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Sarcoidosis is a multiorgan granulomatous disease with a variable course.The purpose of this study is to identify the patients that are more likely to experience disease progression.A retrospective study in patients ≥18 years. Pulmonary function and radiological stage (Scadding criteria) were assessed at diagnosis, and at 1, 3 and 5 years. Sarcoidosis progression was established based on deterioration of radiological or pulmonary function (decrease ≥10% of FVC and/or ≥15% of diffusing capacity of the lung (DLCO).The sample included 277 caucasian patients [mean age, 50±13.6; 69.7% between 31-60 years; 56.3% men]. In total, 65% had stage II sarcoidosis, whereas only 8.3% had stage III/IV disease. Mean pulmonary function (FVC, FEVAt 3 years, a third of patients experienced sarcoidosis progression. Age was the only factor associated with disease prognosis.

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.

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

BackgroundLow-dose dexamethasone demonstrated clinical improvement in patients with coronavirus disease 2019 (COVID-19) needing oxygen therapy; however, evidence on the efficacy of high-dose dexamethasone is limited.MethodsWe performed a randomised, open-label, controlled trial involving hospitalised patients with confirmed COVID-19 pneumonia needing oxygen therapy. Patients were randomly assigned in a 1:1 ratio to receive low-dose dexamethasone (6 mg once daily for 10 days) or high-dose dexamethasone (20 mg once daily for 5 days, followed by 10 mg once daily for an additional 5 days). The primary outcome was clinical worsening within 11 days since randomisation. Secondary outcomes included 28-day mortality, time to recovery and clinical status at day 5, 11, 14 and 28 on an ordinal scale ranging from 1 (discharged) to 7 (death).ResultsA total of 200 patients (mean±sd age 64±14 years; 62% male) were enrolled. 32 (31.4%) out of 102 patients enrolled in the low-dose group and 16 (16.3%) out of 98 in the high-dose group showed clinical worsening within 11 days since randomisation (rate ratio 0.427, 95% CI 0.216–0.842; p=0.014). The 28-day mortality was 5.9% in the low-dose group and 6.1% in the high-dose group (p=0.844). There was no significant difference in time to recovery, and in the seven-point ordinal scale at days 5, 11, 14 and 28.ConclusionsAmong hospitalised COVID-19 patients needing oxygen therapy, high dose of dexamethasone reduced clinical worsening within 11 days after randomisation, compared with low dose.

Resumen El uso de productos del tabaco novedosos, en especial el cigarrillo electronico y los dispositivos de combustion parcial de tabaco (sistemas Heat not Burn), han aumentado de forma exponencial, sobre todo en jovenes y adolescentes. Las autoridades sanitarias y las sociedades cientificas han mostrado preocupacion ante las dudas que existen sobre su seguridad y eficacia (como metodo de abandono del tabaco). Tras el estudio de la evidencia cientifica disponible no es posible asegurar la inocuidad de los vapores o humos que inhalan los usuarios de estos dispositivos. Respecto a la eficacia no pueden recomendarse tras los resultados contradictorios de diferentes ensayos clinicos y metaanalisis, maxime cuando existen tratamientos seguros y eficaces para ayudar a dejar de fumar (vareniclina, terapia sustitutiva con nicotina y bupropion, unido al asesoramiento psicologico).

Currently in developed countries there is an increase in the consumption of roll your own tobacco, which is associated with a higher proportion of users of this form of tobacco who wish to make an attempt to quit. The objective of this study was to analyze the effectiveness of tobacco cessation interventions based on the type of tobacco consumed.Longitudinal study of a cohort of 641 smokers recruited between 2015 and 2018 in a health area of Galicia included in smoking cessation programs, based on psychological counseling and pharmacological treatment. The characteristics and success of the intervention were evaluated in two groups: roll your own tobacco smokers (RYO) and manufactured tobacco smokers (MT). A logistic regression was performed to determine the probability of success in smoking cessation. The risk measure was the odds ratio (OR) with its 95% confidence interval.RYO users started at a younger age and had a lower sociocultural stratum than MT users. Interventions to quit smoking in RYO users were associated with less abstinence at 4 weeks (52% MT vs 38% LT) (OR: 0.5; 95% CI 0.35-0.99; p=0.045;) and at 3 months (42% TM vs 30% TL) (OR:0.6; 95% CI 0.33-0.98; p=0.04).Smoking cessation programs are less effective in short-term RYO users. There are no differences in long-term abstinence between the two groups.Actualmente en los países desarrollados existe un aumento del consumo de tabaco de liar lo que se asocia a una mayor proporción de usuarios de esta forma de tabaco que desean realizar un intento de abandono. El objetivo de este estudio fue analizar la efectividad de las intervenciones de cesación tabáquica en función del tipo de tabaco consumido.Estudio longitudinal de una cohorte de 641 fumadores reclutados entre 2015 y 2018 en un área sanitaria de Galicia incluidos en programas de deshabituación tabáquica, basados en el asesoramiento psicológico y en el tratamiento farmacológico. Se evaluaron las características y el éxito de la intervención en dos grupos: fumadores de tabaco de liar (TL) y fumadores de tabaco manufacturado (TM). Se realizó una regresión logística para determinar la probabilidad de éxito en la cesación tabáquica. La medida de riesgo fue el odds ratio (OR) con su intervalo de confianza al 95%.Los consumidores de TL se iniciaron a una edad más temprana y tenían un estrato sociocultural más bajo que los consumidores de TM. Las intervenciones para abandonar el tabaco en los consumidores de TL se asociaron a una menor abstinencia a las 4 semanas (52%TM vs 38% TL) (OR: 0,5; 95%IC 0,35-0,99; p=0,045;) y a los 3 meses (42%TM vs 30%TL) (OR:0,6; 95%IC 0,33-0,98; p=0,04).Los programas de cesación tabáquica son menos efectivas en los consumidores de TL a corto plazo. No se observan diferencias en la abstinencia a largo plazo entre ambos grupos.

Juan-Antonio Riesco-Miranda,1,2 Segismundo Solano-Reina,3 Carlos Rábade-Castedo,4 José-Ignacio de Granda-Orive,5 Esther Pastor-Esplá,6 Marcos García-Rueda,7 Francisco-Javier Callejas-Gonzalez,8 Ángel Azpeitia-Anadón,9 Silvia Mas,10 Carlos-Andrés Jiménez-Ruiz11 1Servicio de Neumología, Hospital Universitario de Cáceres, Cáceres, Spain; 2CIBERES, Madrid, Spain; 3Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; 4Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain; 5Servicio de Neumología, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, Spain; 6Servicio de Neumología, Hospital Universitario San Juan de Alicante, Alicante, Spain; 7Servicio de Neumología, Hospital Universitario Carlos Haya, Málaga, Spain; 8Servicio de Neumología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain; 9Departamento Médico Labs, Esteve S.A, Barcelona, Spain; 10Universidad Pompeu Fabra, Barcelona, Spain; 11Unidad Especializada de Tabaquismo, Hospital Clínico Universitario, Madrid, SpainCorrespondence: Silvia MasUniversitat Pompeu Fabra, Campus Poble Nou, Roc Boronat 138, Barcelona, 08018, SpainEmail silviamas.md@gmail.comPurpose: Smokers attending smoking cessation units (SCUs) may offer a unique opportunity for early recognition of undiagnosed chronic obstructive pulmonary disease (COPD). We aimed at assessing the impact of SCUs on the early diagnosis of COPD and describing the clinical and smoking profile of newly-diagnosed COPD cases at SCUs certified by the Spanish Society of Respiratory Diseases and Thoracic Surgery (SEPAR).Patients and Methods: A multicenter cross-sectional observational cohort study (DIPREPOQ study) was performed in eight SEPAR-certified SCUs in Spain. Adult current smokers with no previously diagnosed respiratory disease and having one o more respiratory symptoms were included. Lung functional tests were performed and previously undiagnosed COPD cases were identified and characterized based on national guidelines.Results: Out of 401 individuals newly attending the SCUs, 252 participants were included and 73 (28.9%) met the definition of previously undiagnosed COPD. A characterization of patients with COPD being newly recognized in SCUs showed: age (mean±SD) 61± 9 years; men 59%; active work status 53.1%; functional class I/II dyspnea 82.8%, GOLD state mild/moderate/severe 57%/31%/12%; non-exacerbators 90%, CAT 14± 4; emphysema in X-rays 40%. Most common co-morbidities were cardiovascular and psychiatric (anxiety and depression) ones. Usual smoking history included a lengthy smoking history (41± 9 years) and a current consumption of 24± 9 cigarettes/day.Conclusions and Implications: Consistently certified SCUs can have a substantial contribution to early diagnosis of COPD. A typical profile of newly detected cases is reported, with most patients being men at their early sixties, with mild symptoms and with high and lengthy smoking history. Our study reports a high usefulness of lung functional tests to detect undiagnosed COPD in appropriately selected participants attending SCUs at a large national scale, using a standardized methodology. This is likely to be facilitated by the certification of SCUs using well-defined requirements by national scientific societies.Keywords: health consequences, smoking, chronic obstructive pulmonary disease, smoking cessation unit

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

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.

Background: The relationship between clinical judgment and the pneumonia severity index (PSI) score in deciding the site of care for patients with community-acquired pneumonia (CAP) has not been well investigated. The objective of the study was to determine the clinical factors that influence decision-making to hospitalize low-risk patients (PSI ≤2) with CAP. Methods: An observational, prospective, multicenter study of consecutive CAP patients was performed at five hospitals in Spain. Patients admitted with CAP and a PSI ≤2 were identified. Admitting physicians completed a patient-specific survey to identify the clinical factors influencing the decision to admit a patient. The reason for admission was categorized into 1 of 6 categories. We also assessed whether the reason for admission was associated with poorer clinical outcomes [intensive care unit (ICU) admission, 30-day mortality or readmission]. Results: One hundred and fifty-five hospitalized patients were enrolled. Two or more reasons for admission were seen in 94 patients (60.6%), including abnormal clinical test results (60%), signs of clinical deterioration (43.2%), comorbid conditions (28.4%), psychosocial factors (28.4%), suspected H1N1 pneumonia (20.6%), and recent visit to the emergency department (ED) in the past 2 weeks (7.7%). Signs of clinical deterioration and abnormal clinical test results were associated with poorer clinical outcomes (P < 0.005). Conclusions: Low-risk patients with CAP and a PSI ≤2 are admitted to the hospital for multiple reasons. Abnormal clinical test results and signs of clinical deterioration are two specific reasons for admission that are associated with poorer clinical outcomes in low risk CAP patients.

Background: The characteristics of patients with urinothorax (UT) are poorly defined. Methods: A systematic review was performed searching for studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of UT. Case descriptions and retrospective studies were included. Results: The review included 78 studies with a total of 88 patients. Median age was 45 years, male/female ratio was 1.6:1 and in 76% of cases the etiology was trauma. Pleural effusion (PE) was predominantly unilateral (87%) and occupied over 2/3 of the hemithorax in most cases (64.4%). PF was straw-colored (72.7%) or hematic (27.3%) with urine-like odor in all cases. PF was transudate in 56.2% of cases (18/32) and among 14 exudates (43.8%), 3 were concordant exudates, 1 protein-discordant and 10 LDH-discordant, with lymphocyte (44.4%) and neutrophil (38.5%) predominance. The PF/serum (PF/S) creatinine ratio was >1 in all cases except one (97.9%). The diagnosis was established on the basis of PF/S creatinine ratio >1 (56.6%), urinary tract contrast extravasation (12%), abnormal computed tomography (8.4%), laparotomy findings (6%), and association of obstructive uropathy with PE (6%). The outcome was favorable (74/77; 96.1%) when treatment was direct towards the uropathy (alone or associated with thoracentesis/thoracic drainage). Outcome was unfavorable in the 15 patients who were only treated with thoracentesis/thoracic drainage. Conclusions: UT is usually traumatic, unilateral, and PF does not have a specific pattern or cellularity predominance, with a PF/S creatinine ratio almost always >1. Treatment should include the uropathy, with or without PF evacuation.

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.

The use of novel tobacco products, particularly the electronic cigarette (EC) and partial tobacco combustion devices (HnB systems: Heat not Burn), has increased exponentially, particularly among adolescents and young people. The health authorities and scientific societies have shown concern about issues surrounding safety and effectiveness (as a method of smoking cessation). A study of the available scientific evidence has concluded that the safety of the vapor or fumes inhaled by the users of these devices cannot be guaranteed. Contradictory results from various clinical trials and meta-analyses also mean that these devices cannot be recommended for their effectiveness in cessation, especially when safe and effective treatments are available to help quit smoking (varenicline, nicotine replacement therapy, and bupropion, combined with psychological counseling).

Inhaled administration of ethanol in the early stages of COVID-19 would favor its location on the initial replication sites, being able to reduce the progression of the disease and improving its prognosis. Before evaluating the efficacy and safety of this novel therapeutic strategy in humans, its characterization is required. The developed 65° ethanol formulation is stable at room temperature and protected from light for 15 days, maintaining its physicochemical and microbiological properties. Two oxygen flows have been tested for its administration (2 and 3 L/min) using an automated headspace gas chromatographic analysis technique (HS-GC-MS), with that of 2 L/min being the most appropriate one, ensuring the inhalation of an ethanol daily dose of 33.6 ± 3.6 mg/min and achieving more stable concentrations during the entire treatment (45 min). Under these conditions of administration, the formulation has proven to be safe, based on histological studies of the respiratory tracts and lungs of rats. On the other hand, these results are accompanied by the first preclinical molecular imaging study with radiolabeled ethanol administered by this route. The current ethanol formulation has received approval from the Spanish Agency of Medicines and Medical Devices for a phase II clinical trial for early-stage COVID-19 patients, which is currently in the recruitment phase (ALCOVID-19, EudraCT number: 2020-001760-29).

Background: Pseudochylothorax (PCT) (cholesterol pleurisy or chyliform effusion) is a cholesterol-rich pleural effusion (PE) that is commonly associated with chronic inflammatory disorders. Nevertheless, the characteristics of patients with PCT are poorly defined. Methods: A systematic review was performed across two electronic databases searching for studies reporting clinical findings, PE characteristics, and the most effective treatment of PCT. Case descriptions and retrospective studies were included. Results: The review consisted of 62 studies with a total of 104 patients. Median age was 58 years, the male/female ratio was 2.6/1, and in the 88.5% of cases the etiology was tuberculosis (TB) or rheumatoid arthritis (RA). PE was usually unilateral (88%) and occupied greater than one-third of the hemithorax (96.3%). There was no evidence of pleural thickening in 20.6% of patients, and 14 patients had a previous PE. The pleural fluid (PF) was an exudate, usually milky (94%) and with a predominance of lymphocytes (61.1%). The most sensitive tests to establish the diagnosis were the cholesterol/triglycerides ratio (CHOL/TG ratio) >1, and the presence of cholesterol crystals (97.4% and 89.7%, respectively). PF culture for TB was positive in the 34.1% of patients. Favorable outcomes with medical treatment, therapeutic thoracentesis, decortication/pleurectomy, pleurodesis, thoracic drainage and thoracoscopic drainage were achieved in 78.9%, 47.8%, 86.7%, 66.6%, 37.5% and 42.9%, respectively. Conclusions: PCT is usually tuberculous or rheumatoid, unilateral and the PF is a milky exudate. The presence of cholesterol crystals and a CHOL/TG ratio >1 are the most sensitive test for the diagnosis. The lack of pleural thickening does not rule out PCT. Treatment should be sequential, treating the underlying causes, and assessing the need for interventional techniques.

Pleural effusion (PE) is a very uncommon manifestation of sarcoidosis. It is equally observed in men and women, can appear at any age and in all radiologic stages, though it is more common in stages i and ii. Effusions have usually a mild or medium size and mainly involve the right side. Various mechanisms can be implicated. PE will be a serous exudate if there is an increase in the capillary permeability due to direct involvement of the pleural membrane, a chylothorax if mediastinum lymph nodes compress the thoracic duct and/or the lymphatic drainage from the pleural cavity, an hemothorax if granuloma compress or invade pleural small vessels or capillaries, and even a transudate if there is compression of the inferior vena cava, atelectasis due to complete bronchial obstruction or when the resolution of the PE is incomplete with chronic thickening of visceral pleura (trapped lung). It manifests biochemically as a pauci-cellular exudate with a predominance of lymphocytes, though there can be a preponderance of eosinophils or neutrophils. Protein concentrations are usually proportionately higher than lactate dehidrogenase, adenosine deaminase is normally low and it is possible to find increased levels of CA-125 in women. The tuberculin test is negative and pleural or lung biopsies yield the diagnosis by confirming the presence of non-caseating granulomata. These PE can have a favorable self-limited outcome, even though in most cases treatment with corticosteroids is needed, while surgery is required in a few cases.

Resumen Introduccion Las escalas de probabilidad clinica (EPC) determinan la probabilidad pretest de embolia pulmonar (EP) y valoran la necesidad de las pruebas a realizar en estos pacientes. Nuestro objetivo es investigar si el diagnostico de EP se realiza de acuerdo a las guias de practica clinica. Material y metodos Estudio retrospectivo de las sospechas clinicas de EP en el servicio de urgencias entre enero de 2010 y diciembre de 2012. Se considero positivo un dimero-D ≥ 500 ng/ml. El diagnostico de EP se hizo en funcion de la angiotomografia computarizada multicorte y, en menor medida, por otras tecnicas de imagen. La EPC utilizada fue la de Ginebra revisada. Resultados Las sospechas de EP fueron 3.924 (56% mujeres). El diagnostico se establecio en 360 pacientes (9,2%) y la incidencia fue de 30,6 casos/100.000 habitantes/ano. La sensibilidad y valor predictivo negativo del dimero-D fueron 98,7 y 99,2% respectivamente. La EPC solamente se calculo en 24 casos (0,6%) y los algoritmos diagnosticos no se siguieron en 2.125 pacientes (54,2%): en 682 (17,4%) porque no se pudo estimar la probabilidad clinica y en 482 (37,6%), 852 (46,4%) y 109 (87,9%) con probabilidad clinica baja, intermedia y alta respectivamente, porque no se aplicaron los algoritmos diagnosticos para tales probabilidades. Conclusiones Las EPC para el diagnostico de la EP raramente se calculan y el seguimiento del algoritmo diagnostico en la practica clinica es bajo. Esto puede ocasionar el realizar tecnicas innecesarias que pueden dar lugar a importantes efectos secundarios, o a incurrir en un elevado riesgo de infradiagnostico.

Introduction The differential diagnosis of malignant and tuberculous pleural effusion is frequently difficult. Objectives The aim of our study is to determine the discrimination value of demographic parameters and different biological markers in pleural fluid. Methods In pleural fluid obtained from 106 patients with tuberculous, 250 with malignant and 218 with miscellaneous pleural effusion, clinical and analytical parameters were analysed, applying polytomous regression analysis and the receiver operating characteristic (ROC) curves. Results The three groups could be differentiated using the measured markers. Age, tumour necrosing factor-alpha, lactate dehydrogenase (LDH), adenosine deaminase (ADA), C-reactive protein (CRP) and carcinoembryonic antigen (CEA) were significant predictors for discriminating tuberculous from malignant pleural effusions; nucleated cells, lymphocytes, cholesterol, LDH, ADA, CRP, CEA and CA15.3 distinguish between malignant and miscellaneous pleural effusions. The ROC areas (95% confidence interval) were, 0.973 (0.953, 0.992) for tuberculous, 0.922 (0.900, 0.943) for miscellaneous, and 0.927 (0.907, 0.948) for malignant pleural effusion. The polytomous model correctly classified a significantly high proportion of patients with tuberculosis (85.8%) and cancer (81.6%). The incorrect classification rate was 17.8%, which increased to 19.5% in the correction using bootstrap. Conclusions The results obtained to estimate the probability of tuberculous and malignant pleural effusion confirm that this model achieves a high diagnostic accuracy. This model should be applied to determine which patients with a pleural effusion of unknown origin would not benefit from further invasive procedures.

Resumen La fibrosis quistica (FQ) es una enfermedad producida por un defecto de la proteina reguladora de la conductancia transmembrana CFTR. En la actualidad la morbimortalidad asociada a FQ esta relacionada fundamentalmente con la afectacion pulmonar consecuencia de este defecto. Con el progreso de la enfermedad se incrementa el aislamiento de bacilos gramnegativos no fermentadores como colonizadores en estos pacientes. El genero Pandoraea surge de una reclasificacion de especies integradas en el «complejo Burkholderia cepacia », y comprende 9 especies sensibles solamente a tetraciclinas, imipenem y cotrimoxazol. Describimos el primer caso clinico, en Espana, de colonizacion por Pandoraea sputorum en una paciente diagnosticada de FQ a los 11 anos que, tras varias colonizaciones previas por diferentes especies de Pseudomonas , en septiembre de 2005 se aislo en esputo un bacilo gramnegativo identificado por secuenciacion y espectrometria de masas (MALDITOF-MS) como P. sputorum, resultando solo sensible a piperacilina-tazobactam, cotrimoxazol e imipenem. Desde 2005 a 2008 se demostro la colonizacion cronica por este microorganismo, asociandose a un deterioro de la funcion pulmonar que se recupero tras tratamiento con piperacilina-tazobactam e imipenem. En 2010 se volvio a aislar este microorganismo y se trato con imipenem, farmaco al que la paciente respondio favorablemente. En la actualidad se desconoce si este microorganismo es un colonizador cronico, produce una infeccion transitoria o constituye un problema importante en el paciente con FQ, pero dadas las caracteristicas especiales de sensibilidad a antimicrobianos, la identificacion correcta de este genero es fundamental. La espectrometria de masas parece ser una tecnica valida y mas rapida que los metodos de secuenciacion para la identificacion de estas especies.

Consciente da dificultade dos temas que se tratan neste traballo, tanto pola súa amplitude como polas controversias suscitadas no estudo da sintaxe moderna, pareceume adecuado tocar só algúns aspectos fundamentais que atinxen á problemática da fixación das unidades principais e os seus subtipos, así como á complexidade das relacións e funcións sintácticas que operan nesas unidades. O obxectivo non é, pois, elaborar un minitratado de sintaxe, aínda que considero que non está de máis identificar os tipos de relacións, de unidades e de funcións sintácticas con que imos traballar, como paso previo a calquera precisión.