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Influenza virus infection (IVI) is typically subclinical or causes a self-limiting upper respiratory disease. However, in a small subset of patients IVI rapidly progresses to primary viral pneumonia (PVP) with respiratory failure; a minority of patients require intensive care unit admission. Inherited and acquired variability in host immune responses may influence susceptibility and outcome of IVI. However, the molecular basis of such human factors remains largely elusive. It has been proposed that homozygosity for IFITM3 rs12252-C is associated with a population-attributable risk of 5.4 % for severe IVI in Northern Europeans and 54.3 % for severe H1N1pdm infection in Chinese. A total of 148 patients with confirmed IVI were considered for recruitment; 118 Spanish patients (60 of them hospitalized with PVP) and 246 healthy Spanish individuals were finally included in the statistical analysis. PCR-RFLP was used with confirmation by Sanger sequencing. The allele frequency for rs12252-C was found to be 3.5 % among the general Spanish population. We found no rs12252-C homozygous individuals in our control group. The only Spanish patient homozygous for rs12252-C had a neurological disorder (a known risk factor for severe IVI) and mild influenza. Our data do not suggest a role of rs12252-C in the development of severe IVI in our population. These data may be relevant to recognize whether patients homozygous for rs12252-C are at risk of severe influenza, and hence require individualized measures in the case of IVI.

The inflammatory response depends on several factors, including pathogenicity and duration of the stimulus, and also on the balance between inflammatory and antiinflammatory response. Several studies have presented evidence of the importance of genetic factors in severe infections. The innate immune response prevents the invasion and spread of pathogens during the first hours after infection. Each of the different processes involved in innate immunity may be affected by genetic polymorphisms, which can result in susceptibility or resistance to infection. The results obtained in the different studies do not irrefutably prove the role or function of a gene in the pathogenesis of respiratory infections. However, they can generate new hypotheses, suggest new candidate genes based on their role in the inflammatory response, and constitute a first step in understanding the underlying genetic factors.

La respuesta inflamatoria del huesped viene determinada por la virulencia del microorganismo, la duracion del estimulo y el equilibrio entre la respuesta inflamatoria y la antiinflamatoria. Diversos estudios han mostrado la importancia de la genetica en las infecciones graves. La respuesta inmune innata es el mecanismo que impide la invasion y propagacion de microorganismos durante las primeras horas tras la infeccion. Cada uno de los procesos implicados en la respuesta innata puede alterarse por polimorfismos de los genes implicados, pudiendo esto resultar en una mayor susceptibilidad o resistencia a la infeccion. Los resultados obtenidos en los diferentes estudios geneticos no prueban de forma irrefutable el papel o la funcion de un gen en la patogenesis de la infeccion respiratoria. Sin embargo, permiten generar nuevas hipotesis, indican nuevos genes candidatos en base a su papel en la respuesta inflamatoria y proporcionan el primer paso en la comprension de los factores geneticos subyacentes.

Resumen Todas las actuaciones médicas tienen una curva de aprendizaje, pero el razonamiento clínico se mantiene como un elemento clave en cualquiera de ellas. Los médicos experimentados manejan una gran cantidad de información en cualquier proceso clínico. Para conseguir la máxima eficiencia en la utilización de esta información, los clínicos emplean una serie de estrategias que les permiten combinar datos y sintetizarlos en un número reducido de hipótesis diagnósticas, evaluar los riesgos y los beneficios de realizar nuevos procedimientos diagnósticos y aplicar determinados tratamientos, y formular planes en el manejo del paciente. Uno de los objetivos principales de cualquier docente médico es promover el desarrollo de una forma de razonar experta en sus estudiantes. Sin embargo, enseñar estas habilidades cognitivas no es tarea sencilla porque no existe una teoría completa y ampliamente aceptada acerca de los procesos de razonamiento clínico, e incluso los médicos más experimentados a menudo no son conscientes de los métodos de razonamiento que utilizan para alcanzar un diagnóstico. Desde hace más de cuarenta años se ha investigado en este campo. En este artículo se revisan las bases científicas y las teorías propuestas a lo largo de este período acerca del modo de razonar de los clínicos. También se analiza la evolución de las estructuras del conocimiento y se examinan algunos errores frecuentes en razonamiento diagnóstico. Por último, se proponen algunas recomendaciones prácticas específicas para ayudar a los principiantes a fortalecer sus habilidades de razonamiento diagnóstico.

The worldwide variation in asthma prevalence prompted us to carry out a study to assess the variability of asthma-related symptoms in young adults on the islands of Gran Canaria and Tenerife. We used the questionnaire used in the European Community Respiratory Health Survey with the addition of two questions on smoking and ancestors from the Canary Islands. In each island, this questionnaire was distributed to a random sample of 5000 subjects aged 20-44 years. Of the 10,000 subjects, 9,506 (95.06%) were considered eligible. We obtained 7,132 (75.03%) responses. The prevalence of the different symptoms was wheezing 25.3%, nocturnal thoracic tightness 18.0%, awakened by an attack of shortness of breath 13.1%, attack of nocturnal coughing 33.3%, attack of asthma 4.3%, current asthma treatment 6.2%, and nasal allergies 18.0%. Women and smokers showed a significantly higher prevalence of asthma symptoms. No significant difference in symptoms was found between subjects whose ancestors were of Canarian origin and those with ancestors born outside the Canaries. As has been observed on other islands (Great Britain and New Zealand), asthma is common in individuals from 20 to 44 years of age in the Canaries. We hypothesize that climatic conditions play an important role in the prevalence of asthma symptoms.

Hay algunas observaciones clinicas que han llamadola atencion de los medicos desde hace siglos, y una deellas ha sido la variabilidad individual en la susceptibili-dad a presentar enfermedades infecciosas y en la grave-dad de estas. Existen datos historicos de las epidemiasde peste que asolaron Europa en el siglo

In recent years several population based studies using restriction fragment length polymorphism (RFLP) analysis have shown a higher rate of recent transmission of tuberculosis than previously thought. This study was undertaken to determine the transmission patterns of tuberculosis and the potential causes of recent transmission on the island of Gran Canaria (Spain).The strains of all patients diagnosed with tuberculosis confirmed by culture between 1 January 1993 and 31 December 1996 were typed by RFLP using the insertion sequence IS6110. A cluster was defined as two or more isolates with an identical RFLP pattern. Epidemiological linkage through contact tracing was investigated.Of the total of 719 patients, 153 (21.3%) were excluded because there was inadequate bacterial DNA for genotyping (n=129) or the isolates of Mycobacterium tuberculosis had less than five copies of IS6110 (n=24). The isolates from 409 patients (72.3%) were grouped into 78 different clusters with an estimated 58.5% of the cases being due to recent transmission. Young age was the only significant predictor of clustering. Only in 147 (35.9%) of the 409 patients belonging to a cluster could an epidemiological link be found. 111 patients (19.6%) were identified as having had previous contact with a tuberculosis patient and 81 of them (72.9%) belonged to a cluster. The three largest clusters included 75, 49 and 20 patients, respectively.Recent transmission is frequent among patients with tuberculosis on Gran Canaria and could be associated with certain aspects of control measures. Some of the clusters described in the study could be due to the prevalence of particular strains of M tuberculosis on the island.

To validate our experience with standard cervical mediastinoscopy (SCM) and extended cervical mediastinoscopy (ECM) to diagnose mediastinal nodes and masses, we studied 181 patients between January 1992 and February 2001. SCM and ECM were indicated for diagnostic staging of nodes related to bronchogenic carcinoma (Group I) or of mediastinal masses (Group II). An SCM was performed in all cases to explore the paratracheal region (2R, 2L, 4R, 4L, 7, 10R and 10L); in 21 additional cases, an ECM was performed to explore the aortopulmonary window or the subaortic region (area 5) and the para-aortic region (area 6). In Group I, the sensitivity of SCM was 93.6% and specificity was 100%; the positive predictive value (PPV) was 100%, the negative predictive value (NPV) was 82.8%, and the diagnostic yield was 95.1%. The sensitivity of ECM was 91% and specificity was 100%; PPV was 100%, NPV 93.3% and yield was 96%. In Group II, the sensitivity was 93.3%, specificity 100%, PPV 100%, NPV 81.2% and diagnostic yield 94.8%. The sensitivity of ECM in this group was 80%, specificity was 100%, PPV 100%, NPV 66.7% and yield 85.7%. A 2.7% complication rate was observed, with one case of bleeding after injury to the superior vena cava, one tracheal lesion, one recurring paralysis and two cases of surgical wound infection. The mean postoperative stay was 36 hours and mortality was zero. We conclude that SCM is highly specific for the evaluation of mediastinal node involvement in bronchogenic carcinoma and it is the approach of choice when a diagnosis of lesions located in the mid-mediastinal region has not been reached. ECM is a valid, safe alternative to anterior mediastinotomy for staging nodes and masses occupying para-aortic zones or the aortopulmonary window, with good diagnostic yield, low morbidity and absence of mortality.

Introduccion Se presenta un estudio prospectivo multicentrico cuyo principal objetivo es conocer los datos sobre indicaciones, tecnicas, resultados y complicaciones de pacientes sometidos a cirugia videotoracoscopica (CTV) Metodo Han participado en el estudio 17 servicios de cirugia toracica, que en un periodo de 2 anos (julio de 1996 a julio de 1998) han recogido 1.573 procedimientos Resultados Mas del 80% de las indicaciones estuvieron constituidas por neumotorax espontaneo (45,4%), biopsia pulmonar (18,4%), nodulos pulmonares (13,3%) y simpatectomia toracica (5,3%). En el 5,6% de los casos se requirio una minitoracotomia de asistencia. En 167 casos (10,6%) fue precisa la conversion a toracotomia estandar. Hubo algun tipo de complicacion en el 10,8% destacando las fugas aereas persistentes. Hubo recidiva de los neumotorax espontaneos en 17 casos (2,4%). Fallecieron 10 pacientes (0,6%) Conclusiones La evolucion tecnologica ha hecho aparecer nuevas indicaciones de la CTV y ha mejorado los resultados de las indicaciones mas corrientes y bien establecidas. Es aconsejable seguir realizando trabajos controlados, prospectivos y aleatorizados para validar las tecnicas en las que dispone de una menor experiencia

Francisco Alvarez-Lerma, Antonio Torres, Felipe Rodriguez de Castro y la Comision de Expertos del Grupo de Trabajo de Enfermedades Infecciosas de la Sociedad Espanola de Medicina Intensiva, Critica y Unidades Coronarias (GTEI-SEMICYUC ), Area de Trabajo de Tuberculosis e Infecciones Respiratorias de la Sociedad Espanola de Patologia del Aparato Respiratorio (SEPAR) y Grupo de Estudio de Infeccion Hospitalaria de la Sociedad Espanola de Enfermedades Infecciosas y Microbiologia Clinica (GEIH-SEIMC)

El area de trabajo de Tuberculosis e Infecciones Respiratorias de la Sociedad Espanola de Patologia del Aparato Respiratorio (ATTIR-SEPAR), el Grupo de Estudio de Infeccion Hospitalaria de la Sociedad Espanola de Enfermedades Infecciosas y Microbiologia Clinica (GEIH-SEIMC) y el grupo de Trabajo de Enfermedades Infecciosas de la Sociedad Espanola de Medicina Intensiva, Critica y Unidades Coronarias (GTEI-SEMICYUC) han elaborado unas recomendaciones para homogeneizar los criterios de sospecha de las neumonias asociadas con ventilacion mecanica (NAV), las tecnicas utilizadas para la obtencion de muestras respiratorias, los procedimientos microbiologicos complementarios y los criterios de diagnostico definitivo, en el marco de los pacientes ventilados en las unidades de cuidados intensivos multidisciplinarias o de especialidad (quemados, respiratorios, quirurgicas) de nuestro pais. El objetivo de dichas recomendaciones ha sido definir unos criterios minimos, basados en evidencias cientificas y en la opinion de 22 expertos pertenecientes a las 3 sociedades cientificas anteriores, de facil aplicacion para la mayoria de medicos que atienden a pacientes criticos con ventilacion mecanica en nuestro pais.

We studied the cases of three siblings with a history of chronic bronchitis and infertility. The electron-microscopic investigation of the tracheal and bronchial biopsies showed a ciliary defect consisting in the absence of the central microtubules and the transposition of a peripheral doublet. This is a rare and infrequently reported abnormality included in the primary ciliary diskinesia syndrome.

Thoracotomy is used to approach and treat anterior spinal lesions arising from various causes. Between 1990 and 1997, we treated 56 patients (40 men and 16 women) between 14 and 67 years old (mean 38.4). All had spinal lesions that were impossible or difficult to reach by a posterior approach. Thirty-one (55.3%) had suffered spinal damage, 8 (14.3%) had spinal deformities, 7 (12.5%) had metastatic tumors, 5 (8.9%) had herniated discs, 4 (7.1%) had Pott's disease and 1 (1.8%) had osteolysis at D6. Thoracotomy was left-sided in 35 cases (62.5%) and right-sided in 19 (33.9%). Video-assisted thoracoscopy was used twice (3.6%). The level of incision was based on the site of the lesion, and the pleural cavity was opened in all cases except one. The posterolateral pleuro-diaphragmatic fold was dissected and the diaphragm opened for retroperitoneal access in 37 cases (66.1%) of thoracolumbar disease. Orthopedic treatment consisted of autologous bone grafts in all cases and placement of a Kaneda splint in 32 cases (57.1%). One patient had to undergo surgery a second time due to inappropriate placement of the vertebral splint. Pneumothorax occurred in one patient after removal of pleural drains. The incision became infected in one patient, and one case of ileal paralysis was observed. Overall, morbidity was 7.1%. We conclude that thoracotomy offers a good alternative approach to spinal lesions. Results are good and morbidity low.

The inflammatory response depends on several factors, including pathogenicity and duration of the stimulus, and also on the balance between inflammatory and antiinflammatory response. Several studies have presented evidence of the importance of genetic factors in severe infections. The innate immune response prevents the invasion and spread of pathogens during the first hours after infection. Each of the different processes involved in innate immunity may be affected by genetic polymorphisms, which can result in susceptibility or resistance to infection. The results obtained in the different studies do not irrefutably prove the role or function of a gene in the pathogenesis of respiratory infections. However, they can generate new hypotheses, suggest new candidate genes based on their role in the inflammatory response, and constitute a first step in understanding the underlying genetic factors.

The real contribution of the protected specimen brush (PSB) to guide the choice of antimicrobial therapy in ventilated patients with severe pneumonia is not well established. This study aimed to assess how data obtained by PSB changed the initial empirical therapy. One hundred and ten ventilated patients with suspected pneumonia were entered into a prospective study. All patients underwent fibreoptic bronchoscopy within the first 24 h after clinical suspicion of pneumonia. Specimens were obtained by PSB and were processed for quantitative cultures using standard methods. When patients were started on empirical antibiotics, a standard therapeutic regimen was followed. The decision to introduce, withdraw, maintain, or modify antibiotic therapy, according to the PSB culture results, was left to the attending physician. Pneumonia was the final diagnosis in 45 (41%) of the 110 patients. Pneumonia was excluded in 47 (43%) patients and in the remaining 18 (16%) the diagnosis was uncertain. The initial therapeutic plans were considered to be adequate in 40 patients (36%) and inadequate in 37 cases (34%). In 17 patients (15%), therapeutic changes were made based on the results of PSB cultures. In one case appropriate antibiotics were introduced; in nine cases the therapeutic regimen was reduced to select a narrower and rational therapy; and in seven patients therapy was changed because the prescribed antimicrobial agents were ineffective against the organisms recovered. This study shows that therapeutic changes were made based on the results of PSB cultures in 38% of the patients with pneumonia. In contrast, the PSB technique has no impact on antimicrobial therapy of patients without pneumonia.

espanolTodos los paises, cualquiera que sea su grado de desarrollo, se esfuerzan por proporcionar unos cuidados sani- tarios adecuados a sus ciudadanos. Gozar de buena salud es una condicion basica para el desarrollo y la seguridad de las personas, a pesar de lo cual persisten enormes desigualdades en salud entre los paises. Los educadores medicos tienen un papel clave en la reduccion de estas desigualdades al abordar uno de los aspectos esenciales del problema: la acusada escasez de medicos que sufren algunas regiones, especialmente en el Africa subsahariana. Una de las mayores dificulta- des para afrontar esta cuestion es la falta de profesores cualificados, lo que podria solventarse mediante estancias cortas de graduados procedentes de paises desarrollados que voluntariamente quisieran participar en este tipo de iniciativas. Pero el mundo de la educacion medica tampoco es un terreno justo, equilibrado y equitativo, y trabajar en paises pobres y alejados supone un reto importante. En este articulo, presentamos la experiencia en el diseno y desarrollo de un proyec- to de formacion de medicos en la Universidad de Zambeze, en Tete (Mozambique), llevada a cabo desde la Universidad de Las Palmas de Gran Canaria EnglishEvery nation –rich or poor and developed or developing– strives hard to deliver optimal healthcare to its citizens. Good health is the necessary condition for development and human security, but inequities in health persist. Medical educators have a key role to play in reducing inequities in global health by addressing the underlying doctor shortages that have reached crisis levels in some regions. The region in which these health inequities and doctor deficiencies are starkest is sub-Saharan Africa. In poor countries, a major constraint to approach this issue is the scarcity of qualified teachers. One of the options is the short-term placement of graduates from rich countries seeking opportunities to contribute in other countries that are severely deficient in faculty. But the world of medical education is not a level playing field and working in developing countries, and in remote areas in particular, can be challenging. In this article we show a recent experience carried out at the University of Las Palmas de Gran Canaria designing and supporting a project on undergraduate medical education at the University of Zambeze, in Tete, Mozambique

Setting: Since there is no national programme for tuberculosis control in Spain and the epidemiological situation in this country is unknown, a programme against tuberculosis in Gran Canaria (Canary Islands) was started in 1987. Objective: To analyze the impact of this control programme, particularly the trend of new cases of tuberculosis by age groups and risk factors for 1988-92. Design: A detailed search of all new cases of tuberculosis was carried out by examining the files of all public and private hospitals and outpatient clinics of the island, the records of the Services of Clinical Microbiology and Pathology of the public hospitals, and the registers of patients with AIDS. Results: The annual rates of new cases of tuberculosis per 100 000 were 32.2 in 1988 (214 cases), 26.2 in 1990 (174 cases), and 29.4 in 1992 (196 cases), and the rates of sputum-positive cases 13.3 (89 cases), 12 (80 cases) and 15 (100 cases), respectively. The distribution of tuberculosis cases by age peaked in the age groups 40–49 and 30–39 years. Between 1988 and 1992, statistically significant differences were found in the percentage of cured patients (21% [ 45 214 ] vs 85.7% [ 168 196 ]), patients with a delay in diagnosis > 3 months (40.2% [ 86 214 ] vs 21.9% [ 43 196 ]), and contacts evaluated (45.3% [ 97 214 ] vs 90.3% [ 177 196 ]). However, an upward trend in the incidence of tuberculosis for 1990-92 was found in association with an increase of new cases among the homeless, immigrants, and HIV-infected people. When these three population groups were excluded from the analysis, the annual rate for the total population showed a progressive decline from 1988-92. Conclusions: The data studied here show that successful priority control measures (cure rate, early diagnosis, study of contacts) have been achieved in this island. It is necessary, however, to develop strategies for combating the tuberculosis problem in specific high risk populations.

Con la finalidad de revisar nuestra experiencia en el tratamiento del neumotorax espontaneo primario (NEP), realizamos un estudio retrospectivo sobre los pacientes intervenidos en nuestro servicio por dicha patologia entre los anos 1986 y 1993. Los 495 casos tratados tenian edades comprendidas entre los 12 y 81 anos, con una media de 28,2. En 415 ocasiones (83,8%) fueron varones y en 80, mujeres (16,2%). En 262 se trataba de NEP derecho (52,9%) y en 215, izquierdo (43,5%). En 18 (3,6%) los episodios de NEP fueron bilaterales. El tratamiento inicial fue el drenaje pleural y se utilizaron en 85 casos drenajes de pequeno calibre. No existio morbilidad de los drenajes pleurales. La persistencia de fugas aereas, la recidiva y el sangrado agudo fueron indicaciones de tratamiento quirurgico, que se realizo en 185 ocasiones (37,3%). En 15 casos (8,1%) hubo complicaciones posquirurgicas. No existieron recidivas postoperatorias ni mortalidad. No hubo diferencias significativas en cuanto a recidivas de los drenajes convencionales y los de pequeno calibre. Tampoco las hubo en estancia media y complicaciones en la cirugia convencional y la videoasistida, de reciente introduccion. Se concluye que el NEP es una entidad que responde bien al tratamiento con drenaje pleural, constituyendo los drenajes de pequeno calibre una buena alternativa para el tratamiento de los primeros episodios de NEP. La intervencion quirurgica se indica en caso de recidiva o persistencia de fugas aereas. En la actualidad, la cirugia toracoscopica videoasistida sustituye con exito a la toracotomia axilar en la mayoria de ocasiones.

We review our experience of transbronchial fine needle aspiration (TBFNA) over a 3-year period. A total of 112 TBFNAs were performed on 95 patients. Four aspirates were from peripheral lung lesions, 20 from non-ulcerated submucosal infiltrative lesions, 19 from mediastinal abnormalities close to the tracheobronchial tree, and the remaining 69 were for staging of bronchogenic carcinoma with apparent mediastinal lymph node spread, evaluated by chest computed tomography (CT). In the 20 submucosal lesions TBFNA reached a sensitivity of 82.3%, providing the only evidence of a malignant process in five cases. With respect to the 19 mediastinal lesions arising in close proximity to the central airways, TBFNA permitted a diagnosis in cases that would otherwise have required more invasive procedures, although the diagnostic sensitivity of the technique in this group of patients was poor (26%). In the mediastinal staging group, the sensitivity was 76.9%, with no false positive results. Complete sensitivity of TBFNA for the detection of disease was 65.8%. We conclude that TBFNA is a reliable and low risk procedure.

The role of mannose-binding lectin (MBL) deficiency (MBL2 XA/O + O/O genotypes) in host defences remains controversial. The surfactant proteins (SP)-A1, SP-A2 and SP-D, and other collectins whose genes are located near MBL2, are part of the first-line lung defence against infection. We analyzed the role of MBL on susceptibility to pneumococcal infection and the existence of linkage disequilibrium (LD) among the four genes.

We have studied the diagnostic reliability of the specific skin tests done in 30 subjects who presented with chronic bronchitis (CB) as the only clinical manifestation related to exposure to pigeons and in 21 subjects with CB and known risk factors. Additionally, two control groups were included (24 asymptomatic subjects exposed and sensitized to pigeons and 10 subjects not exposed and not sensitized to pigeons). The skin prick tests with pigeon serum were negative in all the subjects tested. The intradermal skin tests showed an immediate positive reaction in 16 of the 30 CB-affected patients and in six of the control group of exposed asymptomatic subjects (chi square: 3.376) (P < 0.1; nearly significant); after 6 h, a positive reaction was recorded in 14 of the CB-affected patients and in three subjects of the control group (chi square: 5.187) (P < 0.005). A delayed reaction was seen in 10/30 CB patients and in only three of the 24 subjects of the control group (chi square: 2.218) (nonsignificant). In the group of the 21 CB patients with known risk factors and not sensitized to pigeons, only two patients showed immediate skin reactivity; the remaining readings were negative. Lastly, in the control group of 10 unexposed, nonsensitized subjects, the intradermal skin tests in the different readings were negative. Our results show that although the skin tests with pigeon serum have low sensitivity, they can be a useful supplement in distinguishing cases of CB attributable to chronic pigeon exposure from those cases attributable to another cause, especially in the consideration of immediate and late readings.

Con el objetivo de analizar la rentabilidad del lavado broncoalveolar (LBA) en el diagnostico microbiologico convencional de la tuberculosis (TB) y de otras micobacteriosis, y su necesidad o no de incorporarlo como tecnica de rutina en el diagnostico de estas afecciones, se ha realizado un estudio sobre 30 enfermos afectados de micobacteriosis (26 TB y 4 infecciones por Mycobacterium avium-intracellulare ) a los que se realizo broncoscopia y se disponia a la vez de estudio bacteriologico de LBA y broncoaspirado (BAS). Los resultados se compararon con los obtenidos en el esputo pre y posbroncoscopia en los enfermos en que se disponia de estas muestras. La rentabilidad conjunta del cultivo del LBA y del BAS fue del 90%. La obtenida con el LBA (83,3%) fue superior a la aportada por el BAS (73,3%), porcentajes muy superiores al 53,8% proporcionado por el cultivo del esputo prebroncoscopia y al 60% obtenido en el esputo posbroncoscopia. Ademas, el LBA fue la unica muestra diagnostica en 7 enfermos, mientras que el BAS solo lo fue en cuatro. La sensibilidad del cultivo era similar con las 2 micobacterias estudiadas. Sin embargo, la rentabilidad de la baciloscopia directa era muy baja; se situo en el 30% para ambas muestras, y alcanzo el 36,6% al analizar conjuntamente BAS y LBA. Concluimos diciendo que se debe realizar broncoscopia en todas las sospechas de micobacteriosis en las que la baciloscopia del esputo sea negativa y en los pacientes que no expectoran, y que debe realizarse rutinariamente toma de LBA ya que es la muestra que se ha mostrado mas rentable y constituye una tecnica de sencilla realizacion y con escasa morbilidad.

El diagnostico de la neumonia nosocomial es especialmente dificil en pacientes intubados debido a la escasa especificidad de sus caracteristicas clinicorradiologicas. El objetivo de este trabajo ha sido evaluar la utilidad diagnostica de las fibras de elastina (FE) en el broncoaspirado (BAS) como marcador de neumonia en pacientes ventilados. Se han estudiado prospectivamente 47 pacientes bajo ventilacion mecanica (VM) con sospecha de neumonia nosocomial. A todos ellos se les practico fibrobroncoscopia (FB) con toma de muestras mediante cateter telescopado (CT) y lavado broncoalveolar (LBA). Ademas, se examino una porcion purulenta del BAS, tras anadir KOH al 40%, para determinar la presencia de FE. Se observaron FE en 15 casos, de las cuales 11 eran neumonias, siendo 3 de los 4 casos restantes portadores de patologia susceptible de producir necrosis pulmonar (sensibilidad del 52% y especificidad del 85%). Diez de los 17 microorganismos aislados en los casos de neumonia con FE positivas fueron gramnegativos, aunque el germen mas frecuentemente encontrado fue S. aureus. No hubo diferencias en el pronostico entre los pacientes con neumonia y FE positivas respecto a los que tenian las FE negativas. En conclusion, una vez descartadas otras neumopatias necrosantes, la presencia de FE en el BAS puede ofrecer un apoyo razonable en el diagnostico de algunos pacientes con neumonia asociada al ventilador.

This study was set in a general, university hospital in the Canary Islands, with the objective to evaluate an enzyme-linked immunosorbent assay (ELISA) using A60 in the serodiagnosis of tuberculosis. IgG antibody to A60 was determined in 205 patients with active disease [149 culture-positive patients with pulmonary tuberculosis (positive sputum smear 94, negative sputum smear 55) and 56 patients with extrapulmonary tuberculosis], 20 patients with inactive disease, 22 patients with lepromatous leprosy, and 51 controls. The mean levels of anti-A60 antibodies were significantly higher in patients with active disease as compared with controls or patients with inactive disease. Differences were also found between tuberculous patients with pulmonary and extrapulmonary disease. In patients with pulmonary disease, significant differences were detected between smear-positive and smear-negative patients. The overall sensitivity of the test (cutoff 240 ELISA units) was 52.2%. The highest sensitivity was found among smear-positive patients with pulmonary tuberculosis (67%) and the lowest among those with extrapulmonary tuberculosis (32.1%). We conclude that ELISA for the measurement of IgG antibody to Mycobacterium tuberculosis antigen A60 could be of interest, specially in smear-negative cases and extrapulmonary tuberculosis.

The objective of this study was the prospective evaluation of the IgG antibody levels to mycobacterial antigen 60 (A60) in serum and pleural fluid and their role in the diagnosis of tuberculous pleuritis. The level of IgG was measured by Elisa in 30 patients with tuberculous pleuritis and 48 control subjects with pleural effusion (24 with carcinoma, 10 with transudative pleural effusion, 11 with empyema or parapneumonic effusion, 1 with pulmonary embolism and 2 due to systemic lupus erythematosus). The median titers of IgG against A60 of both serum and pleural fluid from tuberculous patients [445.6 +/- 133.56 and 263 +/- 72.58 Elisa units (EU) respectively] were significantly higher than those of corresponding median values (97.3 +/- 8.35 and 41.3 +/- 4.93 EU) of the control group (p0.01 and p0.01, respectively). Considering 240 units as cutoff point for a positive test in serum, the sensitivity was 53.3% and the specificity 100%. In the pleural fluid the cutoff point value was established at 150 units, with a sensitivity of 50% and specificity of 100%. We concluded that Elisa using A60 is a reliable and rapid test with an acceptable sensitivity and magnificent specificity.

Tobacco smoking is associated with increased prevalence of various diseases. In this study, we have used an indirect enzyme-linked immunosorbent assay (ELISA) to investigate the specific IgG response to pigeon serum and its relationship to tobacco smoking. In a large group of pigeon fanciers the development of pigeon breeder's disease and some of the clinical features were also investigated. We found a sensitization rate of 31.9%, a lower degree than that found by other authors, in spite of using a less specific antigen. We also found that fanciers who are current cigarette smokers had significantly lower levels of IgG antibody to pigeon serum (P less than 0.001). Finally, 11.9% of the population had chronic bronchitis as their only manifestation of possible pigeon-related disease. 19.6% of the sensitized fanciers had chronic bronchitis, were non-smokers and had no other risk factor for developing chronic bronchitis.

OBJECTIVE To assess the usefulness of the telescoping plugged catheter in the diagnosis of nosocomial pneumonia. DESIGN Prospective study. PATIENTS A total of 103 ventilated patients with suspected pneumonia were prospectively studied over 20 months. RESULTS The quantitative cultures of the protected brush specimen detected pulmonary bacterial infection (greater than 10(3) cfu/mL) in 49 (47.5%) patients. Subsequent follow-up confirmed pneumonia in 41 patients; in only one patient was a positive protected brush specimen culture established as a false-positive result. There were 54 patients with less than 10(3) cfu/mL and the diagnosis was excluded in 36 of them. We identified eight patients with false-negative protected brush specimen cultures. The results obtained by this technique allowed us to modify treatment in 49 (47.5%) patients. CONCLUSIONS The telescoping plugged catheter demonstrated significant bacterial infection in a relatively small proportion of patients in whom bacterial lung infection was suspected. This technique can be safely performed and is a sensitive and specific method to establish the cause of pneumonia, thus allowing specific treatment and the avoidance of inappropriate antibiotic therapy.

Durante 1988 se estudiaron 102 pacientes con tuberculosis confirmada bacteriologicamente a los que se realizo una detallada recogida de datos y un seguimiento bacteriologico a lo largo del tratamiento. Todos los enfermos tenian cultivo positivo de las distintas muestras estudiadas, realizandole a todos ellos estudio de sensibilidad in vitro . Se encontraron cepas resistentes a uno o mas farmacos en el 14,7% de los enfermos, siendo este porcentaje superior en los 13 que habian recibido previamente tratamiento antituberculoso (38,4%) que en los 89 que no referian este dato (11,2%). La resistencia fue mas elevada en las 80 cepas aisladas a partir de muestras respiratorias (16,2%) que en las 22 aisladas de muestras de otras localizaciones (9%). Los farmacos que aportaron mayor resistencia primaria fueron la estreptomicina (6,7%) e isoniacida (5,6%), siendo este ultimo farmaco el que presento la tasa mas elevada de resistencia secundaria (30,7%), seguido de rifampicina (23%) y estreptomicina (23%). De todos los factores analizados en los pacientes, tan solo dieron tasas de resistencia mas elevada que fueran estadisticamente significativas, el grupo de enfermos que habian recibido tratamiento previo (p

La recidiva diafragmatica de un timoma es un hecho excepcional. Se presenta el caso de una mujer de 70 anos de edad, tratada 4 anos antes por un timoma invasor mediante timectomia transesternal y radioterapia adyuvante, que ingreso por recidiva del timoma en el hemidiafragma izquierdo e infiltracion del lobulo inferior del pulmon ipsolateral. Se llevo a cabo una exeresis en bloque que incluyo el hemidiafragma izquierdo, la pared toracica con tres arcos costales y una segmentectomia atipica del lobulo inferior izquierdo, con reconstruccion del hemidiafragma y del defecto de la pared toracica con mallas sinteticas. Se completo el tratamiento quirurgico con radioterapia adyuvante.

Durante 14 meses se realizo broncofibroscopia a 36 pacientes con tuberculosis pulmonar activa, detectandose afeccion endobronquial en 10 de ellos (27,7%), basandose en criterios bacteriologicos e histologicos. Se encontro con mas frecuencia en mujeres jovenes. La duracion de la sintomatologia previo al diagnostico fue elevada debido a lo inespecifico de los sintomas, siendo la tos el mas frecuente. La imagen radiografica fue sugestiva de obstruccion bronquial en el 30%, en otro 20% se evidencio un nodulo pulmonar solitario y tan solo otro 20% presentaba imagen radiologica compatible con tuberculosis. Las lesiones se localizaron preferentemente en campos superiores y no hubo predominio del lado derecho. En ningun paciente existia frotis previo de esputo positivo. En 2 de los enfermos (20%) el cuadro clinico, la imagen radiologica y la vision endoscopica sugirieron carcinoma broncogenico. La mayor rentabilidad diagnostica se obtuvo con la biopsia bronquial, tanto en el estudio histologico como en el frotis y cultivo. Los resultados de este trabajo sugieren que la afeccion endobronquial de la tuberculosis es un hecho relativamente frecuente en esta enfermedad.