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Introduction: Approximately one-third of patients hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD) are readmitted to the hospital within 90 days. It is of interest to identify biomarkers that predict relapse in order to prevent readmission in these patients. In our prospective study of patients admitted for COPD exacerbation, we aimed to analyse whether routine haematological parameters can help predict the three-month readmission risk. Material and methods: 106 patients were included, of whom 23 were female (22%). The age (mean ± SD) was 73 ± 10 years, and the forced expiratory volume in 1 second (FEV1) was 44 ± 15%. The haematological parameters were obtained from the first blood test result during admission. The variables were as follows: red cell distribution width, mean platelet volume (MPV), platelet (PLT) count, neutrophil to lymphocyte ratio, PLT to lymphocyte ratio, MPV to PLT ratio, and eosinophil count. Patients were differentiated into two groups for each haematological parameter according to median value, and the percentage of readmissions in each of the groups was recorded. Results: Twenty-five patients (24%) were readmitted to hospital within three months of discharge. Only the difference in low-MPV and high-MPV patients was significant (37% vs. 10%, p = 0.001). The predictive capacity for three-month readmission measured by the area under the curve (AUC) did not show clinically applicable values; the best result was for MPV (AUC 0.64). In the remaining values, the AUC was between 0.52 and 0.55. Conclusion: Routine haematological parameters proposed as prognostic biomarkers in COPD obtained at the moment of hospital admission were not useful for predicting three-month readmission.

Ditercalinium (2,2'-([4,4'-bipiperidine-1,1'-diyl] di-2,1-ethane diyl) bis (10-methoxy-7H-pyrido[4,3c] carbazolium) tetra(methyl sulphonate--NSC 366241), a DNA bis-intercalating compound presently under clinical trial, elicits an original mechanism of action and thus appears as the first of a new class of anti-tumour drugs. Previous studies have shown that a reduced flexibility of the linking chain of these dimers is essential for their biological activity. In order to analyze their mechanism of action at the molecular level and to obtain structure-activity relationships in this series, new derivatives with additional methylene groups between the two piperidine rings have been synthesized. Whereas the addition of a single methylene group in the chain preserves the anti-tumour activity of the dimers, the addition of a second methylene diminishes it; the addition of three methylenes completely abolishes it. Lengthening of sonicated DNA and unwinding of supercoiled DNA support a bis-intercalation mechanism for these drugs. In addition, analyses of poly d(A-T) melting curves in the presence of the drugs, and competition experiments with ethidium dimer, show that these compounds bind to DNA with high affinity (10(7)-10(8) M-1). N.m.r. studies of the dimers in aqueous medium show that the introduction of a single methylene group in the linker leads to compounds with a conformationally-induced decrease of intermolecular stacking interactions, which might be related to the DNA affinity enhancement observed for these dimers. Different hypotheses concerning structure-activity relationships in the different series are discussed.

Resumen Objetivo Evaluar en pacientes diagnosticados de tuberculosis pulmonar la frecuencia de asistencias en Urgencias en los 6 meses previos al diagnostico, conocer los motivos de la asistencia, el grado de sospecha en Urgencias y los factores a los que se asociaba esta sospecha. Metodo Estudio retrospectivo de los casos de tuberculosis pulmonar atendidos en un servicio de Urgencias generales entre 2011 y 2017. Resultados De los 54 pacientes incluidos, 38 (70%) habian sido atendidos en el servicio de Urgencias en los 6 meses previos al diagnostico: 6 (16%) por procesos sin relacion con la tuberculosis y 32 (84%) con relacion potencial. En 12 (38%) de estos pacientes se sospecho en Urgencias la posibilidad del diagnostico de tuberculosis pulmonar, y no se sospecho en los restantes 20 pacientes (62%). El grupo en el que se sospecho tenia mas frecuencia de sintomas generales y respiratorios y mas frecuencia de cavitacion en la radiografia. Conclusiones Un elevado porcentaje de pacientes con tuberculosis pulmonar han consultado en Urgencias en los 6 meses previos al diagnostico, y con mucha frecuencia esta posibilidad diagnostica no se sospecha.

Objective To assess the frequency of care in an emergency department in the 6 months prior to the diagnosis of tuberculosis and to determine the reasons for the care, the degree of suspicion in the emergency department and the factors associated with this suspicion. Method A retrospective study was conducted on patients with pulmonary tuberculosis treated in the general emergency department between 2011 and 2017. Results Of the 54 included patients, 38 (70%) had been treated in the emergency department in the 6 months prior to the diagnosis: 6 (16%) patients had been treated for processes unrelated to the tuberculosis, and 32 (84%) were treated for processes that were potentially related to the tuberculosis. Pulmonary tuberculosis was suspected in the emergency department for 12 (38%) of these patients and not suspected in the remaining 20 patients (62%). The group in which pulmonary tuberculosis was suspected had a higher rate of general and respiratory symptoms and cavitation in the radiography. Conclusions A high percentage of patients with pulmonary tuberculosis were admitted to the emergency department in the 6 months prior to the diagnosis, and this diagnostic possibility was often not suspected.

Introduction Organ tropism of SARS-CoV-2 to the respiratory tract could potentially aggravate asthma. The susceptibility of patients with asthma to develop an exacerbation when they are infected with SARS-CoV-2 is unknown. We aimed to investigate the symptoms presented in patients with asthma who became infected with SARS-CoV-2. Methods and results All patients over 14 years of age who tested positive for SARS-CoV-2 (by RT-PCR) were included (n = 2995). In patients with asthma (n = 77, 2.6%; 44 females), symptoms, therapy and phenotype were recorded. Seventeen (22%) patients had mild asthma, 55 (71%) moderate and five severe (6%). Twenty-six patients with asthma (34%) were asymptomatic, 34 (44%) developed symptoms but did not require hospital admission, and 17 (22%) were hospitalised. One patient was admitted because of asthma exacerbation without pneumonia or other symptoms. Ten patients (13%) had wheezes (six with pneumonia). Comparison of wheezing between patients with non-T2 asthma and the rest of the patients was statistically significant, (p Conclusions SARS-CoV-2 infection is not a significant cause of asthma exacerbation, although some patients may present wheezing, especially in cases of pneumonia. The severity of asthma does not seem to be associated with symptoms of the disease.

Background Efforts have been made to search for parameters that facilitate the prediction of the 3-month survival for clinical decisions in patients with malignant pleural effusion (MPE). We sought to evaluate whether the platelet-to-lymphocyte ratio (PLR) may be a useful marker of 3-month survival in a series of consecutive patients with MPE. Methods A total of 81 patients with MPE were included, 46 (57%) of whom were female. Twenty-six patients (32%) died during the first 3 months according to thoracentesis data. Results The area under the receiver operating characteristics curve was 0.73 for PLR. Using a cutoff point of 158, patients with higher PLR values experienced higher mortality at 3 months (p = 0.001). Conclusions PLR was able to successfully differentiate patients with different survival at 3 months. Outcomes of the PLR (a fast and inexpensive test) could be included among the prognostic factors able to guide the personalized management of MPE.

Introduction The prevalence of asthma in patients hospitalized with SARS-CoV-2 has been studied and varies widely in the different series. However, the prevalence in SARS-infected patients not requiring hospitalization is not known. The objective of this study was to analyze the presence of asthma in a consecutive series of patients who tested positive in the RT-PCR assay for SARS-CoV-2 and did not require hospital admission. Methods and results A total of 218 patients (58% of those who tested positive) did not require hospitalization; they had a median age of 45 years (IQR 34–57) and 57% were female. Six patients (2.8%) had a previous diagnosis of asthma. Only one patient developed a mild aggravation of asthma symptoms associated with SARS-CoV-2 infection. Conclusions Few patients with asthma were infected by SARS-CoV-2, and this infection was not a significant cause of asthma exacerbation.

Highlights • Hydroxychloroquine (HCQ) has been widely used to treat COVID-19 worldwide even without good evidence of efficacy. • We analyzed the changes occurring in the QTc interval and their predictors in patients treated with HCQ-containing regimens for COVID-19. • Evidence of myocardial injury with elevated troponin and strong inflammatory response, specifically higher neutrophil-to-lymphocyte ratio, were major contributors to moderate-to-severe QTc prolongation requiring careful QTc interval monitoring. • In this closely screened and monitored cohort, no complications derived from QTc prolongation were observed., This longitudinal, prospective cohort study aimed to assess risk of QTc interval prolongation and its predicting factors in subjects treated with combinations containing hydroxychloroquine (HCQ) for COVID-19. Moderate-to-severe QTc prolongation during therapy was defined as a QTc interval >470 ms in men or >480 ms in women. Patients were treated under strict cardiac supervision. A total of 105 adults were included [56% male; median (IQR) age 69 (57–79) years]. All patients received therapy with HCQ in combination with azithromycin (AZM), and 95 (90%) also with lopinavir/ritonavir (LPV/r). Concomitant medications classified as having risk of developing torsades de pointes (TdP) were simultaneously used in 81 patients (77%). Moderate-to-severe QTc prolongation was observed in 14 patients (13%), mostly at Days 3–5 from baseline, with 6 (6%) developing severe prolongation (>500 ms). There was no evidence of TdP arrhythmia or TdP-associated death. Adding LPV/r to HCQ+AZM did not significantly prolong the QTc interval. Multivariable Cox regression revealed that comedications with known risk of TdP (HR = 11.28, 95% CI 1.08–117.41), higher neutrophil-to-lymphocyte (NLR) ratio (HR = 1.10, 95% CI 1.03–1.18 per unit increase) and higher serum hs-cardiac troponin I (HR = 4.09, 95% CI 1.36–12.2 per unit increase) were major contributors to moderate-to-severe QTc prolongation. In this closely screened and monitored cohort, no complications derived from QTc prolongation were observed during pharmacological therapy containing HCQ for COVID-19. Evidence of myocardial injury with elevated troponin and strong inflammatory response, specifically higher NLR, are conditions requiring careful QTc interval monitoring.

Background: Pleural effusions due to heart failure are associated with a high 1-year mortality. Several hematological parameters have been shown to provide prognostic information in patients with cardiovascular diseases. The objective was to assess whether hematological markers can also provide prognostic information in patients with pleural effusion caused by heart failure. Methods: This was a retrospective study of patients with pleural effusion due to heart failure who underwent a diagnostic thoracentesis. The hematological parameters evaluated were as follows: neutrophils, lymphocytes, neutrophil-to-lymphocyte ratio, platelet count, platelet-to-lymphocyte ratio, mean platelet volume (MPV), and MPV-to-platelet ratio. Patients were divided into two groups: those who died within 1 year and survivors of more than 1 year. Differences and possible correlations were analyzed with non-parametric tests. Diagnostic values were estimated. Survival analysis was performed using the Kaplan-Meier method. Cox regression analysis was performed to identify independent variables. Results: Twenty five of 55 (45%) patients died within 1-year from thoracentesis. Patients who died in this period were older, aged 83 years (73 - 87, median and interquartile range, IQR) vs. 74 (65 - 82); with lower platelet count: 181 x 10(3) (140 - 258 x 10(3)) vs. 241 x 10(3) (198 - 324 x 10(3)); and higher MPV/platelet: 48.1 (34.9 - 75.6) vs. 35.6 (27.1 - 42.9). In the regression analysis only the MPV/platelet had statistical significance (p = 0.002). MPV/platelet > 50 had a specificity of 87% for 1-year mortality, and a ratio > 30 had a sensitivity of 84%. Conclusions: Simple hematological parameters such as platelet count and MPV/platelet, may provide useful prognostic information for predicting 1-year mortality in patients with pleural effusion due to heart failure.

Resumen El estudio bioquimico del liquido pleural es, con frecuencia, fundamental para el diagnostico de la etiologia del derrame. Existen parametros basicos que aportan informacion relevante de forma inmediata (pH, glucosa, proteinas, lactato deshidrogenasa, adenosina desaminasa). Pero tambien existen otras magnitudes bioquimicas que pueden permitir el diagnostico de determinadas causas de los derrames, como beta-2 transferrina, proteina-traza, creatinina, amilasa, bilirrubina, colesterol y trigliceridos o proteina C reactiva. Sin embargo, con frecuencia se solicitan al laboratorio numerosos parametros de dudosa utilidad. La relacion entre el medico asistencial y el laboratorio clinico es esencial para obtener la mayor rentabilidad diagnostica del analisis bioquimico en liquido pleural. Una adecuada seleccion de los parametros bioquimicos, a traves del conocimiento y de la informacion compartida, conlleva una mejor aproximacion diagnostica en el estudio del derrame pleural.

To identify the bacterial diversity (microbiota) in expectorated sputum, a pyrosequencing method that investigates complex microbial communities of expectorated sputum was done in 19 stable chronic obstructive pulmonary disease patients (mean (SD) FEV1: 47 (18%) of predicted value). Using conventional culture, 3 phyla and 20 bacterial genera were identified, whereas the pyrosequencing approach detected 9 phyla and 43 genera (p < 0.001). In sputum the prevalent genera with pyrosequencing approach were Streptococcus, Actinomyces, Neisseria, Haemophilus, Rothia, Fusobacterium, Gemella, Granulicatella, Porphyromonas, Prevotella and Veillonella. Enterobacteriaceae, detected frequently in conventional culture, were not significantly detected with pyrosequencing methods. In addition, we found that important pathogens such as Haemophilus and Moraxella were detected more frequently with the new genetic procedures. The presence of Enterobacteriaceae is probably overestimated with conventional culture, whereas other difficult cultivable pathogens are underestimated. These studies open a new perspective for evaluating the role of bacterial colonization in chronic obstructive pulmonary disease pathogenesis and progression.

To the Editor: The emergence of new massive sequencing methods has proved revolutionary for the study of complex microbial populations such as the microbiota of the respiratory tract in patients with chronic obstructive pulmonary disease (COPD) [1]. Using this powerful methodology, our objective was to compare the microbiota in two groups of patients with COPD of different severity in order to detect potential microbiological markers that could help to provide a better understanding of the pathogenesis of this disease and the role played by the microbiota in its severity. The current study recruited nine patients with mild or moderate COPD and 10 patients with severe or very severe COPD in a stable condition (at least 3 months without exacerbation or use of antibiotics for any other reason). Diagnosis and classification of COPD was established according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations [2]. After DNA extraction from good quality expectorated sputum, quantitative (q)PCR (7500 real time PCR system thermocycler; Life Technologies, Grand Island, NY, USA) was used to quantify the copy number of the 16S rRNA gene in each sample (total bacterial load), yielding a 468 bp amplicon located between nucleotides 340–808 in reference to the 16S rRNA gene of Escherichia coli strain MG1655 (National Center for Biotechnology Information (NCBI) reference sequence: NR_102804.1). In order to compare the results obtained, they were normalised to the number of human cells in the sample, quantified by qPCR, using the human albumin gene [3]. A region measuring 525 bp, between position 8 and 533 of the 16S rRNA gene was amplified and pyrosequenced (Roche GS FLX Titanium with Lib-L type microspheres; 454 Life Sciences, Branford, CT, USA). This region comprises the regions of gene hypervariability from V1 to V3 of the 16S rRNA gene …

MPE consists in the accumulation of fluid in the pleural space due to a malignant disease. MPE is a difficult to treat clinical condition which frequently results in severe symptoms like dyspnoea (that can be invalidating) or pain, and poor quality of live. The majority of MPE is caused by metastases from distant cancers, most commonly from the lungs and breast (1), but it is possible to occur in almost all types of cancer, and up to 15% of all patients with any malignant disease have an MPE (2). This condition affects 500–700 individuals per million population annually (3).

Molecular methods have been reported to have different sensitivities in the diagnosis of pleural tuberculosis and this may in part be caused by the use of different methods of DNA extraction. Our study compares nine DNA extraction systems in an experimental model of pleural tuberculosis. An inoculum of Mycobacterium tuberculosis was added to 23 pleural liquid samples with different characteristics. DNA was subsequently extracted using nine different methods (seven manual and two automatic) for analysis with real-time PCR. Only two methods were able to detect the presence of M. tuberculosis DNA in all the samples: extraction using columns (Qiagen) and automated extraction with the TNAI system (Roche). The automatic method is more expensive, but requires less time. Almost all the false negatives were because of the difficulty involved in extracting M. tuberculosis DNA, as in general, all the methods studied are capable of eliminating inhibitory substances that block the amplification reaction. The method of M. tuberculosis DNA extraction used affects the results of the diagnosis of pleural tuberculosis by molecular methods. DNA extraction systems that have been shown to be effective in pleural liquid should be used.

Resumen Introduccion El objetivo del estudio ha sido analizar la produccion cientifica espanola sobre tuberculosis durante una decada (1997–2006) y contextualizarla en el marco de la Union Europea (UE). Material y metodos Se ha realizado un estudio bibliometrico a traves de la base de datos MEDLINE via PubMed, mediante la busqueda de “ tuberculosis ” o “ tuberculous ” en cualquier campo de la base de datos. Resultados Se recopilaron 35.735 documentos que trataban sobre tuberculosis, de los cuales 1.191 (el 4,1% de la produccion mundial) fueron publicados por autores espanoles. Espana fue el tercer pais con mas documentos de la UE, con el 13,5%. El 51,2% (n=610) se publicaron en ingles y el 48,8% (n=581) en espanol. El numero de documentos fue constante a lo largo de los anos. La especialidad del primer firmante mas frecuente fue microbiologia, con 225 documentos (20,6%), seguida de medicina interna (n=154; 14,1%) y neumologia (n=117; 10,7%). Las revistas con un mayor numero de documentos publicados fueron Medicina Clinica y Enfermedades Infecciosas y Microbiologia Clinica , con 78 (6,5%) cada una, Anales de Medicina Interna (n=72), Revista Clinica Espanola (n=64) y Archivos de Bronconeumologia (n=63). Las provincias mas productoras fueron Madrid y Barcelona, con 272 (22,8%) y 256 (21,5%) documentos publicados, respectivamente. Las instituciones mas productivas fueron los hospitales, con 900 documentos (75,6%), seguidos de las universidades, con 132 (11,1%). Conclusiones La investigacion sobre tuberculosis en Espana ha sido constante a lo largo de los ultimos 10 anos y ha supuesto una aportacion importante en el conjunto de la UE. La mitad de las publicaciones espanolas se hicieron en revistas extranjeras y procedian predominantemente de los hospitales.

Mycobacterium chelonae is one of the most antibiotic-resistant species of the pathogenic, rapidly-growing mycobacteria. The objective of this study was to evaluate the bactericidal activity of classical and new potential drugs, alone and in combinations, against clinical isolates of Mycobacterium chelonae. Clarithromycin was seen to be the most bactericidal drug. In drug combinations, this compound is most useful with gentamicin, fluoroquinolones, rifampicin, linezolid, other aminoglycosides, doxycyline and carbapenems. The combination of tobramycin with ciprofloxacin or moxifloxacin also exhibits similar activity. In conclusion, this study on bactericidal activity of drug combinations against Mycobacterium chelonae confirms the utility of clarithromycin associated with other drugs, and, of the new drugs, the value of moxifloxacin and linezolid.

SummaryRed cell macrocytosis has been frequently described in hypoxemic patients with chronic obstructive pulmonary disease (COPD). However, macrocytosis is not related to hyoxemia. The objective of this study was to determine the frequency of macrocytosis (defined as mean corpuscular volume (MCV) higher than 94fl) in stable COPD patients without respiratory insufficiency, and to analyze the possible relationship between its presence and clinical and functional parameters. Fifty-eight consecutive patients with COPD, and without other significant comorbid conditions, were included in the study. Macrocytosis was present in 17 of the 58 stable COPD patients (29%). The differences between patients with and without macrocytosis were not statistically significant, except for MCV. In the subgroup of 36 ex-smoker COPD patients, macrocytosis was present in nine patients (25%). In this subgroup, MCV significantly correlated with dyspnea (r=0.36, P=0.03) and forced expiratory volume in 1s (FEV1) (r=−0.35, P=0.03). We conclude that macrocytosis is a frequent finding in stable non-hypoxemic COPD patients, and that in ex-smoker patients the degree of macrocytosis is associated with a worse clinical situation in terms of dyspnea and FEV1.

Objective: Our aim was to study the influence of efflux pump systems in the resistance of Mycobacterium tuberculosis to fluoroquinolones and linezolid. Methods: We studied the mutations in gyrA and gyrB genes and the influence of efflux pump systems with 2 inhibitors (reserpine and MC 207.110). Results: The effect of the active efflux system on the decrease in sensitivity to ciprofloxacin, moxifloxacin, levofloxacin, ofloxacin, gatifloxacin and linezolid was studied by investigating the variation in the in vitro activity of these compounds when assayed in association with reserpine and MC 207.110. These inhibitors exhibit activity both in strains that are resistant and in strains that are susceptible to these antibiotics. However, they are seen to be most active in resistant strains, since the minimum inhibitory concentration of the antibiotics studied in these strains was reduced between 2- and 6-fold. Conclusions: Therefore, these mechanisms are involved in the resistance to both compounds. It would be of interest to carry out further studies to determine to what extent these active efflux systems influence resistance to the different groups of drugs used in the treatment of tuberculosis, with a view to the possibility of using the inhibitors of these systems in future therapeutic applications.

Purpose of review The presence of urine in the pleural space (urinothorax) is a rarely recognized cause of pleural effusion. To date, only 58 cases have been reported. In this article the features of urinothorax are analyzed, and clinical and biochemical characteristics are reviewed in order to propose a classification, founded on pathogenic criteria, that will be useful in achieving the diagnosis. Recent findings Recently reported cases of urinothorax provide a more detailed description of the biochemical characteristics that allow a better understanding of this entity. Summary Urinothorax can be divided into two categories: (1) obstructive urinothorax, due to bilateral obstructive uropathy; and (2) traumatic urinothorax, due to unilateral traumatic injury of the urinary system, mostly iatrogenic. In patients with urinothorax, the pleural effusion usually has the biochemical characteristics of a transudate, with a pH lower than 7.30 and a pleural fluid/serum creatinine ratio higher than 1. These characteristics are not always present, however, and individually are shared by a significant number of pleural effusions of different etiology.

Hoover's sign (the inward motion of the lower lateral rib cage with inspiration) is conventionally considered to be a sign of severe disease in chronic obstructive pulmonary disease (COPD). However, no studies have been done regarding the frequency of Hoover's sign in patients with stable COPD. We aim to establish the frequency of Hoover's sign in a large series of stable patients with COPD and to analyse the characteristics associated with its presence. One hundred and fifty-seven consecutive patients with COPD, 150 of whom were men (95%), with a mean (standard deviation) age of 68 (8) years were included. Seventy-one patients had Hoover's sign (45%) on clinical examination. Hoover's sign was not detected in mild COPD patients, and it was present in 36% of moderate, 43% of severe and 76% of very severe COPD patients. In the multivariate analysis, dyspnea, body mass index (BMI), number of exacerbations and number of prescribed drugs were independently associated with the presence of Hoover's sign in COPD. Hoover's sign is a frequent finding in COPD, and the frequency increases with severity. Its presence is independently related to higher values of dyspnea, BMI, number of exacerbations and number of prescribed drugs.

Background:C-reactive protein (CRP) pleural fluid levels have been found to be higher in tuberculosis and parapneumonic effusions than in other causes of pleural effusion. Objective:The aim of this study was to analyze whether CRP (a simple and inexpensive test) may be a diagnostic aid for tuberculosis in lymphocytic pleural effusions. Methods:One hundred and forty-four patients with a lymphocytic pleural effusion (more than 50% lymphocytes in the differential white blood cell count) were included. The patients were 93 men (65%) and 51 women (35%), aged 64 ± 18 years (mean ± SD). The diagnoses were as follows: tuberculosis, 20; pleural effusion associated with malignancy, 69; transudates, 38; other benign exudates, 17. Results: The CRP pleural fluid level was higher in tuberculous pleuritis (54 ± 24 mg/l) than in lymphocytic effusions of other origin (21 ± 16 mg/l; p < 0.001). High CRP levels (≧50 mg/l) have a high specificity for tuberculosis (95%), and low levels (Conclusions: CRP pleural fluid level determination is useful in the diagnostic workup of lymphocytic pleural effusions. High CRP levels are very suggestive of tuberculous pleuritis, and low CRP levels make this diagnosis unlikely.

AIM: To investigate whether the measurement of arterial oxygen saturation (SpO(2)) with pulse oximetry can identify those patients for whom spirometric screening for COPD would be useful, and those patients for whom spirometric assessment would not be useful. METHODS: Two hundred and ten patients, aged over 40, without significant dyspnoea, referred by their primary care physicians to the outpatient pulmonary clinic. The value of SpO(2) was recorded with a finger clip pulse oximeter sensor. Diagnostic values were obtained in order to diagnose COPD (defined as an FEV(1)/FVC ratio

Study objective To evaluate the diagnostic accuracy of Hoover sign for detecting obstructive airway disease (OAD), compared with wheezes, rhonchi, reduced breath sounds, and clinical impression, and to analyze the observer agreement on these signs. Design Prospective, blind comparison, with a reference standard (spirometry) among a consecutive series of patients. Setting Outpatient pulmonary clinic. Patients One hundred seventy-two patients (117 men [68%] and 55 women [32%]), who were > 40 years of age, had not been known previously by the participating physicians, and met at least one of the following criteria: smokers of > 20 pack-years; patients who had received a diagnosis of or had self-reported COPD (or chronic bronchitis or emphysema); patients who had received inhaler bronchodilator treatment for > 6 months; or patients with any degree of dyspnea. Measurements Patients were examined by a first-year resident in family medicine and by a pulmonologist. Spirometry was performed by a blinded trained technician. OAD was defined as an FEV 1 /FVC ratio of Results OAD was present in 64 patients (37%). Observer agreement (κ statistic) was 0.74 for Hoover sign and was lower for the rest of the signs. Hoover sign had a sensitivity of 58% and a specificity of 86% for detecting OAD, and it had a positive likelihood ratio of 4.16, which was higher than that of the other signs. Conclusions Hoover sign, a frequently forgotten sign, is easy to recognize and is useful for detecting OAD.

BACKGROUND: Tests able to help in the diagnostic work-up of pleural exudates are needed. C-reactive protein (CRP) may be useful for distinguishing between benign and malignant exudates. METHODS: A total of 123 consecutive patients diagnosed as having exudative pleural effusion (60 associated with malignancy and 63 benign effusions) were included in the study. Sensitivity, specificity, positive and negative predictive values (PV+, PV-), and positive and negative likelihood ratios (LR+, LR-) were established at different cut-off points. RESULTS: Pleural fluid CRP level was 23+/-12 mg/l (mean+/-S.D.) in pleural exudates associated with malignancy and 50+/-33 mg/l in benign effusions (P0.001). With a cut-off point below 20 mg/l for malignancy, sensitivity of CRP was 0.50, specificity 0.89, PV+ 0.81, PV- 0.65, LR+ 4.50, and LR- 0.65. With a cut-off point above 45 mg/l for benign diseases, sensitivity was 0.44, specificity 0.95, PV+ 0.90, PV- 0.62, LR+ 8.89, and LR- 0.58. CONCLUSIONS: The pleural CRP level provides useful information for the study of pleural exudates. A level below 20 mg/l suggests a malignant origin and a level above 45 mg/l virtually rules out this possibility. Additional advantages of measuring CRP level are that it is an inexpensive test and is easy to perform.

To compare the bactericidal activity of various fluoroquinolones against Mycobacterium tuberculosis in the latent and exponential growth phases.Ciprofloxacin, levofloxacin and moxifloxacin were tested against 16 M. tuberculosis clinical isolates (4 resistant and 12 susceptible to fluoroquinolones) from Elche, Spain, isolated between 1992 and 2009. To study bactericidal activity, an inoculum of approximately 10(5) cfu of each isolate was cultured in Middlebrook 7H9 broth. The broth was previously acidified to pH 4.6 to obtain the microorganism in the stationary phase. Cultures with different concentrations (0.1 to 50 mg/L) of antibiotic and antibiotic-free controls were incubated for 48 h then plated onto Middlebrook 7H11 to detect bacterial killing. In all stages of the process the M. tuberculosis strain ATCC 41323 was included as a quality control to ensure reproducible results.Moxifloxacin and levofloxacin were found to exhibit bactericidal activity at lower concentrations and against more strains in both the latent and the exponential growth phases compared with ciprofloxacin. The bactericidal activity of moxifloxacin was greater than that of levofloxacin against microorganisms in the exponential growth phase, but the opposite was true in the latent phase.Our data confirm the usefulness of moxifloxacin in the treatment of tuberculosis and suggest that levofloxacin may be used as an alternative drug in the treatment of latent tuberculosis when it is not possible to use isoniazid. Based on the results presented, ciprofloxacin appears to be a poor choice.