titres of anti-Acr and anti-ICL IgA antibodies were higher in patients than in healthy controls, with an area under the receiver operating characteristic curve of 0.71 for anti-ICL IgA antibodies. CONCLUSION ICL could be used in combination with other M. tuberculosis antigens to improve the sensitivity and specificity of current serological TB diagnostic methods.

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

Mario Juárez-Ortega,1 Oscar Rojas-Espinosa,1 Raquel Muñiz-Salazar,2 Enrique Becerril-Villanueva,3 Alejandro Hernández-Solís,4 Patricia Arce-Paredes,1 Sergio Islas-Trujillo,1 Raúl Cicero-Sabido4 1Department of Immunology, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico; 2School of Health Sciences, Unidad Ensenada, Universidad Autónoma de Baja California, Ensenada, BC, Mexico; 3Laboratory of Psychoimmunology, Dirección de Investigaciones en Neurociencias, Instituto Nacional de Psiquiatría Ramón de la Fuente, Mexico City, Mexico; 4Pneumology Unit, Hospital General de México “Eduardo Liceaga”, UNAM, Mexico City, Mexico Background: Resident alveolar macrophages, dendritic cells, and immigrating neutrophils (NEU) are the first cells to contact Mycobacterium tuberculosis in the lung. These cells, and additional lymphoid cells in the developing granuloma, release a series of components that may concentrate in the serum and affect disease progression. Purpose: The aim of this study was to investigate the effect of the serum from tuberculosis (TB) patients and their household contacts (HHC) on the nuclear morphology of NEU. Materials and methods: NEU from healthy (HLT) people were incubated with sera from patients with active pulmonary TB, their HHC, and unrelated people. Changes in the nuclear morphology of NEU were analyzed by light and electron microscopy. Results: Sera from patients with TB induced changes in the nuclear morphology of NEU that included pyknosis, swelling, apoptosis, and netosis in some cases. Sera from some HHC induced similar changes, while sera from HLT people had no significant effects. Bacteria did not appear to participate in this phenomenon because bacteremia is not a recognized feature of nonmiliary TB, and because sera from patients that induced nuclear changes maintained their effect after filtration through 0.22µm membranes. Neither anti-mycobacterial antibodies, TNFα, IL-6, IFNγ, or IL-8 participated in the phenomenon. In contrast, soluble mycobacterial antigens were likely candidates, as small quantities of soluble M. tuberculosis antigens added to the sera of HLT people led to the induction of nuclear changes in NEU in a dose-dependent manner. Conclusion: These results might help to detect subclinical TB within HHC, thus leading to a recommendation of prophylactic treatment. Keywords: tuberculosis, serum, neutrophils, pyknosis, apoptosis, netosis

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.

Resumen Objetivo Comparar los resultados de la monitorizacion de calidad despues de la implementacion de estrategias de mejora en la unidad de cuidados intensivos respiratorios (UCIR). Diseno Estudio de intervencion prospectivo, comparativo y longitudinal. Ambito La UCIR del Hospital General de Mexico. Pacientes Todos los pacientes ingresados a la UCIR de marzo de 2012 a marzo de 2013. Intervenciones Se implemento un paquete de intervenciones basadas en la evidencia para reducir las tasas de tres indicadores: extubacion no programada (ENP), re-intubacion y neumonia asociada a la ventilacion mecanica (NAV). Variables de interes Tasas de ENP, re-intubacion y NAV. Resultados Ingresaron 232 pacientes con edad promedio de 49,5 ± 17,8 anos; 119 (50,5%) fueron mujeres. El promedio de Simplified Acute Physiology Score (SAPS-3) fue de 49,8 ± 17 y la puntuacion promedio de Sequential Organ Failure Assessment (SOFA) fue de 5,3 ± 4,1. La mortalidad en la UCIR fue de 38,7%, y la tasa de mortalidad estandarizada, de 1,50 (IC 95%: 1,20-1,84). Los indicadores ENP y re-intubacion mostraron mejoria comparados con la cohorte de 2011: 1,6% vs. 7% en la tasa de re-intubacion (p = 0,02) y 8,1 vs. 17 episodios/1.000 dias de ventilacion mecanica para ENP (p = 0,04). El indicador NAV empeoro: 18,4 vs. 15,1 episodios/1.000 dias de ventilacion mecanica (p = 0,5). Conclusiones La mejora de la calidad con la identificacion de areas de oportunidad e implementacion de estrategias en la UCIR es factible. Sin embargo, la sola implementacion de paquetes de medidas preventivas no garantiza la mejora.

ResumenAntecedentesEl quiste broncogénico es una malformación congénita benigna poco frecuente, se localiza principalmente en el mediastino y en el parénquima pulmonar.ObjetivoDeterminar las características clínicas de los pacientes con diagnóstico de quiste broncogénico, su localización y las bacterias responsables en caso de presentar un proceso infeccioso, diagnosticados del 1 de enero de 2005 al 1 de enero de 2013, en un hospital de concentración de tercer nivel.Material y métodosSe estudiaron los casos de quistes broncogénicos resecados por toracotomía que fueron confirmados por estudio histopatológico; se evaluaron: sexo, edad, diagnóstico de ingreso, localización, tamaño, cuadro clínico, estudios de imagen y cultivos bacteriológicos.ResultadosSe encontraron 12 casos de pacientes con diagnóstico de quiste broncogénico resecados quirúrgicamente por toracotomía, 6 pacientes del género masculino y 6 del femenino; el 50% con localización pulmonar y el 50% en mediastino, de estos últimos uno fue paraesofágico. El estudio bacteriológico del contenido quístico demostró que el 58% de los casos tenía una infección agregada.ConclusionesLos quistes broncogénicos son lesiones congénitas raras de naturaleza benigna, deben ser resecados porque su contenido puede infectarse. El estudio histopatológico es determinante para confirmar el diagnóstico conjuntamente con el examen bacteriológico. La toracotomía es un procedimiento seguro para resecar quistes broncogénicos.AbstractBackgroundBronchogenic cyst is a rare congenital malformation and commonly located in the mediastinum and lung parenchyma.ObjectiveTo determine the clinical characteristics of the patients with diagnosis of bronchogenic cysts, their location and the infectious bacteria when the cysts are infected. The cases were collected from 1 January 2005 to 1 January 2013, in a third level hospital.Material and methodsThe cases with bronchogenic cysts resected by thoracotomy were confirmed by histological study. Age, sex, admission diagnosis, location, size, imagenologic studies, and bacteriological cultures were evaluated.ResultsOf the12 cases with diagnosis of bronchogenic cysts surgically resected by thoracotomy, six were male and six female, with 50% located in lung parenchyma and 50% in mediastinum, one of the latter was para-oesophageal. Bacteriological study of the cystic content demonstrated bacterial infection in seven (58%) cases.ConclusionsBronchogenic cysts are rare congenital benign lesions. They must be resected because their content might be infected. The histopathology study is necessary to confirm the diagnosis, together with bacteriological examination. Thoracotomy is a safe procedure to resect bronchogenic cysts.

Background Bronchogenic cyst is a rare congenital malformation and commonly located in the mediastinum and lung parenchyma. Objective To determine the clinical characteristics of the patients with diagnosis of bronchogenic cysts, their location and the infectious bacteria when the cysts are infected. The cases were collected from 1st January 2005 to 1st January 2013, in a third level hospital. Material and methods The cases with bronchogenic cysts resected by thoracotomy were confirmed by histological study. Age, sex, admission diagnosis, location, size, imagenologic studies, and bacteriological cultures were evaluated. Results Of the12 cases with diagnosis of bronchogenic cysts surgically resected by thoracotomy, six were male and six female, with 50% located in lung parenchyma and 50% in mediastinum, one of the latter was para-oesophageal. Bacteriological study of the cystic content demonstrated bacterial infection in seven (58%) cases. Conclusions Bronchogenic cysts are rare congenital benign lesions. They must be resected because their content might be infected. The histopathology study is necessary to confirm the diagnosis, together with bacteriological examination. Thoracotomy is a safe procedure to resect bronchogenic cysts.

Antecedentes: la espirometría es una prueba clínica que se utiliza para evaluar la función pulmonar en asmáticos. La función pulmonar puede estar afectada por el género, tiempo de evolución clínica, edad pulmonar y edad cronológica.Objetivo: evaluar la relación edad pulmonar-edad cronológica (EP/EC) como indicador de gravedad en pacientes asmáticos.Material y método: estudio prospectivo en el que se evaluó la gravedad del asma mediante la clasificación GINA. La espirometría se realizó al inicio del estudio y a los días 46, 96 y 192, durante 10 meses de seguimiento. Se usaron la prueba t Student, ANOVA de dos vías, modelos de correlación y regresión múltiple y curvas ROC; un valor p< 0.05 se consideró significativo.Resultados: se incluyeron 70 pacientes asmáticos (22 hombres y 48 mujeres); la media de la edad cronológica (EC) fue de 35 años, la media de la edad pulmonar (EP) fue de 48 años, con valor del indicador EP-EC=1.4 y la evolución clínica de la enfermedad fue de 13 años. El valor del indicador EP-EC=1 (intervalo de 0.5 a 0.9) se observó en pacientes asintomáticos. El indicador EP-EC mayor a 1 se relacionó con obstrucción de la vía aérea y el indicador EP-EC mayor a 2 se correlacionó con grado 3 de GINA. El análisis de la edad cronológica y pulmonar en las mujeres demostró diferencia de más de 10 años entre ambas edades (GINA grados 2 y 3); mientras que en los hombres se observaron (GINA grados 1, 2 y 3). El valor del indicador EP-EC ≤ 1 se consideró normal.Conclusiones: la relación edad pulmonar-edad cronológica puede usarse como indicador clínico de la gravedad y mejoría clínica de pacientes asmáticos, con buena correlación entre la función pulmonar y la edad cronológica.

Primary tracheobronchial amyloidosis (TBA) is a rare disease characterized by extracellular focal or diffuse submucosal deposits of amyloid proteins. Various types of endobronchial lesions have been described in TBA when bronchoscopy is performed using white light. Narrow-band imaging bronchoscopy has been mainly employed for detecting preneoplastic and neoplastic endobronchial lesions as it provides more detailed images of the microvasculature reflective of an altered angiogenesis process. Here, we describe bronchoscopic findings with white light and narrow-band imaging in 2 patients presenting with central airway obstructive disease later confirmed as having primary TBA.

Purpose. We describe characteristics, utility, and safety of fiberoptic bronchoscopy (FOB) in an intensive care unit (ICU). Methods. Prospective and descriptive cohort of patients admitted to a respiratory ICU from March 2010 to June 2012. Results. A total of 102 FOBs were performed in 84 patients among 580 patients that were admitted to the ICU. Mean age was years. FOB was useful in 65% of diagnostic procedures and 83% of therapeutic procedures, with an overall utility of 75%. Indications and utility according to indication were pneumonia in 31 cases, utility of 52%; percutaneous tracheostomy guidance in 26 cases, utility of 100%; atelectasis in 25 cases, utility of 76%; airway exploration in 16 cases, utility of 75%; hemoptysis in two cases, utility of 100%; and difficult airway intubation in two cases, utility of 100%. A decrease in oxygen saturation (SpO 2) of >5% during FOB was present in 65% of cases, and other minor complications were present in 3.9% of cases. Conclusions. Reasons for performing FOB in the ICU have remained relatively stable over time with the exception of the addition of percutaneous tracheostomy guidance. Our series documents current indications and also the utility and safety of this procedure.

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.

We present the case of a 33-year-old woman who was being treated for bronchial asthma for 4 years. A tracheal tumor was evident on a computed tomography of the thorax and removed with argon plasma coagulation. It was diagnosed as pleomorphic adenoma of the trachea. It is a rare tracheal tumor without definite treatment guidelines. Our endoscopic approach to this rare lesion is discussed.

To establish the frequency of infectious aetiology in Mexican adult patients with cervical lymphadenopathies (CLAs), 87 consecutive patients with enlarged cervical lymphatic nodes, HIV negative and without anti-tuberculous treatment, were selected from a tertiary-level speciality concentration hospital. Histopathological studies, investigation of acid-fast bacilli, cultures in Löwenstein–Jensen and Mycobacterium growth indicator tube (MGIT) media, and in-house polymerase chain reaction (PCR) with IS6110-based primers for Mycobacterium tuberculosis complex were performed in resected lymphatic nodes. Non-infectious aetiology corresponded to 45 cases (52%). Tuberculosis was suspected in 42 cases (48%) by histology and confirmed positive results were obtained by staining in 8 (19%), by culture in 23 (55%), and by PCR in 34 (81%) patients. All were confirmed after therapeutic success. In addition to the epidemiological transition process occurring in Mexico, tuberculosis remains an important cause of CLA. Histopathology with confirmatory studies including PCR can detect tuberculous aetiology.

Massive hemoptysis is a life-threatening event that requires emergency treatment. The aim of this study was to assess the effects of bronchial artery embolization on survival in cases of massive hemoptysis. This prospective study included 24 consecutive patients with massive hemoptysis who

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.

We performed a retrospective chart review to evaluate the indications for endotracheal intubation via flexible fiberoptic bronchoscopy in patients who were scheduled for surgery or who were hospitalized in the intensive care unit of our 1,100-bed, tertiary care university hospital. We reviewed 9,201 clinical records of anesthetic procedures during which endotracheal intubation had been performed from January to December 2002. We identified 66 patients who had been intubated with flexible fiberoptic bronchoscopy. On preanesthetic examination, 61 of these patients had been found to be poor candidates for conventional laryngoscopic intubation—51 because of abnormal head and neck anatomy and 10 because of reduced visual access to the airway (Mallampati class IV). The remaining 5 patients were intubated via flexible fiberoptic bronchoscopy after conventional intubation had failed during emergency surgery. Our study emphasizes (1) the importance of the preanesthetic examination of surgical patients, to identify those in whom conventional intubation would likely be problematic, and (2) the need to have fiberoptic bronchoscopes and an anesthesiologist or bronchoscopist skilled in their use available in operating suites and intensive care units.

To test the efficacy of intrapleural fibrinolytic therapy in patients with loculated pleural effusions, we conducted an open, prospective, and multicenter trial among five hospitals in Mexico. We enrolled patients with hemothorax or empyema, clotted and/or loculated, that was not resolved through conventional pleural drainage with chest tube and antibiotics in patients with empyema. All patients received repeated doses of 250,000 IU of streptokinase through chest tube. Effectiveness criteria were before and after intrapleural streptokinase (IPSK) drainage, and poststreptokinase radiographic and respiratory function test improvement. Forty-eight patients were studied; there were 30 patients with empyemas, 14 with hemothorax, and 4 patients with malignant pleural effusions without lung trapping. Successful fibrinolysis was obtained in 44 patients, with complete resolution of the pleural collection and adequate radiologic and spirometric improvement. In three of four patients with multiloculated malignant hemothorax with high-yielding pleural drainage, IPSK allowed successful lysis of loci and an adequate pleurodesis was achieved. Only four patients required surgical treatment. The overall success rate in our series was 92%, similar to previous reports. The results in this first prospective and multicentric trial suggest that intrapleural fibrinolysis is an effective and safe adjunctive treatment in patients with heterogeneous pleural coagulated and loculated collections to restore the pulmonary function assessed by respiratory function tests and can obviate surgery in most cases.

Background: There is a progressive increase in nontuberculous mycobacteria (NTM) in pulmonary and extrapulmonary infections that might cause confusion with the Mycobacterium tuberculosis complex. To determine the frequency of finding NTM in clinical samples from patients diagnosed with active tuberculosis, with negative acid-alcohol-resistant bacilli (acid-fast bacillus [AFB]) in a third-level specialty hospital's mycobacterial laboratory between January 2013 and December 2014. Methods: This is a prospective, descriptive study where isolated strains of biological material were studied in Lowenstein–Jensen and BACTEC MGIT 960 cultures. Results: Clinical samples of 120 patients were studied, with pulmonary samples of 99/120 (82%) and extrapulmonary samples of 21/120 (18%). We identified NTM in 37/120 samples (30.8%), of which 16 in pulmonary, 13 in genitourinary, 3 in bone marrow, and 5 in various specimens. Mycobacterium avium was isolated in 20 samples, Mycobacterium intracellulare in seven samples, and various other species of NTM in the other 10 samples. Conclusion: To establish adequate treatment, we point out the importance of identifying the presence of NTM in the clinical samples of active tuberculosis patients with negative AFB, as possibly becoming confused with M. tuberculosis and which is essential in deciding which treatment is the most adequate.

Tracheal stenosis (TS) requires a precise diagnosis and an experienced operator in both endoscopic and surgical treatment. We describe a case series at a tertiary care teaching hospital. Twenty patients with TS and/or subglottic stenosis were included. All underwent flexible bronchoscopy (FB). Spirometry (SP) was obtained in 8 patients, and helical computed tomography with three-dimensional reconstruction (HCT3D) was obtained in 11 patients. All cases were graded by each modality on a scale of 1 to 3, and the findings were correlated among modalities. Mean follow-up was 11.1 months (range: 3 to 47 mo). Postintubation injury was the most frequent cause of stenosis in 16 patients (80%). Mean stenosis grade±SD was 2.0±0.92 for SP, 2.3±0.86 for FB, and 2.54±0.68 for HCT3D. A significant correlation was found between HCT3D and FB (r=0.76, P

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.

Subglottic stenosis is an ancient but persistent problem as a cause of airway obstruction. The etiology and the results of surgical treatment with thyrotracheal anastomosis were reviewed.Fifty-six patients with subglottic stenosis were studied. All were subjected to laryngotracheal reconstruction by thyrotracheal anastomosis with partial resection of the cricoid.Of all 56 cases of subglottic stenosis, 48 (86%) had history of previous tracheal intubation, and only 8 (14%) had different non-neoplastic obstructive processes such as scleroma, direct injury, hamartoma, and amyloidosis. Immediate results were good in all cases. After 1 year follow-up, results of thyrotracheal anastomosis were successful in 44 (91%). In 4 other cases a restenosis was observed. Eight patients were lost to follow-up.Subglottic stenosis is still frequent after tracheal intubation, but other causes must be considered. Laryngotracheal reconstruction with thyrotracheal anastomosis with partial cricoid resection was feasible with good results in 91% of the cases with follow-up, but this procedure must be performed by a skilled surgical team.

We studied the hemodynamic behavior of the pulmonary circulation at rest and during exercise in six patients with MTB. As a group, in contrast to advanced fibrocaseous tuberculosis, these patients exhibited normal pulmonary hemodynamics at rest and during exercise. Only minor abnormalities in pulmonary vascular resistance at exercise (increased PAd-PWP gradient) were noted in two of the patients. The increase in Rp during exercise does not appear to be related to acute hypoxic vasoconstruction but rather to functional changes (compliance or recruitment or both) of the pulmonary microvasculature. In the genesis of these functional changes, chronic alveolar hypoxia and the inflammatory-fibrotic process might be interacting. (Chest 1991; 99:152–54)

Background Spirometry is a very useful clinical test to evaluate pulmonary function in asthma. However pulmonary function could be affected by the sex, time of clinical evolution, lung age (LA) and chronological age (CA). The aim of this study was to evaluate LA/CA as index of clinical improvement or severity in asthma patients. Methods The tenets of the Declaration of Helsinki were followed, and all patients gave their informed consent to participate in this study. Asthma severity was evaluated according with GINA classification. Spirometry was performed at the beginning of this study, at 46 days, 96 days, 192 days and after 8 months. Statistical analysis was performed using t test, 2-way ANOVA test, correlation and multiple regression models as well as ROC curves were also performed, a P < 0.05 was considered as significant. Results 70 asthma patients were included (22 male and 48 female), mean CA was 35-years old; mean LA was 48-years with a LA/CA index = 1.4, time of clinical evolution was 13 years. A LA/CA index = 1 (range 0.5 to 0.9) was observed in asymptomatic patients. LA/CA index over 1 were related with airway inflammation, and a LA/CA index more than 2 correlated with GINA step 3. Interestingly when we analyzed CA and LA, we observed that in female group more than 10 years of difference between CA and LA, (GINA Step2 and 3); while in male we observed (GINA Step1, Step2 and Step3). LA/CA index ≤ 1 was considered as normal. Conclusions LA/CA index is a good as clinical indicator of clinical improvement or severity in asthma patients in with excellent correlation of pulmonary function and age.