Altair da Silva Costa Jr

Randomized trial - oxybutynin for treatment of persistent plantar hyperhidrosis in women after sympathectomy

OBJECTIVE: Hyperhidrosis is a common disease, and thoracoscopic sympathectomy improves its symptoms in up to 95% of cases. Unfortunately, after surgery, plantar hyperhidrosis may remain in 50% of patients, and compensatory sweating may be observed in 70%. This clinical scenario remains a challenge. Our objective was to evaluate the effectiveness of oxybutynin in the treatment of persistent plantar hyperhidrosis and compensatory sweating and its effects on quality of life in women after thoracoscopic sympathectomy. METHOD: We conducted a prospective, randomized study to compare the effects of oxybutynin at 10 mg daily and placebo in women with persistent plantar hyperhidrosis. The assessment was performed using a quality-of-life questionnaire for hyperhidrosis and sweating measurement with a device for quantifying transepidermal water loss. Clinicaltrials.gov: NCT01328015. RESULTS: Sixteen patients were included in each group (placebo and oxybutynin). There were no significant differences between the groups prior to treatment. After oxybutynin treatment, there was a decrease in symptoms and clinical improvement based on the quality-of-life questionnaire (before treatment, 40.4 vs. after treatment, 17.5; p = 0.001). The placebo group showed modest improvement (p = 0.09). The outcomes of the transepidermal water loss measurements in the placebo group showed no differences (p = 0.95), whereas the oxybutynin group revealed a significant decrease (p = 0.001). The most common side effect was dry mouth (100% in the oxybutynin group vs. 43.8% in the placebo group; p = 0.001). CONCLUSION: Oxybutynin was effective in the treatment of persistent plantar hyperhidrosis, resulting in a better quality of life in women who had undergone thoracoscopic sympathectomy.

Forty-Year-Old Intrathoracic Gossypiboma After Cardiac Valve Surgery

A 59-year-old asymptomatic man, who had undergone cardiac valve surgery 40 years earlier, demonstrated a paracardiac mass on routine chest x-ray (Figure 1). Subsequently, a chest computed tomography scan was performed, which showed a 14.0×9.5 cm heterogeneous lesion, with lobulated contours, along the inferior aspect of the left and right ventricles (Figure 2). It was possible to identify areas of low density as well as high-density areas. Peripheral calcification was also present. There was mild peripheral enhancement after iodinated intravenous contrast injection. It was not possible to exclude cardiac invasion because this lesion had extensive contact with the cardiac ventricles. Figure 1. A, Posteroanterior chest radiograph showing an ill-defined opacity at the left pericardic region. B, This is better identified in the lateral projection (white arrows). Figure 2. …

An assessment of the quality indicators of operative and non-operative times in a public university hospital

ABSTRACT Objective To assess the operative time indicators in a public university hospital. Methods A descriptive cross-sectional study was conducted using data from operating room database. The sample was obtained from January 2011 to January 2012. The operations performed in sequence in the same operating room, between 7:00 am and 5:00 pm, elective or emergency, were included. The procedures with incomplete data in the system were excluded, as well as the operations performed after 5:00 pm or on weekends or holidays. Results We measured the operative and non-operative time of 8,420 operations. The operative time (mean and standard deviation) of anesthesias and operations were 177.6±110 and 129.8±97.1 minutes, respectively. The total time of the patient in operative room (mean and standard deviation) was 196.8±113.2. The non-operative time, e.g., between the arrival of the patient and the onset of anesthesia was 14.3±17.3 minutes. The time to set the next patient in operating room was 119.8±79.6 minutes. Our total non-operative time was 155 minutes. Conclusion Delays frequently occurred in our operating room and had a major effect on patient flow and resource utilization. The non-operative time was longer than the operative time. It is possible to increase the operating room capacity by management and training of the professionals involved. The indicators provided a tool to improve operating room efficiency.

A Video-Assisted Endotracheal Suture Technique for Correction of Distal Tracheal Laceration After Intubation

The incidence of tracheal laceration is 1 of 20,000 intubations. The most frequently affected area is the posterior tracheal wall (membranous). Risk factors include several forced attempts at intubation, inexperience of the clinician, tracheal introducers (guidewires) that protrude beyond the tip of the tube, and emergency procedures. Surgical treatment of tracheal lacerations can be by a transtracheal suture technique or a right thoracotomy. Using the concept of minimally invasive surgical procedures, we reported the treatment of 2 patients with tracheal lacerations greater than 5 cm in the distal trachea that were treated with endotracheal video-assisted suturing using a cervical incision.

Tratamento cirúrgico das malformações pulmonares em pacientes pediátricos

classification to five types. In addition, Stocker(6) proposed a change in nomenclature, from “cystic adenomatoid malformation” to “adenomatoid lung malformation”. Ferreira et al.(1) referred to this new classification as having four types (I to IV). However, other studies involving the expanded classification show five types (0 to IV), according to the origin of the malformation(4-6): type 0 (tracheal); type I (bronchial); type II (bronchiolar); type III (bronchiolar/alveolar duct); and type IV (alveolar/distal acinar). The scarcity of publications on this topic in Brazil reflects the difficulty in diagnosing lung malformations. Unfortunately, we treat, each year, 5-6 patients with this type of malformation at our institution,(2) similar to the numbers cited by our colleagues.(1) In the state capital of São Paulo, 64,000 patients under 9 years of age were hospitalized with pneumonia between 2004 and 2005.(7) The incidence of recurrent pneumonia (more than two episodes per year) ranges from 6% to 8%, and the cause is identified in approximately 90% of the patients. (8) Congenital pulmonary changes account for 2-9% of the cases of recurrent pneumonia.(8) Of the 64,000 children mentioned, it is likely that at least 3,840 (6%) had recurrent pneumonia. Of those, at least 76 cases of pneumonia were probably caused by malformations (2%). Therefore, there should be, in São Paulo, over 70 patients with lung malformations per year, which does not correspond to our statistics. In 1993, Adzick published a study, conducted in the USA, comprising a sample of 350 patients over a period of 7 years (approximately 50 cases/ year).(9) In 2009, the same author published a study comprising a sample of over 600 patients over a period of 14 years.(10) I report that we have treated a 14-year-old patient who had over 80 episodes of pneumonia in the right upper lobe, due to a congenital anomaly—esophageal bronchus. At this writing, the patient remains free of pulmonary infection, having experienced no recurrence since undergoing the surgical procedure in 2004. Why was this patient not correctly diagnosed earlier, To the Editor:

Digital drainage system: how far can we go?

A maioria das cirurgias pulmonares necessita da drenagem do espaco pleural para eliminar o liquido e o ar pleural no pos-operatorio e possibilitar a expansao adequada do pulmao remanescente. A perda aerea prolongada e uma complicacao esperada em aproximadamente 10% dos pacientes.(1) A equipe precisa ser capacitada para o manejo adequado do sistema de drenagem. A medicao ou a classificacao dos vazamentos de ar ainda e subjetiva e depende da experiencia do profissional para quantifica-los. Portanto, a interpretacao da perda aerea esta relacionada a variabilidade do observador.(1,2) Por ser subjetiva, discordâncias entre observadores, mesmo que experientes, ocorrem. Quando persiste a duvida, o paciente permanece pelo menos mais um dia ou periodo internado. Desde que os sistemas de drenagem toracica digitais surgiram, os pacientes tem a sua disposicao algumas vantagens.(2,3) E portatil, com autonomia para 12 h atraves de uma bateria recarregavel. Dispoe de alarmes e alertas para diversas situacoes, como dreno obstruido, sistema desconectado, falha na aspiracao, entre outras. Por ser um sistema completamente fechado, nao existe contato do liquido com o meio externo, o que acrescenta uma enorme biosseguranca a equipe e ao proprio paciente. Outra vantagem e justamente na perda aerea, pois o sistema minimiza as diferencas entre observadores. O vazamento de ar e medido de maneira objetiva, em mL/min, e tambem pode ser visto em forma de grafico. A pressao de aspiracao e regulada no proprio aparelho, independentemente da rede de vacuo do hospital. Quando houver uma perda aerea menor que 40 mL/min nas ultimas 6 h, o que pode ser observado no grafico no proprio aparelho, o dreno pode ser retirado. (2-4) O montante liquido e computado de forma tradicional atraves do recipiente graduado. O sistema digital e bem tolerado pelos pacientes, oferece mais seguranca e mobilidade. Pode reduzir o periodo de internacao e custos pois o dreno e retirado em menor tempo.(2,4,5) Relatamos o uso de um sistema de drenagem digital em um paciente grave submetido a resseccao pulmonar. O dispositivo foi utilizado em um paciente idoso grave, hipertenso, diabetico e portador de arteriosclerose, DPOC e neoplasia pulmonar. Apresentava, na epoca, escarro hemoptico com alguns episodios de hemoptise e uma massa em lobo medio. Apos a resseccao pulmonar, permaneceu em ventilacao mecânica por cinco dias, em terapia intensiva. Tambem apresentou perda aerea pelo dreno e a partir do segundo dia pos-operatorio foi monitorizado pelo sistema digital Thopaz® (Medela, Baar, Suica; Figura 1). Atraves do visor, podemos obter informacoes do que ocorre no momento, com a indicacao da perda aerea e da pressao de aspiracao utilizada. Pelo grafico, temos as informacoes do que ocorreu nas ultimas 24 h (Figura 2). Assim, durante as visitas medicas ou de enfermagem, podemos consultar essas informacoes e tomar decisoes melhores. Alem disso, as informacoes podem ser exportadas para um computador atraves do programa ThopEasy (Medela). Assim, obtemos mais parâmetros, como o tempo de drenagem, com a data e a hora inicial e final de uso do sistema, valor maximo e valor minimo de aspiracao e de perda aerea (Figura 2). A aspiracao pode ser

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in diagnosis of mediastinal lesions

❚ RESUMO Objetivo: Descrever os resultados da utilização de punção aspirativa por agulha guiada por ultrassom endobrônquico na definição do diagnóstico em casos de lesões mediastinais por diferentes causas. Métodos: Estudo transversal retrospectivo de pacientes submetidos à punção aspirativa por agulha guiada por ultrassom endobrônquico em instituição privada, entre junho de 2013 e outubro de 2016. Foram incluídos todos os casos referenciados para coleta de materiais de linfonodos ou massas peritraqueais/peribrônquicas por punção aspirativa por agulha guiada por ultrassom endobrônquico, estudados com tomografia ou PET-CT. Os procedimentos foram realizados por pneumologistas intervencionistas e cirurgiões torácicos com experiência no método. Rapid on-site evaluation da punção aspirativa por agulha fina foi realizada por patologista experiente. A análise do material incluiu citologia dos esfregaços em lâminas e análise citopatológica do emblocado celular. Outras análises específicas (imunocitoquímica, pesquisas e culturas de agentes infecciosos) foram realizadas se necessárias. Resultados: Foram incluídos 72 pacientes; destes, 6 foram excluídos por apresentarem lesões endobrônquicas passíveis de biópsia broncoscópica convencional ou lesões intratorácicas não acessíveis a punção aspirativa por agulha guiada por ultrassom endobrônquico. Assim, a média de idade dos 66 pacientes incluídos para análise foi 61,17 anos (±14,67 anos), com predomínio do sexo masculino (64%). A punção aspirativa por agulha guiada por ultrassom endobrônquico foi definitivo para o diagnóstico em 60 casos (91%). Três casos (4,5%) foram inconclusivos. Não houve complicações maiores relacionadas ao procedimento. Conclusão: A punção aspirativa por agulha guiada por ultrassom endobrônquico teve elevado rendimento diagnóstico, com mínima morbidade, constituindo excelente opção na abordagem diagnóstica de pacientes com linfadenopatia ou lesões intratorácicas e no estadiamento de neoplasias.

Punção aspirativa por agulha guiada por ultrassom endobrônquico (EBUS-TBNA) no diagnóstico de lesões do mediastino

ABSTRACT Objective To describe the results of endobronchial ultrasound-guided transbronchial needle aspiration in making diagnosis of mediastinal injuries associated to different causes. Methods A retrospective cross-sectional study of patients submitted to Endobronchial ultrasound-guided transbronchial needle aspiration at a private organization, between June 2013 and October 2016. All cases referred for collection of lymph nodes or peritracheal/peribronchial masses by endobronchial ultrasound-guided transbronchial needle aspiration, and evaluated through tomography or PET-CT were included. Interventional pulmonologists and thoracic surgeons with experience in the method did the procedures. Rapid on-site evaluation of fine needle aspiration was performed by an experienced pathologist. Material analysis included cytological smear and cytopathological analysis of paraffin-embedded cell blocks. Other specific analyses (immunocytochemistry, tests and cultures of infectious agents) were performed whenever necessary. Results We included 72 patients; 6 were excluded for presenting endobronchial lesions in which bronchoscopic biopsy could be performed, or intrathoracic lesions that were not accessible by endobronchial ultrasound-guided transbronchial needle aspiration. The mean age of 66 patients included for analysis was 61.17 years (±14.67 years), with a predominance of males (64%). Endobronchial ultrasound-guided transbronchial needle aspiration was definitive for diagnosis in 60 cases (91%). Three cases (4.5%) had inconclusive test results. There were no major complications related to the procedure. Conclusion Endobronchial ultrasound-guided transbronchial needle aspiration had a high diagnosis yield, with minimal morbidity, being an excellent option for diagnostic approach of patients with lymphadenopathy or intrathoracic lesions, and for neoplasm staging.