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Although pleural effusion is a frequent finding in clinical practice, determining its aetiology may be challenging, and up to 20% of cases remain undiagnosed. Pleural effusion may occur secondary to a nonmalignant gastrointestinal disease. A gastrointestinal origin is confirmed based on a review of the medical history of the patient, thorough physical examination and abdominal ultrasonography. In this process, it is crucial to correctly interpret findings on pleural fluid obtained by thoracentesis. In the absence of high clinical suspicion, identifying the aetiology of this type of effusion may be difficult. Clinical symptoms will be determined by the gastrointestinal process causing pleural effusion. In this setting, correct diagnosis relies on the specialist's ability to evaluate pleural fluid appearance, test for the appropriate biochemical parameters and determine whether it is necessary or not to send a specimen for culture. The established diagnosis will determine how pleural effusion is approached. Although this clinical condition is self-limited, many cases will require a multidisciplinary approach because some effusions can only be resolved with specific therapies.

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

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

BACKGROUND: An integrated care pathway (ICP) is intended to improve the management of prevalent resource-consuming, life-threatening diseases. The purpose of this study was to determine whether the quality of patient care improved with the establishment of a dedicated unit for pulmonary embolism (PE). METHODS: A quasi-experimental pre-post study (pre: years 2010–2013; post: 2015–2020; year 2014, “washing” period) of PE patients ≥18 years (January 2010–June 2020). The intervention involved the implementation of an ICP for PE. RESULTS: The sample was composed of 1,142 patients (510 pre-intervention and 612 post-intervention) without significant differences between the two populations. In the post-intervention period, significant reductions were observed in the median length of hospital stay (LOS) (8 vs. 6 days); time to start of oral anticoagulation therapy (4.5 vs. 3.5 days; P

Resumen Introduccion La diabetes mellitus y el sindrome de apnea-hipopnea del sueno parecen estar relacionados, pero no esta bien definido si en los pacientes con ambas enfermedades existe un mayor riesgo de neuropatia periferica. Para ello, realizamos una revision sistematica. Metodos Busqueda bibliografica en 3 bases de datos electronicas usando una estrategia predefinida y la metodologia PRISMA. Solamente se incluyeron estudios originales (cualquier tipo de diseno) y publicados a partir del ano 2000 en ingles, frances, portugues o espanol. Se establecio una escala de calidad de los estudios. Resultados Se seleccionaron 12 articulos, de los que 6 estudiaban pacientes diabeticos tipo 2. La prevalencia global de sindrome de apnea-hipopnea del sueno fue del 43,7% (1.559/3.564 pacientes). La neuropatia diabetica fue mas frecuente en los pacientes con sindrome de apnea-hipopnea del sueno en 9 estudios, aunque solo en 4 de manera significativa (60 vs. 27%, p Conclusiones Los resultados observados indican una relacion entre diabetes mellitus y sindrome de apnea-hipopnea del sueno en la aparicion de neuropatia diabetica.

Diabetes mellitus and sleep apnoea-hypopnoea syndrome appear to be related, but it is not well defined whether there is an increased risk of peripheral neuropathy in patients with both diseases. For this reason, we conducted a systematic review.Bibliographic search in 3 electronic databases using a predefined strategy and the PRISMA methodology. Only original studies (any type of design) published from 2000 onwards in English, French, Portuguese or Spanish were included. A study quality scale was established.Twelve articles were selected, of which six studied type 2 diabetic patients. The overall prevalence of sleep apnoea-hypopnoea syndrome was 43.7% (1,559/3,564 patients). Diabetic neuropathy was more frequent in patients with sleep apnoea-hypopnoea syndrome in nine studies, although significantly only in four (60% vs 27%, P.001; 64.5% vs 36%, P=.03; 37% vs 23.4%, P.02; 66.6% vs 0%, P=.007). In one study, diabetic neuropathy was more frequent in patients without sleep apnoea-hypopnoea syndrome (although not statistically significant) and in 2 no comparison was made between patients with/without sleep apnoea/hypopnoea syndrome.The observed results suggest a relationship between diabetes mellitus and sleep apnoea-hypopnoea syndrome in the occurrence of diabetic neuropathy.

Objective Nasal diseases are among the main motives for the early discontinuation of continuous positive airway pressure therapy and for long-term therapeutic compliance with mandibular advancement device. Although our clinical experience leads us to the belief that recumbency impacts nasal airflow in some patient populations, there is no consensus regarding the magnitude of this effect and the specific group of patients who are the most affected by this condition. In this study, we conducted a meta-analysis to assess the effect of the recumbent position on nasal resistance and nasal airflow. Review methods PubMed (Medline), Cochrane Library, EMBASE, Scopus, and SciELO databases were checked for relevant studies by two members of the YO-IFOS study group. The two authors extracted the data. The main outcome was expressed as the difference between nasal resistance and nasal airflow before and after recumbency. Results Nine studies with a total population of 291 individuals were included in the meta-analysis for nasal resistance after recumbency. We found a statistically significant difference in nasal airway resistance of -0.18 Pa sec/cm3 as compared to before and after recumbency through rhinomanometry (RMM) analysis. A subgroup analysis revealed a variation of -0.20 Pa sec/cm3 for patients with snoring or sleep apnea and - 0.10 Pa sec/cm3 for healthy individuals. Regarding nasal airflow measured with RMM, three studies (n = 32) in asymptomatic controls revealed a statistically significant difference of 47.33 ml/sec. Conclusions Recumbency increases nasal resistance and diminishes nasal airflow. This finding is of utmost importance in snorers and sleep apnea patients. Laryngoscope, 2021.

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

The prognosis of a patient with Covid-19 pneumonia is uncertain. Our objective was to establish a predictive model of disease progression to facilitate early decision-making. A retrospective study was performed of patients admitted with Covid-19 pneumonia, classified as severe (admission to the intensive care unit, mechanic invasive ventilation, or death) or non-severe. A predictive model based on clinical, analytical, and radiological parameters was built. The probability of progression to severe disease was estimated by logistic regression analysis. Calibration and discrimination (receiver operating characteristics curves and AUC) were assessed to determine model performance. During the study period 1,152 patients presented with Covid-19 infection, of whom 229 (19.9%) were admitted for pneumonia. During hospitalization, 51 (22.3%) progressed to severe disease, of whom 26 required ICU care (11.4); 17 (7.4%) underwent invasive mechanical ventilation, and 32 (14%) died of any cause. Five predictors determined within 24 hours of admission were identified: Diabetes, Age, Lymphocyte count, SaO2, and pH (DALSH score). The prediction model showed a good clinical performance, including discrimination (AUC 0.87 CI 0.81, 0.92) and calibration (Brier score = 0.11). In total, 0%, 12%, and 50% of patients with severity risk scores ≤5%, 6-25%, and >25% exhibited disease progression, respectively. A simple risk score based on five factors predicts disease progression and facilitates early decision-making according to prognosis. Carlos III Health Institute, Spain, Ministry of Economy and Competitiveness (SPAIN) and the European Regional Development Fund (FEDER) Instituto de Salud Carlos III

Background: The prognosis of a patient with Covid-19 pneumonia is uncertain. Our objective was to establish a predictive model of disease progression to facilitate early decision-making. Methods: A retrospective study was performed of patients admitted with Covid-19 pneumonia, classified as severe (admission to the intensive care unit, mechanic invasive ventilation, or death) or non-severe. A predictive model based on clinical, analytical, and radiological parameters was built. The probability of progression to severe disease was estimated by logistic regression analysis. Calibration and discrimination (receiver operating characteristics curves and AUC) were assessed to determine model performance. Findings: During the study period 1,152 patients presented with Covid-19 infection, of whom 229 (19.9%) were admitted for pneumonia. During hospitalization, 51 (22.3%) progressed to severe disease, of whom 26 required ICU care (11.4); 17 (7.4%) underwent invasive mechanical ventilation, and 32 (14%) died of any cause. Five predictors determined within 24 hours of admission were identified: Diabetes, Age, Lymphocyte count, SaO2, and pH (DALSH score). The prediction model showed a good clinical performance, including discrimination (AUC 0.87 CI 0.81, 0.92) and calibration (Brier score = 0.11). In total, 0%, 12%, and 50% of patients with severity risk scores ≤5%, 6-25%, and >25% exhibited disease progression, respectively. Interpretation: A simple risk score based on five factors predicts disease progression and facilitates early decision-making according to prognosis. Funding Statement: This project was funded by the Carlos III Health Institute, Spain, Grant/Award Number: COV20/00404; Ministry of Economy and Competitiveness (SPAIN) and the European Regional Development Fund (FEDER). Declaration of Interests: The authors declare no conflicts of interest associated with this publication. Ethics Approval Statement: The study was conducted in accordance with the guidelines of the Declaration of Helsinki and the principles of good clinical practice and was approved by the Institutional Review Board (IRB) of the Galician Health Service on April 3, 2020 (#2020/194). Informed consent forms were waived by the IRB.

Introduction The aim of this study was to identify factors influencing hospital stay due to pulmonary embolism. Methods We performed a retrospective cohort study of patients hospitalized between 2010 and 2015. Patients were identified using information recorded in hospital discharge reports (ICD-9-CM codes 415.11 and 415.19). Results We included 965 patients with a median stay of 8 days (IQR 6-13 days). Higher scores on the simplified Pulmonary Embolism Severity Index (sPESI) were associated with increased probability of longer hospital stay. The probability of a hospital stay longer than the median was 8.65 (95% CI 5.42-13.79) for patients referred to the Internal Medicine Department and 1.54 (95% CI 1.07-2.24) for patients hospitalized in other departments, compared to those referred to the Pneumology Department. Patients with grade 3 on the modified Medical Research Council dyspnea scale had an odds ratio of 1.63 (95% CI: 1.07-2.49). The likelihood of a longer than median hospital stay was 1.72 (95% CI: 0.85-3.48) when oral anticoagulation (OAC) was initiated 2-3 days after admission, and 2.43 (95% CI: 1.16-5.07) when initiated at 4-5 days, compared to OAC initiation at 0-1 days. Conclusions sPESI grade, the department of referral from the Emergency Department, the grade of dyspnea and the time of initiating OAC were associated with a longer hospital stay.

Introduction. Influenza A H1N1 community-acquired pneumonia (CAP) is a quite frequent respiratory disease. Despite being considered more serious than other CAPs, there are very few studies comparing its characteristics with noninfluenza CAP. We aim to establish the differences between pneumonia due to H1N1 virus and pneumonia not caused by H1N1 influenza virus and to determine the probability that a pneumonia is due to an H1N1 virus infection based on the most relevant variables. Methods. We used a case-control study where cases were H1N1 CAP patients with confirmed microbiological diagnosis and controls were patients with CAP admitted to hospital. H1N1 and other influenza types were discarded among controls. We calculated the probability of being a case or control using multivariate logistic regression. Results. We included 99 cases and 270 controls. Cases were younger than controls (53 vs 71 years, respectively). Mortality was much higher for H1N1 patients (13% vs 0.3%), and admission to intensive care unit was more frequent for H1N1 cases. The variables most associated with presenting H1N1 CAP were bilateral affectation on chest X-rays (OR: 5.70; 95% CI 2.69–10.40), followed by presence of arthromyalgias, with cases presenting close to three times more arthromyalgias compared to controls. Low leukocytes count and high AST values were also significantly associated with H1N1 CAP. H1N1 CAPs are characterized by bilateral affectation, low leukocyte count, presence of arthromyalgias, and high AST. Conclusions. A few and easy to obtain clinical parameters might be extremely useful to distinguish H1N1 CAP from CAPs of other origin.

Introduction The aim of this study was to identify factors influencing hospital stay due to pulmonary embolism. Methods We performed a retrospective cohort study of patients hospitalized between 2010 and 2015. Patients were identified using information recorded in hospital discharge reports (ICD-9-CM codes 415.11 and 415.19). Results We included 965 patients with a median stay of 8 days (IQR 6–13 days). Higher scores on the simplified Pulmonary Embolism Severity Index (sPESI) were associated with increased probability of longer hospital stay. The probability of a hospital stay longer than the median was 8.65 (95% CI 5.42–13.79) for patients referred to the Internal Medicine Department and 1.54 (95% CI 1.07–2.24) for patients hospitalized in other departments, compared to those referred to the Pneumology Department. Patients with grade 3 on the modified Medical Research Council dyspnea scale had an odds ratio of 1.63 (95% CI: 1.07–2.49). The likelihood of a longer than median hospital stay was 1.72 (95% CI: 0.85–3.48) when oral anticoagulation (OAC) was initiated 2–3 days after admission, and 2.43 (95% CI: 1.16–5.07) when initiated at 4–5 days, compared to OAC initiation at 0–1 days. Conclusions sPESI grade, the department of referral from the Emergency Department, the grade of dyspnea and the time of initiating OAC were associated with a longer hospital stay.

Introduction: Endobronchial ultrasound (EBUS) has been a major breakthrough in the staging of lung cancer, but its usefulness in the diagnosis of other diseases is limited by the size of the needles available. Objectives: Analyze the diagnostic yield of EBUS without ROSE, and the influence of the use of the cell block in the diagnosis of sarcoidosis. Methods: From August 2010 through November 2015, 804 EBUS were performed without ROSE. Until June 2012 a smear of the material obtained in puncture was subsequently referred to the pathology department. Thereafter the samples were prepared as cell block. Results: Among the 804 EBUS performed, we found 44 (5.4%) sarcoidosis [30 men (68.2%; mean age 51.5 ± 16.2 years) and 14 women (31.8%; 55 7 ± 18.2 years)]. In 13/44 patients (29.5%) had previously undergone another diagnostic procedure with negative results. EBUS was diagnostic in 35 patients (79.5 %). In the remaining 9 patients, the diagnosis was established by mediastinoscopy (7 patients) peripheral lymph node biopsy and transbronchial biopsy. EBUS diagnostic yield increased to 88% (32/36) when cell block was used. On the other hand it fell to 37.5% (3/8) when a conventional smear was used. An average of 1.84 lymph nodes per patient were punctured. Stations most frequently punctured were 7, 4R and 11R (in 38, 16 and 11 cases, respectively). No significant differences were found in diagnostic yield in relation with the number of stations punctured (p=0.259). Conclusions: EBUS is an useful technique for the diagnosis of sarcoidosis. The use of the cell block technique for processing EBUS samples ,improves the diagnostic yield in sarcoidosis and should be the method of choice.