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Introduction Cytological samples obtained by endobronchial ultrasound (EBUS) are capital for diagnosis, staging and molecular profile in non-small cell lung carcinoma (NSCLC). Objective To assess the success rate of complete, partial and individual of molecular analysis in samples obtained by EBUS-guided transbronchial needle aspiration (TBNA) and/or by oesophageal ultrasound-guided fine needle aspiration with an echobronchoscope (EUS-B-FNA) in patients with NSCLC. Methods Prospective study including 90 patients with non-squamous NSCLC, or non-smoking squamous. Cytological samples were classified into two groups. Group 1: PEN membrane slide and/or cell blocks for the determination of mutations of EGFR, KRAS, ERBB2 and BRAF. Group 2: silane coated slides or cell blocks for rearrangements of ALK, ROS1 and MET amplification. Results The success rate was 78.6% for 4 molecular alterations (EGFR, KRAS, ALK and ROS1), and 44% for 7 determinations. The individual success rate for EGFR was 97%, KRAS 96.3%, ALK 85%, ROS1 82.3%, ERBB2 71.4%, BRAF 67.7% and MET 81.1%. There were no significant differences (p = 0.489) in the number of molecular analyses (1–3 vs. 4) in group 1, depending on the types of samples (cell block vs. PEN membrane slide vs. cell block and PEN membrane slide). Conclusions In patients with NSCLC, the cytological material obtained by ultrasound-guided needle aspiration is sufficient for individual and partial molecular analysis in the vast majority of cases. Membrane slides such as cell blocks are valid samples for molecular analysis.

Bronchoscopy is a widely use technique in critically ill patients. Nosocomial coinfections are a cause of morbidity and mortality in intensive care units.Our aim was to describe bronchoscopy findings and analyze microbiological profile and probably coinfection through bronchial aspirate (BA) samples in patients with coronavirus disease 2019 pneumonia requiring intensive care unit admission.Retrospective observational study analyzing the BA samples collected from intubated patients with coronavirus disease 2019 in a referral Hospital (Spain).One hundred fifty-five consecutive BA samples were collected from 75 patients. Ninety (58%) were positive cultures for different microorganisms, 11 (7.1%) were polymicrobial, and 37 (23.7%) contained resistant microorganisms. There was a statistically significant association between increased days of orotracheal intubation and positive BA (18.9 vs. 10.9 d, P0.01), polymicrobial infection (22.11 vs. 13.54, P0.01) and isolation of resistant microorganisms (18.88 vs. 10.94, P0.01). In 88% of the cases a new antibiotic or change in antibiotic treatment was made.Bronchoscopy in critically ill patient was safe and could be useful to manage these patients and conduct the microbiological study, that seems to be higher and different than in nonepidemic periods. The longer the intubation period, the greater the probability of coinfection, isolation of resistant microorganisms and polymicrobial infection.

The aim of our study was to describe the incidence of infectious complications of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) and to analyze the potential risk factors in a prospective cohort of patients.We conducted a prospective multicenter study, with all consecutive patients referred for an EBUS-TBNA with patients at risk of developing an infectious complication (considering10 nodal samplings, known immunosuppression, bronchial colonization and cavitated or necrotic lesions) and a second group without any risk factor.Three hundred seventy patients were included: 245 with risk factors and 125 without risk factors (as the control group). Overall, 15 patients (4.05%) presented an acute infectious complication: fourteen in cases (5.7%) and 1 in controls (0.8%). Of these, 4 patients presented pneumonia, 1 mediastinitis, 4 obstructive pneumonitis and 6 mild complications (respiratory tract infection that resolved with antibiotic). Also 7 (1.9%) patients had self-limited fever. One-month follow-up showed 1 mediastinitis at sixteenth day post-EBUS, which required surgical treatment, and 3 pneumonias and 3 respiratory tract infections at nineteenth day (1.9%). All patients had a good evolution and there were no deaths related with infectious complication. We observed an increased risk of complication in patients with risk factors and in patients with necrosis (p=0.018).The incidence of infectious complications in a subgroup of patients with risk factors was higher than in patients without risk factors. Nevertheless, it remains low, and no fatal complication occurred, which reinforces the idea that EBUS-TBNA is a safe technique for the assessment of the mediastinum. Necrotic lesions are a risk factor of post-EBUS infection, and their puncture should be avoided.

Resumen Introduccion Los autoanticuerpos sericos apoyan el diagnostico de sospecha en la enfermedad intersticial difusa (EPID) asociada a enfermedades autoinmunes sistemicas (EPID-EAS). Su presencia en el lavado broncoalveolar (LBA) no ha sido estudiada. Objetivos Demostrar la presencia de autoanticuerpos en el LBA de pacientes con EPID de inicio, compararlos con los resultados del suero y analizar los aspectos clinicos de los pacientes con autoanticuerpos en el LBA. Metodos Se analizaron autoanticuerpos contra antigenos extraibles del nucleo (ENA) mediante inmunoblot en el LBA de 155 pacientes con sospecha diagnostica de EPID y 10 controles. Resultados Se detectaron 7 especificidades ENA en el LBA de 19 pacientes (anti-Ro52, anti-Ro60, CENP-B, anti-La, Jo-1, Sm/RNP y anti-SL70), siendo el anti-Ro52 el mas frecuente (13 pacientes; 68,4% de los positivos). Siete pacientes presentaron mas de una especificidad. Catorce fueron diagnosticados de EPID-EAS, 3 de neumonia intersticial con rasgos autoinmunes, uno de neumonia intersticial no especifica idiopatica y otro de silicosis. En 10 casos (52%) se detectaron autoanticuerpos de clase IgA en el LBA. Los autoanticuerpos detectados en LBA tambien se hallaron en el suero de 17 pacientes (90%). No hubo diferencias clinicas significativas entre los pacientes con autoanticuerpos en LBA con respecto a aquellos con EPID-EAS o neumonia intersticial con rasgos autoinmunes con LBA negativo. Conclusion El estudio de ENA en LBA es factible y puede ser una herramienta util en el algoritmo inicial en la EPID, concretamente, para apoyar el diagnostico de sospecha de la EPID-EAS.

Introduction Serum autoantibodies support the diagnosis of interstitial lung disease (ILD) related to systemic autoimmune diseases (SAD-ILD). Nevertheless, their presence in the bronchoalveolar lavage (BAL) has not been explored. Objectives To demonstrate the presence of autoantibodies in the BAL of ILD patients at onset of clinical evaluation, its relation with serum autoantibodies and to analyze clinical features of patients with autoantibodies in BAL. Methods Autoantibodies against extractable nuclear antigens (ENAs) were analyzed by immunoblot in the BAL of 155 patient with suspected diagnosis of ILD and 10 controls. Results Seven ENAs were detected in the BAL of 19 patients (Anti-Ro52, Anti-Ro60, CENP-B, Anti-La, Jo-1, Sm/RNP and Anti-SL70). The most frequent ENA was anti-Ro52 (13 patients; 68,4% of positives ones). Seven patients presented more than one ENAs. Fourteen were diagnosed of SAD-ILD, 3 of interstitial pneumonia with autoimmune features, one of non-specific idiopathic pneumonia and other of silicosis. In 10 cases (52%) IgA autoantibodies were also detected. The autoantibodies observed in BAL were also detected in the serum of 17 patients (90%). There were no significant clinical differences with the patients with SAD-ILD or interstitial pneumonia with autoimmune features with patients with negative BAL. Conclusion The study of ENAs in BAL is feasible and can be a useful tool in the ILD initial algorithm, specifically sustaining the suspected diagnosis of SAD-ILD.

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF.

Background: Palbociclib is a specific inhibitor of cyclin-dependent kinases 4 and 6 that is approved for the treatment of advanced or metastatic breast cancer patients. Despite a good toxicity profile in pivotal trials, where asymptomatic neutropenia was the main adverse effect, its wider use in clinical practice may show less prevalent but serious toxicities. Case Presentation: Here, we describe a case of pneumonitis due to palbocicblib. A 57-year-old female with breast cancer with bone metastasis presented dyspnea at rest 3 months after beginning treatment with palbociclib and letrozole. Palbociclib-induced pneumonitis was considered the most probable cause after ruling out all alternatives, and the patient was successfully treated with steroids and showed complete remission. Conclusions: In summary, we present a well-documented case report of pneumonitis related to palbociclib. However, the mechanism of toxicity is still unknown, and there are as yet no reliable biomarkers to predict toxicity with cyclin-dependent kinase 4/6 inhibitors. In this case report, we alert physicians about new drugs that can provoke old toxicities.

BackgroundThe role of bronchoscopy in coronavirus disease 2019 (COVID-19) is a matter of debate.Patients and methodsThis observational multicentre study aimed to analyse the prognostic impact of bronchoscopic findings in a consecutive cohort of patients with suspected or confirmed COVID-19. Patients were enrolled at 17 hospitals from February to June 2020. Predictors of in-hospital mortality were assessed by multivariate logistic regression.ResultsA total of 1027 bronchoscopies were performed in 515 patients (age 61.5±11.2 years; 73% men), stratified into a clinical suspicion cohort (n=30) and a COVID-19 confirmed cohort (n=485). In the clinical suspicion cohort, the diagnostic yield was 36.7%. In the COVID-19 confirmed cohort, bronchoscopies were predominantly performed in the intensive care unit (n=961; 96.4%) and major indications were: difficult mechanical ventilation (43.7%), mucus plugs (39%) and persistence of radiological infiltrates (23.4%). 147 bronchoscopies were performed to rule out superinfection, and diagnostic yield was 42.9%. There were abnormalities in 91.6% of bronchoscopies, the most frequent being mucus secretions (82.4%), haematic secretions (17.7%), mucus plugs (17.6%), and diffuse mucosal hyperaemia (11.4%). The independent predictors of in-hospital mortality were: older age (OR 1.06; pConclusionBronchoscopy may be indicated in carefully selected patients with COVID-19 to rule out superinfection and solve complications related to mechanical ventilation. The presence of haematic secretions in the distal bronchial tract may be considered a poor prognostic feature in COVID-19.

Calidad del broncoscopio de un solo uso Ambu aScope4tm

Interferon gamma (IFN-γ) release assays (IGRAs) are increasingly used to test for latent tuberculosis (TB) infection. Although highly specific, IGRAs have a relatively high false-negative rate in active TB patients. A more sensitive assay is needed. IFN-γ-induced protein 10 (IP-10) is an alternative biomarker with a 100-fold-higher expression level than IFN-γ, allowing for different analysis platforms, including molecular detection. The PCR technique is already an integrated tool in most TB laboratories and, thus, an obvious platform to turn to. In this case-control study, we investigated the diagnostic sensitivity and specificity of a molecular assay detecting IP-10 mRNA expression following antigen stimulation of a blood sample. We included 89 TB patients and 99 healthy controls. Blood was drawn in QuantiFeron-TB gold in-tube (QFT) assay tubes. Eight hours poststimulation, IP-10 mRNA expression was analyzed, and 20 h poststimulation, IP-10 and IFN-γ protein plasma levels were analyzed using an in-house IP-10 enzyme-linked immunosorbent assay (ELISA) and the official QFT ELISA, respectively. The IP-10 mRNA assay provided high specificity (98%), sensitivity (80%), and area under the concentration-time curve (AUC) (0.97); however, the QFT assay provided a higher overall diagnostic potential, with specificity of 100%, sensitivity of 90%, and AUC of 0.99. The IP-10 protein assay performed on par with the QFT assay, with specificity of 98%, sensitivity of 87%, and AUC of 0.98. We have provided proof of high technical performance of a molecular assay detecting IP-10 mRNA expression. As a diagnostic tool, this assay would gain from further optimization, especially on the kinetics of IP-10 mRNA expression.

Background:The disposable bronchoscope is an excellent alternative to face the problem of SARS-CoV-2 and other cross infections, but the bronchoscopist's perception of its quality has not been evaluated. Methods: To evaluate the quality of the Ambu-aScope4 disposable bronchoscope, we carried out a cross-sectional study in 21 Spanish pulmonology services. We use a standardized questionnaire completed by the bronchoscopists at the end of each bronchoscopy. The variables were described with absolute and relative frequencies, measures of central tendency and dispersion depending on their nature. The existence of learning curves was evaluated by CUSUM analysis.Results:The most frequent indications in 300 included bronchoscopies was bronchial aspiration in 69.3% and the median duration of these was 9.1 minutes. The route of entry was nasal in 47.2% and oral in 34.1%. The average score for ease of use, image, and aspiration quality was 80/100. All the planned techniques were performed in 94.9% and the bronchoscopist was satisfied in 96.6% of the bronchoscopies. They highlighted the portability and immediacy of the aScope4TM to start the procedure in 99.3%, the possibility of taking and storing images in 99.3%. The CUSUM analysis showed average scores> 70/100 from the first procedure and from the 9th procedure more than 80% of the scores exceeded the 80/100 score.Conclusions:The aScope4 ™ scored well for ease of use, imaging, and aspiration. We found a learning curve with excellent scores from the 9th procedure. Bronchoscopists highlighted its portability, immediacy of use and the possibility of taking and storing images.

Interferon (IFN)-γ release assays (IGRAs) are used to diagnose latent tuberculosis (TB) infection (LTBI). To improve the accuracy of these tests, different approaches, such as alternative cytokine detection and using different antigens, are considered. Following this purpose, this study aims to evaluate the addition of EspC, EspF and Rv2348-B to those present in the QuantiFERON-TB Gold In-Tube (QFN-G-IT). We included 115 subjects: 74 active TB patients, 17 LTBI individuals and 24 healthy controls. Whole blood samples were collected in QFN-G-IT and in-house tubes containing different combinations of EspC, EspF and Rv2348-B, together with ESAT-6, CFP-10, and TB7.7. After overnight incubation at 37 ºC, plasma was harvested and IFN-γ quantified. IFN-γ levels in the QFN-G-IT and in-house tubes correlated very good (Spearman Rho(r) > 0.86). In-house antigen combinations distinguished healthy individuals from those with active TB and LTBI (specificities and sensitivities higher than 87.5% and 96.3%, respectively [AUC > 0.938]). Adding EspC, EspF and Rv2348-B, increased the sensitivity of the test, being the addition of EspC and Rv2348-B the combination that yielded a higher sensitivity with no specificity loss. Addition of these antigens could improve diagnosis in patients with impaired or immature immune response who are at high risk of developing TB.

BackgroundNosocomial co-infections are a cause of morbidity and mortality in Intensive Care Units (ICU).ObjectivesOur aim was to describe bronchoscopy findings and analyse co-infection through bronchial aspirate (BA) samples in patients with COVID-19 pneumonia requiring ICU admission.MethodsWe conducted a retrospective observational study, analysing the BA samples collected from intubated patients with COVID-19 to diagnose nosocomial respiratory infection.ResultsOne-hundred and fifty-five consecutive BA samples were collected from 75 patients. Of them, 90 (58%) were positive cultures for different microorganisms, 11 (7.1%) were polymicrobial, and 37 (23.7%) contained resistant microorganisms. There was a statistically significant association between increased days of orotracheal intubation (OTI) and positive BA (18.9 days versus 10.9 days, pConclusionNosocomial respiratory infection in intubated COVID-19 patients seems to be higher than in non-epidemic periods. The longer the intubation period, the greater the probability of co-infection, isolation of resistant microorganisms and polymicrobial infection. Microbiological sampling through BA is an essential tool to manage these patients appropriately.

Resumen Introduccion La informacion sobre la asociacion del cancer de pulmon (CP) y combinacion de fibrosis pulmonar y enfisema (CFPE) es limitada y procedente casi exclusivamente de series asiaticas. El objetivo principal del estudio fue valorar el impacto del CP en la supervivencia en la CFPE y en pacientes diagnosticados de fibrosis pulmonar idiopatica (FPI). Metodos Se realizo un estudio retrospectivo con los datos de pacientes con CFPE y FPI diagnosticados en nuestro centro en un periodo de 5 anos. Resultados Se incluyo a 66 pacientes, 29 en el grupo de CFPE y 37 pacientes con FPI. Nueve tenian un diagnostico de CP (6 con CFPE y 3 con FPI); 6 pacientes (67%) recibieron tratamiento paliativo a pesar de que 3 de ellos presentaban estadios i y ii . No hubo diferencias significativas en la mortalidad global de los 2 grupos; sin embargo, en los pacientes con CP la supervivencia fue significativamente menor con respecto a los que no tenian CP (p = 0,044). Las causas mas frecuentes de muerte fue la insuficiencia respiratoria secundaria a la exacerbacion de la fibrosis pulmonar (44%). En el analisis multivariante, la odds ratio de morir en los pacientes con CP respecto a los pacientes sin CP fue de 6,20 (p = 0,037, intervalo de confianza [IC] del 95%: 1,11 a 34,48). Conclusion El CP empeora la supervivencia de estas 2 entidades. El manejo diagnostico y terapeutico del CP se ve dificultado por el mayor riesgo de complicaciones posteriores al tratamiento elegido, incluso tras el tratamiento paliativo.

Aims: The aims of our study were to quantify the incidence of infectious complications in EBUS-TBNA, in a selected group of patients and try to identify the major risk factors. Material/Methods: Prospective + multicentre study, with patients submitted to an EBUS-TBNA. We collected clinical characteristics: presence of necrosis signs in radiology or EBUS image and mediastinal adenopathies evaluation. A post-procedure blood test, bronchoaspirate (BAS), blood cultures and chest X-ray were performed. All these tests repeated 48h late. Results: First 24h: 3 patients presented bacteremia and fever (1 pneumonia, 1 respiratory infection and 1 asymptomatic) and 4 presented fever without bacteremia (1 pneumonia and 3 asymptomatic). 48h: 1 presented fever and bacteremia developing a mediastinitis and 1 presented self-limited fever. After 30 days of follow-up: The rate of infectious complications was 6.4%. We identified a significant increase in white blood cell count (WBC) and C-reactive protein (CRP) in those patients. We analyzed the possible relationship between immunosuppression, the characteristics of the lesions, the number of punctures performed and the appearance of fever in the follow 48h, without significant association. A slight non-significant trend was observed at a higher risk of fever in >10 lymph nodes puncture (OR 3.9 (95% CI 0.80-19.24 p=0.092)), but not in other groups. Conclusions: The average of infectious complications was higher than those described in literature. A subgroup of susceptible patients could be identified. There was an WBC/CRP increase and a non-significant tendency of higher risk of fever in >10 lymph nodes puncture. Supported by SEPAR

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF.

Resumen Introduccion La sedacion durante la ecobroncoscopia es importante debido a la duracion prolongada de esta exploracion. Evaluamos distintos modelos de sedacion y sus complicaciones. Metodo Se realizo un estudio multicentrico, prospectivo y observacional en el que recogieron distintas variables en 307 pacientes con distintos modelos de sedacion: a) midazolam en bolo; b) propofol en perfusion; c) midazolam en bolo y propofol en perfusion; d) propofol en perfusion y remifentanilo en perfusion, y e) midazolam en bolo y fentanilo en bolo. Finalizada la prueba, los pacientes contestaron una encuesta de satisfaccion. Resultados Los pacientes por modelo de sedacion fueron: A 24, B 37, C 107, D 62 y E 77. Las puntuaciones de las sensaciones percibidas de recuerdo, dolor, tos, disnea y exploracion prolongada (0,65 ± 1,11; 0,3 ± 0,73; 0,46 ± 0,9; 0,29 ± 0,73; 0,59 ± 0,96) fueron menores frente a miedo y nerviosismo antes de la exploracion (1,26 ± 1,37 y 1,5 ± 1,41). Los valores elevados de indiferencia ante la repeticion (1,49 ± 1,3) y de sensacion agradable de la prueba (1,23 ± 1,17), junto con cifras bajas la sensacion de angustia (0,49 ± 0,85) e incomodidad de la exploracion (0,62 ± 1,1), muestran que los distintos modelos de sedacion fueron bien tolerados. El 46,6% de los pacientes no encontraron ningun momento malo y el 89,6% se repetiria la prueba. Los modelos E y C fueron los que menos complicaciones presentaron (12,9 y 31,7%) y, en todos los casos, se resolvieron con medidas terapeuticas sencillas. Conclusiones Los modelos de sedacion analizados fueron bien tolerados y la mayoria aceptarian la repeticion de la ecobroncoscopia. Las complicaciones fueron escasas y sencillas de resolver.

Introduction Sedation during endobronchial ultrasound (EBUS) is essential due to the long duration of this procedure. We evaluated different models of sedation and their complications. Method A multicenter, prospective, observational study of 307 patients undergoing EBUS was conducted. Patients were sedated with: (a) midazolam bolus; (b) propofol infusion; (c) midazolam bolus and propofol infusion; (d) propofol infusion and remifentanil infusion, or (e) midazolam bolus and fentanyl bolus, and clinical variables were collected. Patients were asked to complete a satisfaction survey following the test. Results Patients per sedation model were: A 24, B 37, C 107, D 62 and E 77. Scores for perceived sensations of recall, pain, cough, dyspnea and prolonged examination (0.65±1.11, 0.3±0.73, 0.46±0.9, 0.29±0.73, and 0.59±0.96, respectively) were lower compared to fear and nervousness before the examination (1.26±1.37 and 1.5±1.41, respectively). High levels of indifference to repeating the procedure (1.49±1.3) and a reported pleasant feeling during the test (1.23±1.17), with low levels of anxiety (0.49±0.85) and discomfort (0.62±1.1), show that different models of sedation were well tolerated. Almost half the patients (46.6%) did not report any “worst moment” during the procedure, and 89.6% were willing to undergo a repeat test. The E and C models presented fewest complications (12.9% and 31.7%, respectively), and all were resolved with simple therapeutic measures. Conclusions The models of sedation evaluated were well tolerated and most patients were willing to undergo repeat EBUS. Complications were few and easily resolved.

Real-time elastography performed during endoscopic ultrasonography is a relatively new method for characterizing tissue stiffness, and has been used successfully as a predictor of malignancy in mediastinal lymph nodes. This case report describes our practical experience with this technique using an ultrasound bronchoscope to examine mediastinal lymph nodes. We present a case of sectorial endobronchial ultrasound and the first published case of endoscopic ultrasound elastography using ultrasound bronchoscope in two patients with non-small cell lung carcinoma. Qualitative tissue color pattern was obtained in both cases and correlated with pathological evaluation. The initial feasibility results are promising and suggest that ultrasound bronchoscopy techniques, such as guided nodal staging, merit additional studies. It may be important to categorize the risk of malignancy to facilitate sampling decisions.

Resumen La elastografia en tiempo real realizada durante la ultrasonografia endoscopica digestiva es una tecnica relativamente nueva que permite caracterizar la dureza de los tejidos, y ha sido utilizada con exito como predictor de malignidad en ganglios mediastinicos. En la presente nota clinica se describe nuestra experiencia practica en la tecnica de la elastografia con ecobroncoscopio en el estudio de los ganglios linfaticos mediastinicos. Presentamos un caso realizado mediante ultrasonografia endobronquial sectorial y el primer caso publicado de elastografia por ultrasonografia endoscopica con ecobroncoscopio, en 2 pacientes con carcinoma de pulmon no microcitico. El patron cualitativo en color del tejido se obtuvo en ambos casos y se correlaciono con la evaluacion anatomopatologica. Los resultados de viabilidad iniciales son prometedores y las aplicaciones ecobroncoscopicas, como la estadificacion ganglionar guiada, requieren ser evaluadas. Categorizar el riesgo de malignidad puede ser importante para ayudar a tomar decisiones en la obtencion de muestras.

Background To evaluate the accuracy of systematic mediastinal staging by endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) (sampling of all visible nodes measuring ≥5 mm from stations N3 to N1 regardless of their positron emission tomography/computed tomography [PET/CT] features) and compare this staging approach with targeted EBUS-TBNA staging (sampling only 18F-fluorodeoxyglucose [FDG]-avid nodes) in patients with N2 non-small cell lung cancer on PET/CT. Methods Retrospective study of 107 patients who underwent systematic EBUS-TBNA mediastinal staging. The results were compared with those of a hypothetical scenario where only FDG-avid nodes on PET/CT would be sampled. Results Systematic EBUS-TBNA sampling demonstrated N3 disease in 3 patients, N2 disease in 60 (42 single-station or N2a, 18 multiple-station or N2b) and N0/N1 disease in 44. Of these 44, 7 underwent mediastinoscopy, which did not show mediastinal disease; 6 of the 7 proceeded to lung resection, which also showed no mediastinal disease. Thirty-four N0/N1 patients after EBUS-TBNA underwent lung resection directly: N0/N1 was found in 30 and N2 in 4 (1 N2b with a PET/CT showing N2a disease, 3 N2a). Sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy of systematic EBUS-TBNA were 94%, 100%, 90%, 100% and 96%, respectively. Compared with targeted EBUS-TBNA, systematic EBUS-TBNA sampling provided additional important clinical information in 14 cases (13%): 3 N3 cases would have passed unnoticed, and 11 N2b cases would have been staged as N2a. Conclusions In clinical practice, systematic sampling of the mediastinum by EBUS-TBNA, regardless of PET/CT features, is to be recommended over targeted sampling.

Transbronchial lung cryobiopsy (TBCB) is an effective technique to obtain tissue samples for pathological examination. However, TBCB in middle third lung lesions was presumed to be associated with significant hemorrhage. Objectives: To evaluate safety of TBCB for middle third lung lesions and compare it with outer third lung lesions. Methods: The lesions were divided radiologically into middle and outer thirds groups based on CT. Radial ultrasound mini-probe (RP-EBUS) was introduced through a thin bronchoscope (Olympus) to identify the lesions and surrounding vessels. Virtual bronchoscopy system (Lung Quest software/bronchus Lung Point systems) was used in 6 patients. In eligible lesions (no surrounding large vessels ≥3 mm or hypervascularization seen by thin-slice chest CT or RP-EBUS), 4 TBCB were performed using a flexible cryoprobe 1.9 mm (ERBE). Results: 26 patients with parenchymal lung lesions were included from March 2015 to January 2017. 15 patients had middle third lung lesions with mean diameter 39.9 mm. Out of them, 3 patients were excluded for TBCB (20%). 7 were positive for adenocarcinoma (58.3%) and moderate bleeding occurred in 5/12 (41.7%). 11 patients had peripheral third lesions with mean diameter 43.1 mm. 1 patient was excluded for TBCB (9.1%). 4 were positive for adenocarcinoma, 1 was undifferentiated NSCLC, 1 was UIP and 1 was colloid carcinoma. Diagnostic value was (70%) and moderate bleeding occurred in 2/10 (20%). Conclusions: RP-EBUS guided TBCB for middle third lung lesions was not associated with severe complications; however tendency to moderate bleeding was higher. Carefull selection of potential candidates is mandatory Funded partially by a grant AEER 2016

Background: The present study sought to evaluate the usefulness of EBUS-TBNA in the diagnosis of locoregional recurrence of lung cancer in a cohort of lung cancer patients who were previously treated surgically, and describe our initial experience of EUS-B-FNA in this clinical scenario. Methods: We retrospectively studied the clinical records of all patients with a previous surgically-treated lung cancer who were referred to our bronchoscopy unit after suspicion of locoregional recurrence. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy of EBUS-TBNA for the diagnosis of locoregional recurrence were evaluated. Results: Seventy-three patients were included. EBUS-TBNA confirmed malignancy in 40 patients: 34 confirmed to have locoregional recurrence, six had metachronous tumours. Of the 33 patients with non-malignant EBUS-TBNA; 2 had specific non-malignant diseases, 26 underwent radiological follow up and 5 patients underwent surgery. Of the 26 patients who had radiological follow up; 18 remained stable, three presented thoracic radiological progression and 5 presented extrathoracic progression. Of the 5 patients who underwent surgery; 3 had metachronous tumours, one confirmed to be a true negative and one presented nodal invasion. Seven patients underwent EUS-B-FNA, four of them confirmed to have recurrence. The sensitivity, specificity, NPV, PPV and overall accuracy of EBUS-TBNA for the diagnosis of locoregional recurrence were 80.9, 100, 69.2, 100 and 86.6% respectively. Conclusions: EBUS-TBNA is an accurate procedure for the diagnosis of locoregional recurrence of surgically-treated lung cancer. EUS-B-FNA combined with EBUS-TBNA broads the diagnostic yield of EBUS-TBNA alone.

Resumen Introduccion La embolizacion arterial (EA) es util en el tratamiento de la hemoptisis amenazante. El objetivo de este trabajo es describir la experiencia de un centro universitario terciario con la EA como tratamiento de la hemoptisis amenazante, caracterizar los hallazgos angiograficos cuando hay recidivas, y analizar los factores asociados con estos hallazgos. Material y metodos Estudio observacional retrospectivo en el que se incluyeron todos los pacientes con una EA debido a hemoptisis amenazante durante un periodo de 13 anos. Los efectos de: a) tiempo hasta recurrencia; b) uso de coils , y c) numero de arterias embolizadas sobre la probabilidad que el sangrado tuviera el mismo origen vascular que en el episodio previo fueron analizados. Resultados Se incluyeron 176 pacientes en el estudio. Murieron por hemoptisis 22 pacientes (12,5%). La probabilidad de sobrevivir libre de recidiva al mes fue de 0,91 (IC 95%: 0,87 a 0,95), a los 12 meses de 0,85 (IC 95%: 0,79 a 0,91) y a los 3 anos de 0,75 (IC 95%: 0,66 a 0,83). La probabilidad de que la recurrencia fuera debida a una afectacion de la misma arteria dependia del tiempo hasta la recurrencia (estimado = 0,0157, valor de z = 2,41, valor de p = 0,016). Conclusion La EA es efectiva en el tratamiento de la hemoptisis, pero las recidivas no son infrecuentes. La recidiva del sangrado por recanalizacion de la arteria embolizada esta relacionada con el tiempo transcurrido hasta la recidiva, pero no con el uso de coils ni con el numero de arterias embolizadas.

a b s t r a c t Introduction: Artery embolization (AE) is a safe and useful procedure in the management of massive hemoptysis. The objective of our study was to describe the experience of AE in a tertiary referral center, to characterize angiographic findings at the time of recurrence, and to analyze factors associated with these findings. Material and methods: Observational retrospective study of patients presenting with life-threatening hemoptysis. All consecutive patients with at least one episode of hemoptysis that required AE during a 13-year period were included. The effects of (i) time to recurrence, (ii) use of coils, and (iii) number of arteries embolized on the likelihood that the recurrence was secondary to recanalization were assessed. Results: One hundred and seventy-six patients were included in the study. Twenty-two patients (12.5%) died due to hemoptysis. Probability of recurrence-free survival at one month was 0.91 (95% CI: 0.87-0.95), at 12 months was 0.85 (95% CI: 0.79-0.91), and after 3 years was 0.75 (95% CI: 0.66-0.83). A longer time to recurrence was associated with a higher probability that the hemorrhage affected the same artery (estimate=0.0157, z-value=2.41, P-value=.016). Conclusion: AE is a safe and useful technique in the management of massive and recurrent hemop- tysis. Nevertheless, recurrence after embolization is not uncommon. Recurring hemoptysis due to recanalization is related to time to recurrence, but not to the use of coils or number of arteries embolized.

Introduction Few studies have evaluated the functional and mental status of older persons with chronic kidney disease (CKD) not under dialysis. The aim of this study was to determine functional and mental status in a cohort of older patients with distinct degrees of renal function. Methods A total of 54 clinically stable, older individuals were included (74.1% women) from geriatric and nephrology consultations. We established 2 groups according to levels of glomerular filtration rate (GFR) calculated on the basis of the Modification of Diet in Renal Disease (MDRD) equation: Group 1 (n = 17: MDRD = 60 ml/min) and group 2 (n = 37: MDRD < 60 ml/min). Mental and functional status were analyzed in a cross section between January and April, 2008 in older patients attending consultations since 2006. We registered demographic information, renal function parameters, antecedents of vascular disease, and the type of antihypertensive treatment. We analyzed the results of the Barthel Index (BI) and the mini�mental state examination (MMSE). The statistical analysis was carried out with the SPSS 11.0 program. Results There were no significant differences in vascular comorbidities or antihypertensive treatment. MMSE scores were lower in group 2 (22.62 ± 10) than in group 1 (28.4 ± 4) (P=.010). No differences were found in functional status between the 2 groups. The results of the BI and the MMSE showed no correlations with renal function parameters. The results of the Barthel Index correlated with those of the MMSE (r =.74; P=.000). The results of the MMSE were inversely correlated with age (r =-0.27; P=.047). Conclusions The results of this study suggest a possible association between renal disease and cognitive deterioration in older individuals.

Polyphenols are chemically and biologically active compounds. Grape seed extracts (GSEs) have been widely used as a human food supplement for health promotion and disease prevention. However, there is little information regarding its application in animal feeds. An experiment was conducted to investigate the effect of inclusion of GSE at 0.025, 0.25, 2.5 and 5.0 g/kg in a wheat soya bean control diet on growth performance, protein and amino acid (AA) digestibility and plasma lipid and mineral concentrations in broiler chickens at 21 days of age. Performance was not affected by dietary treatment except in the case of birds fed the diet with the highest GSE concentration, which showed a worsening of weight gain and feed conversion. Apparent ileal digestibility (AID) of protein was significantly reduced in the birds fed the highest concentration of GSE, which also had a reduction on the AID of arginine, histidine, phenylalanine, cystine, glutamic acid and proline compared with those fed control diet. The inclusion of graded concentration of GSE in the chicken diets caused a significant linear decrease in the concentrations of plasma copper, iron and zinc. Plasma cholesterol, triglycerides and lipoproteins (high-density lipoprotein, low-density lipoprotein and very-low-density lipoprotein) concentrations were not affected by dietary GSE. In conclusion, this study demonstrated that incorporation of GSE in chicken diets up to 2.5 g/kg had no adverse effect on growth performance or protein and AA digestibility. Feed conversion was reduced and growth rate was retarded, when chickens were fed 5 g/kg of GSE. This study also indicated that grape polyphenols reduce the free plasma minerals., The authors wish to thank the Spanish Ministry of Science and Innovation (MICINN, Spain) and Comunidad Autonoma de Madrid (CAM) for financial support of this investigation, Projects AGL2009-07417/GAN and S2009/AGR-1704 (NEWGAN), respectively. S. Chamorro was supported by a post-doctoral contract (JAE-Doc) from the Spanish Research Council (CSIC).

Peripheral lung lesions are a common finding, however diagnosis is considered difficult because they cannot be visualized using conventional bronchoscopy and tissue obtained with the usual techniques may be insufficient. OBJ: To evaluate the diagnostic yield and usefulness of the combination of transbronchial cryobiopsy (TBCB) with a commercialized cryoprobe guided by RP-EBUS using a pediatric bronchoscope. METHODS: We included,03-2015 to 01-2016,patients with indication of TCB for peripheral lung lesions.After identifying the lesion by a radial ultrasonic miniprobe through a pediatric bronchoscope(BF-P180;Olympus),the TBCB were performed without guide sheath.In 2 cases fluoroscopy was also used and in one case virtual bronchoscopy simulation (LungQuest software/bronchusLungPoint systems)to calculate the trajectories to the target. Results: 10 patients were evaluated (7 men,mean age 65±11 years),9 with focal lesions.In all cases the miniprobe of RP-EBUS could be positioned within or adjacent to the lesion.The larger diameter of the focal lesions for pathologic examination was 4.4±1.9cm.7 cases were diagnosed as neoplastic disease (2likely),1 UIP and in 2 cases there were inflammatory changes.TBBperformed in 7 of the focal lesions,using both conventional forceps as cryoprobe,diagnosis of malignancy only by cryoprobe in 3(42.8%),2 of them adenocarcinoma with lepidic pattern.3 grade II bleedings occurred after TCB(30%) and no pneumothorax. CONCLUSIONS: TBCBperformed with pediatric bronchoscope and guided by RP-EBUS is a useful and feasible technique.It can increase the diagnostic yield in peripheral lung lesions compared to TBB with forceps.

AIM: Endobronchial valve placement is a safe alternative to surgery in patients with persistent pulmonary air leak. The aim of our study is to describe our experience in a series of patients with persistence air leak who underwent endobronchial valve placement. MATERIAL AND METHODS: We conducted a retrospective study that included patients with persistent air leak treated by means of endobronchial valve placement in two tertiary hospitals. The pulmonary area responsible of the air leak was located by means of collapsing the target bronchi with a catheter with a balloon. Once located, the endobronchial valve was placed in the target bronchi under bronchoscopy guidance. RESULTS: We included 6 patients (sex 6 males, age (mean): 64.8 years). Air leaks were secondary to pneumothorax in 3 (42.8%) cases and lung cancer surgery in 2 patients. The mean time of drainage prior to valve placement was 19.3 days. The mean number of valves placed per patient was 2 (range 1-3). Air leaks were resolved in all patients. Mean time before valve removal was 68.5 days. No severe adverse events were found during or after the valve placement. One patient developed granulation tissue by the bronchial valve. CONCLUSIONS: Endobronchial valve placement is a safe and effective alternative to surgery in patients with persistent air leak.

The Ro52 is a ubiquitous protein over-expressed during inflammation and apoptosis. The presence of anti-Ro52 antibodies in the serum of patients with Connective Tissue Diseases (CTD) has been associated with interstitial lung involvement. In situ formation of anti- SS-A / Ro antibodies has been demonstrated in the salivary glands of patients with primary Sjogren sindrome. These findings support the possibility of in situ production of anti-Ro52 antibodies in the lung. The aim of the study is to detect the presence of anti-Ro52 antibodies in the BAL of patients with ILDs and evaluate its potential clinical value. Methods: Anti-Ro52 antibodies (IgG and IgA) were prospectively analyzed by immunoblot in the BAL and serum of ILDs patients at the onset of clinical evaluation Results: Anti-Ro52 antibodies were found in 4 patients with final diagnosis of ILD associated with CTD. In 2 of them the initial ANA serum determination was weakly positive The positive result in BAL helped us to suspect the diagnosis. Conclusions: The determination of anti-Ro52 antibodies in the BAL as complementary tool might help in the multidisciplinary approach to ILDs diagnosis.

Objetivo: Describir las características clínicas, el perfil hormonal y los marcadores de autoinmunidad de pacientes con enfermedad de Graves (EG), atendidos en el servicio de endocrinología de un hospital general. Material y métodos: Estudio descriptivo, retrospectivo de pacientes con diagnóstico de EG atendidos en el servicio de endocrinología del Hospital Nacional Cayetano Heredia durante el año 2005. Los pacientes fueron identificados utilizando el Registro Diario de Atención y Otras Actividades del consultorio externo. Para el análisis estadístico se utilizó el programa SPSS versión 12,0. Resultados: Se revisaron 111 historias clínicas. La edad promedio fue de 40,6 ± 14 años. El 71,2% eran mujeres. El 20,7% tenía antecedente familiar de otra enfermedad autoinmune. El tiempo de enfermedad promedio antes de la consulta fue 18,9 ± 30,4 meses. Los síntomas más frecuentes fueron: tremor, piel delgada, palpitaciones y baja de peso. El peso promedio de la glándula tiroides estimado por palpación fue 69 ± 27,5 gr, 38,7% presentaba exoftalmos y 18,9% mixedema pretibial. El perfil hormonal mostró TSH suprimida, T4 libre y T3 total elevados. El 86,7% de los casos tenía autoanticuerpos anti-peroxidasa tiroidea (anti-TPO) positivo. En 95,5% el tratamiento incluyó el uso de tionamidas. El análisis bivariado mostró que las mujeres tuvieron antecedente familiar de enfermedad tiroidea autoinmune en mayor frecuencia que los varones (27,8 vs. 9,4%) (p=0,04). Conclusión: La población estudiada con EG fueron con mayor frecuencia mujeres entre la tercera y sexta década de la vida. El peso estimado de la glándula tiroides fue tres veces lo normal, con alta frecuencia de oftalmopatía y mixedema. La mayoría tiene marcadores humorales de autoinmunidad y el tratamiento inicial se basa en el uso de tionamidas. (Rev Med Hered 2008; 19:152-157). Objective: To describe the clinical characteristics, thyroid function profile and autoimmune markers in patients with Graves’ disease (GD) treated at the endocrine service of a general hospital. Material and methods: Descriptive and retrospective study in patients with GD treated at the Hospital Nacional Cayetano Heredia during 2005, identified in the Daily Registry of Attention and Other Activities of the Endocrine Service. For statistical analysis, SPSS software was used. Results: We reviewed 111 medical charts. The mean age was 40.6 ± 14 years. 71.2% were women. Twenty three patients (20.7%) reported familial history of autoinmune disease. The mean time of disease was 18.9 ± 30.4 months before diagnosis. The most frequent symptoms were: tremor, thin skin, palpitations and weight loss. The mean thyroid weight was 69 ± 27.5 grams. In 38.7% exophthalmos was present and 18.9% had myxedema. Hormonal profile showed suppressed TSH, elevated levels of free T4 and total T3. In 86.7% autoantibodies against thyroid peroxidase (anti-TPO) were positive. The initial treatment included thionamides in 95.5% of patients. Further statistical analysis showed that women had more frequent familiar history of autoinmune thyroid disease than men (27.8% vs. 9.4%) (p = 0.04). Conclusions: Most of our patients with GD were women between third and sixth decade of life. The estimated weight of the thyroid gland was three times the normal weight and ophthalmopathy and myxedema were frequent. Most of our patients had positive autoimmune markers and the initial treatment included thionamides. (Rev Med Hered 2008; 19:152-157).