Erick Joel Rendón-Ramírez

Acute pancreatitis (AP) is an inflammatory condition associated with significant morbidity and mortality that often leads to thoracic complications. Timely identification of these complications, including pleural effusion (PE), is of utmost importance because it may indicate AP severity. This prospective cohort aimed to determine the association between the presence of PE and other lung findings identified by thoracic ultrasound (TUS) and AP severity. We included patients diagnosed with AP according to the Atlanta classification. TUS was performed within the first 48 h of diagnosis, six quadrants per hemithorax were examined to assess the presence of PE and different pulmonary patterns. AP severity scales were applied, and mortality was calculated based on the presence or absence of PE or other lung findings. We included 107 patients with AP with a mean age of 37 (28–51) years, 66 (62%) females. TUS identified PE in 20.5% of the cases. The Atlanta classification system revealed a higher proportion of severe AP among the patients with PE (40.9% vs. 2.4%, p < 0.001). Also, patients with PE showed a higher Marshall (2 ± 2.13 vs. 1.12 ± 1.17, p = 0.0295) and APACHE II scores (8.36 ± 5.34 vs. 5.52 ± 3.62, p = 0.022). PE and Marshall score were independent factors associated with higher mortality in a multivariate model, with odds ratios of 6.89 (1.18–50.49) and 3.00 (1.42–7.90), respectively. Early detection of PE using TUS in patients with AP is strongly associated with disease severity and mortality.

Fluid overload in patients with end-stage kidney disease (ESKD) usually results in pleural effusions (PEs). While volume overload remains the primary etiology of PE, other possible causes must be ruled out. Thoracic ultrasonography (TUS) is a practical and efficient method for evaluating volume in patients undergoing hemodialysis (HD), although evidence regarding its usefulness in this context is limited. We aimed to investigate the relationship between pleuropulmonary TUS patterns and overload symptoms and their correlation with optimal HD, as measured by total urea clearance (Kt/V) and the urea reduction rate (URR). This prospective longitudinal observational study included patients with ESKD who underwent renal replacement therapy with HD. Point-of-care TUS was performed before and after HD sessions. The ultrasound parameters recorded included the presence, location, sonographic patterns and volume of PE. A total of 136 patients were included in the study. TUS abnormalities compatible with interstitial syndrome (B-lines) were identified in 56 (41%) patients. Forty-four patients (32%) had PE. The PE volume showed a statistically significant decrease after HD and normalized in 12% of the patients. No significant difference in the proportion of patients who achieved a URR > 65 or optimal Kt/V was observed between patients with abnormal (B-lines) and normal TUS results (P = .39). The presence of PE and B-lines was significantly associated with overload symptoms; however, these overload symptoms were not related to optimal HD, as measured by the Kt/V or URR. PE and B-lines demonstrated a stronger association with overload symptoms than Kt/V or URR in HD patients. No relationship was found between the TUS pleuropulmonary changes and HD efficacy.

Aim: To analyze the association between pleural effusion detected by chest point of care ultrasound (POCUS) and clinical outcomes in patients with septic shock admitted to an intensive care unit (ICU). Material and methods: A prospective evaluation of ICU patients with septic shock in whom chest POCUS was performed during the first 24 hours of diagnosis to identify the presence and characteristics of pleural effusion. Results: Of 45 patients with septic shock, 17 (38%) had pleural effusion. Mortality (13 vs 17 patients, p=0.44), as well as length of stay in ICU (11.0 vs 6.5 days, p=0.161) were similar among groups. However, there was a significant difference in the modified Nutrition Risk in Critically Ill (mNUTRIC) score between the pleural effusion (5.82±1.13) and non-pleural effusion groups (4.00±2.39, p=0.001). In addition, patients with pleural effusion required more days on mechanical ventilation than those without pleural effusion (10 vs 7, p=0.04). A subgroup analysis of chest POCUS characteristics between surviving and non-surviving patients with pleural effusion identified a higher median size of pleural effusion in the non-surviving group (3±2.16 cm vs 1.9±0.6, p=0.01). Conclusion: Pleural effusion in patients with septic shock is associated with high mNUTRIC scores and more days on mechanical ventilation. The larger the pleural effusion, the lower the survival rate.

Single-center prospective cohort diagnostic accuracy study. Our study aimed to evaluate the accuracy and reproducibility of Thoracic Ultrasound (TUS) in detecting pulmonary pathology in immunosuppressed patients. We conducted a single-center prospective study. Consecutive patients with febrile neutropenia who underwent CT (Computerized Tomography) underwent TUS evaluation within 24h of CT. Both studies were performed by an expert who was blinded to the clinical information and results of the alternative imaging modalities. 34 patients met the inclusion criteria. The median age was 39.9 years (±17 standard deviation). TUS as a diagnostic test had a sensitivity of 92.9% and specificity of 83.3%, negative predictive value of 71.4%, and positive predictive value of 96.3%. Substantial between-method agreement was demonstrated with a kappa of 0.71 (P = .001) between the TUS and chest CT findings. We obtained a kappa of 1 (P = .001) for the final diagnosis of Pleural Effusion (PE). We concluded that TUS is a promising screening test for immunocompromised individuals. The results showed good diagnostic performance of TUS compared to CT for the detection of pulmonary findings highly suggestive of pathology with high accuracy and reproducibility.

Is there a CD4+ and CD8+ immunity alteration in patients with pulmonary tuberculosis (TB) and diabetes (DM) that does not recover after antituberculosis treatment? This prospective comparative study evaluated CD4+ and CD8+ lymphocytic subpopulations and antituberculosis antibodies in patients with diabetes and tuberculosis (TB-DM), before and after antituberculosis treatment. CD4+ T cell counts were lower in patients with TB-DM compared to those with only TB or only DM, and these levels remained low even after two months of anti-TB treatment. Regarding the CD8+ T cell analysis, we identified higher blood values in the DM-only group, which may be explained by the high prevalence of latent tuberculosis (LTBI) in patients with DM. IgM antituberculosis antibodies levels were elevated in patients with only TB at baseline, and 2 months post-anti-TB treatment, IgG did not express any relevant alterations. Our results suggest an alteration in CD4+ immunity in patients with TB-DM that did not normalize after antituberculosis treatment.

In this study, we aim to evaluate whether thoracic ultrasound (TUS) and tracheal amylase (TA) alone or in combination can predict the development of ventilator-associated pneumonia (VAP) in neurocritical patients. Consecutive adult patients with neurocritical disease with normal chest radiographs who required intensive care unit admission and mechanical ventilation between March 2015 and July 2018 were included. TUS and Amylase levels were measured during the first 24 hours and repeated 48 hours after orotracheal intubation. Forty-three patients with a median age of 34 years (17–82) were included. TUS had a sensitivity of 100% and specificity of 96.3% as a predictor of VAP within the first 48 hours when nonpattern A was observed. TA levels > 200 UI/L in the first 48 hours had a sensitivity of 87.5%, and specificity of 63% as a predictor of VAP. Moreover, no benefit of TUS plus TA compared to TUS alone as a predictor of VAP was found. The identification of abnormal TUS patterns in the first 48 hours of orotracheal intubation is a significant predictor of VAP in neurocritical patients.

Objetivo. Proporcionar recomendaciones para la detección temprana de pacientes con alto riesgo de desarrollar cáncer de pulmón (CP) en el primer nivel de atención y su referencia oportuna. Material y métodos. Se realizó una búsqueda detallada de la evidencia científica disponible para responder las preguntas de investigación clínica y se utilizó el Panel Delphi modificado para lograr un consenso entre expertos. Resultados. Se generaron 14 recomendaciones siguiendo los estándares de una GPC. Conclusión. El CP representa un problema de salud pública en México; por ello, esta guía establece recomendaciones que apoyan la toma de decisiones sobre la detección precoz y la referencia de pacientes con sospecha de CP en el primer nivel de atención.

Coronary involvement in IgG4-related disease (IgG4-RD) has been scarcely reported, and myocardial ischemia as its presenting feature is even rarer. Here, we describe an additional case with novel and relevant observations. The patient was a previously healthy, middle-aged woman who presented to the clinic with new-onset typical angina. One tumefactive lesion encasing the left anterior descending artery was found during her workup. The most common underlying malignancies with secondary cardiac involvement were rationally ruled out. Symptoms persisted despite medical treatment, and she was therefore referred to surgery. Tumor excision was successfully performed, and she received coronary bypass grafting. IgG4-related coronary arteritis with pseudotumor formation was subsequently diagnosed following the comprehensive diagnostic criteria. This condition was clinically classified as active and circulating plasmablasts were found to be increased (5480/mL), even when these were determined 38 days after surgery. A PET/CT revealed an additional hypermetabolic lymph node. She was therefore treated with rituximab as induction therapy (two 1000 mg doses, administered 15 days apart). Three months later, her disease remained clinically inactive. Circulating plasmablasts were repeated and these had dropped to 0/mL. We thereafter review the current and pertinent literature on the topic, emphasizing the previous cases with similar presenting features (n = 7). We lastly suggest that IgG4-RD should be part of the differential diagnosis of any patient with tumefactive lesions surrounding the coronary arteries, since it can initially presented as sudden cardiac death.