João Aléssio Juliano Perfeito

Tratamento operatório de 60 pacientes com malformações pulmonares: o que aprendemos?

OBJECTIVE To retrospectively analyze the medical charts of patients with pulmonary malformations submitted to surgical treatment and to investigate the clinical evolution prior to the definitive diagnosis. METHODS We analyzed the medical charts of patients with pulmonary malformations operated on at the São Paulo Hospital-Federal University of São Paulo/Paulista School of Medicine-from 1969 to 2004. Each medical chart was analyzed as to the following aspects: clinical profile; diagnosis; previous treatment; surgical treatment; and nosocomial complications. The inclusion criteria were having received a diagnosis of pulmonary malformation, having undergone pulmonary resection, and chart data being complete. RESULTS The analysis of the medical charts revealed that 60 patients diagnosed with pulmonary malformations-27 cases of bronchogenic cyst, 14 cases of congenital lobar emphysema, 10 cases of pulmonary sequestration, and 9 cases of cystic adenomatoid malformation-underwent surgery. Ages ranged from 4 days to 62 years (mean, 17.9 years). There was a predominance of males (55%). Ninety-two percent of the patients presented symptoms (mean duration: 15.37 months). Of the 60 patients undergoing surgery, 27 (45%) received preoperative home or hospital treatment with antibiotics. Regarding complications, we observed that morbidity was 23%, and mortality was 3.3%. Surgical times ranged from 1 to 8 h (mean, 3.2 h). CONCLUSIONS Misdiagnosis or delayed diagnosis of pulmonary malformations resulted in unnecessary treatments and hospitalizations, as well as in frequent, recurrent infectious complications. We believe that the definitive treatment is surgery, which is curative and has low morbidity and mortality rates.

Traqueostomia na UTI: vale a pena realizá-la?

OBJETIVO: Analisar a viabilidade, as complicacoes e a mortalidade da traqueostomia realizada em ambiente de unidade de terapia intensiva (UTI). METODOS: Analise retrospectiva dos prontuarios medicos dos 73 pacientes que foram submetidos a traqueostomia nos leitos das UTIs do Hospital Sao Paulo da Universidade Federal de Sao Paulo no periodo de janeiro a novembro de 2003. Os procedimentos foram realizados sempre por um residente de cirurgia, sob a orientacao de um cirurgiao toracico, utilizando a tecnica aberta sistematizada no servico. RESULTADOS: A idade media dos pacientes foi de 55,2 anos, sendo que 47 eram do sexo masculino (64,4%) e 26 eram do sexo feminino (35,6%). A indicacao mais frequente foi a intubacao orotraqueal prolongada (76,7%). Nao houve mortalidade relacionada ao procedimento, e em todos os pacientes o procedimento pode ser realizado na UTI. As complicacoes imediatas ocorreram em 2 pacientes (2,7%), nos quais houve sangramento local aumentado que cessou com compressao local. A complicacao tardia foi a infeccao ao redor da ferida operatoria, a qual ocorreu em 2 pacientes (2,7%) e foi tratada com curativos locais, sem maiores repercussoes clinicas. CONCLUSOES: Com base nos resultados de nossa analise, os quais sao comparaveis aos resultados sobre traqueostomias realizadas no centro cirurgico encontrados na literatura, concluimos que a traqueostomia na UTI e viavel e apresenta baixo indice de complicacoes, mesmo quando realizada em pacientes graves por cirurgioes em treinamento. Portanto, a nosso ver, e possivel afirmar que vale a pena realizar a traqueostomia na UTI.

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.

Desenvolvimento e avaliação de um programa multimídia de computador para ensino de drenagem pleural

OBJECTIVE: To develop a multimedia educational computer program designed to teach pleural drainage techniques to health professionals, as well as to evaluate its efficacy. METHODS: We planned and developed a program, which was evaluated by 35 medical students, randomized into two groups. Group 1 comprised 18 students who studied using the program, and group 2 comprised 17 students who attended a traditional theoretical class given by an experienced teacher. Group 1 students were submitted to two subjective evaluations using questionnaires, and both groups took an objective theoretical test with multiple choice questions and descriptive questions. The results of the theoretical test were compared using the Mann-Whitney test. RESULTS: The subjective evaluation of the technological aspects and content of the program ranged from excellent to very good and good. The software was considered highly instructive by 16 students (88.9%), and 17 students (94.4%) thought it might partially substitute for traditional classes. Between the two groups, there was no significant difference in the multiple choice test results, although there was such a difference in the descriptive question results (p < 0.001), group 1 students scoring higher than did those in group 2. CONCLUSIONS: The computer program developed at the Federal University of Sao Paulo Paulista School of Medicine proved to be a feasible means of teaching pleural drainage techniques. The subjective evaluation of this new teaching method revealed a high level of student satisfaction, and the objective evaluation showed that the program was as efficacious as is traditional instruction.

Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients

OBJECTIVE: To determine morbidity and mortality rates by risk category in accordance with the American College of Chest Physicians guidelines, to determine what role pulmonary function tests play in this categorization process, and to identify risk factors for perioperative complications (PCs). METHODS: This was a historical cohort study based on preoperative and postoperative data collected for cases of lung cancer diagnosed or suspected between 2001 and 2010. RESULTS: Of the 239 patients evaluated, only 13 (5.4%) were classified as being at high risk of PCs. Predicted postoperative FEV1 (FEV1ppo) was sufficient to define the risk level in 156 patients (65.3%); however, cardiopulmonary exercise testing (CPET) was necessary for identifying those at high risk. Lung resection was performed in 145 patients. Overall morbidity and mortality rates were similar to those reported in other studies. However, morbidity and mortality rates for patients at an acceptable risk of PCs were 31.6% and 4.3%, respectively, whereas those for patients at high risk were 83.3% and 33.3%. Advanced age, COPD, lobe resection, and lower FEV1ppo were correlated with PCs. CONCLUSIONS: Although spirometry was sufficient for risk assessment in the majority of the population studied, CPET played a key role in the identification of high-risk patients, among whom the mortality rate was seven times higher than was that observed for those at an acceptable risk of PCs. The risk factors related to PCs coincided with those reported in previous studies.

Late-onset, insidious course and invasive treatment of congenital central hypoventilation syndrome in a case with the Phox2B mutation: case report

Congenital central hypoventilation syndrome (CCHS) is a rare disorder of respiratory control characterized by ventilatory impairment that results in arterial hypoxemia. This condition is worse during sleep and occurs in patients with normal mechanical properties of the lung. It is diagnosed in the absence of primary neuromuscular disease, identifiable brainstem lesions, and other sleep disturbances or substance use [1]. Amiel et al. [2] identified a mutation in the Phox2B gene associated with CCHS, characterized by five to nine alanine expansions within a 20-residue polyalanine region in exon 3 of the Phox2B gene. Several reports confirmed the findings of Amiel et al., supporting the view that this gene is a master switch for the development of the autonomic nervous system network linked to respiratory control [3–6]. Transgenic animals carrying the human Phox2B mutation develop a similar phenotype and lack glutamatergic neurons located in the parafacial region in the brainstem, which are involved in breathing control [7]. Although patients typically present with CCHS as newborns and rarely in later infancy, there have been reports of patients presenting with CCHS in adulthood. In cases of late-onset CCHS, most patients report having had some symptoms since childhood, and they have parents with a history of CCHS. Symptoms of right-sided heart failure are generally observed at the time of diagnosis, and nocturnal noninvasive ventilation is frequently indicated [8–15]. L. R. A. Bittencourt (*) :M. Pedrazzoli : F. Yagihara : G. P. Luz : S. Garbuio :G. A. Moreira : S. Tufik Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 925, 04024-002 Sao Paulo, Sao Paulo, Brazil e-mail: lia@psicobio.epm.br

Entrapped victims in motor vehicle collisions: characteristics and prehospital care in the city of São Paulo, Brazil

OBJECTIVE: To examine the severity of trauma in entrapped victims and to identify risk factors for mortality and morbidity. INTRODUCTION: Triage and rapid assessment of trauma severity is essential to provide the needed resources during prehospital and hospital phases and for outcome prediction. It is expected that entrapped victims will have greater severity of trauma and mortality than non‐entrapped subjects. METHODS: A transverse, case–control, retrospective study of 1203 victims of motor vehicle collisions treated during 1 year by the prehospital service in São Paulo, Brazil was carried out. All patients were drivers, comprising 401 entrapped victims (33.3%) and 802 non‐entrapped consecutive controls (66.7%). Sex, age, mortality rates, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), corporal segments, timing of the prehospital care and resource use were compared between the groups. The results were analysed by χ2, Zres, analysis of variance and Bonferroni tests. RESULTS: Entrapped victims were predominantly men (84.8%), aged 32±13.1 years, with immediate mortality of 10.2% and overall mortality of 11.7%. They had a probability of death at the scene 8.2 times greater than that of non‐entrapped victims. The main cause of death was hemorrhage for entrapped victims (45.2%) and trauma for non‐entrapped victims. Of the entrapped victims who survived, 18.7% had a severe GCS (OR = 10.62), 12% a severe RTS (OR = 9.78) and 23.7% were in shock (OR = 3.38). Entrapped victims were more commonly transported to advanced life support units and to tertiary hospitals. CONCLUSION: Entrapped victims had greater trauma severity, more blood loss and a greater mortality than respective, non‐entrapped controls.

Reoperação de tromboendarterectomia pulmonar em recidiva de tromboembolismo pulmonar crônico hipertensivo

Pulmonary thromboendarterectomy has been established as the standard method for the treatment of chronic thromboembolic pulmonary hypertension, with excellent results. However, repeat pulmonary thromboendarterectomy due to recurrence of pulmonary embolism has never been reported in the Brazilian literature. Its safety and effectiveness remain obscure. We report the case of a patient presenting recurrence of chronic thromboembolic pulmonary hypertension five years after the first pulmonary thromboendarterectomy and requiring a second operation for resolution of the symptoms.

Análise e validação de modelos probabilísticos de malignidade de nódulo pulmonar solitário em uma população no Brasil

OBJECTIVE: To analyze clinical and radiographic findings that influence the pathological diagnosis of solitary pulmonary nodule (SPN) and to compare/validate two probabilistic models for predicting SPN malignancy in patients with SPN in Brazil. METHODS: This was a retrospective study involving 110 patients diagnosed with SPN and submitted to resection of SPN at a tertiary hospital between 2000 and 2009. The clinical characteristics studied were gender, age, presence of systemic comorbidities, history of malignancy prior to the diagnosis of SPN, histopathological diagnosis of SPN, smoking status, smoking history, and time since smoking cessation. The radiological characteristics studied, in relation to the SPN, were presence of spiculated margins, maximum transverse diameter, and anatomical location. Two mathematical models, created in 1997 and 2007, respectively, were used in order to determine the probability of SPN malignancy. RESULTS: We found that SPN malignancy was significantly associated with age (p = 0.006; OR = 5.70 for age > 70 years), spiculated margins (p = 0.001), and maximum diameter of SPN (p = 0.001; OR = 2.62 for diameters > 20 mm). The probabilistic model created in 1997 proved to be superior to that created in 2007-area under the ROC curve (AUC), 0.79 ± 0.44 (95% CI: 0.70-0.88) vs. 0.69 ± 0.50 (95% CI: 0.59-0.79). CONCLUSIONS: Advanced age, greater maximum SPN diameter, and spiculated margins were significantly associated with the diagnosis of SPN malignancy. Our analysis shows that, although both mathematical models were effective in determining SPN malignancy in our population, the 1997 model was superior.

Estudo das pressões no interior dos balonetes de tubos traqueais

BACKGROUND AND OBJECTIVES Since controlling tracheal tube cuffs internal pressure is unusual and there is no detailed description in the literature on how to maintain it below 30 cmH2O without manometer, this study aimed at checking tracheal tube intra-cuff pressures in intensive care unit and operating room patients. A maneuver was tested to keep intra-cuff pressure below 30 cmH2O, but at minimum levels needed for ventilator cycling with no tidal volume leakage. METHODS Tracheal tube intra-cuff pressures were evaluated in 50 intensive care unit intubated patients (Group I) and 72 intubated patients in the operating room (Group II). A maneuver was tested to obtain the minimum tracheal tube intra-cuff pressure to maintain adequate ventilation with no air leakage. Initial tracheal tube intra-cuff pressure (P1) was recorded using a gaged digital manometer (cmH2O) coupled to a 15-ml syringe. Oropharynx secretion was aspirated. With the investigators external acoustic meatus positioned 10-20 cm apart from patients mouth and cuff connected to the manometer, cuff was slowly deflated until a murmur sound was heard, determined by tidal volume leakage during the inspiratory period of artificial ventilation. At this moment, cuff was slowly inflated until murmur disappearance. Final intra-cuff pressure (P2) and the remaining air volume in the manometer syringe (V) were recorded. RESULTS Mean P1 values in groups I and II were 85.3 and 56.2 cmH2O, respectively. Mean P2 values in groups I and II were 26.7 and 15.5 cmH2O, respectively. After the maneuver, standard deviation decreased from 56.3 to 8.2 in group I, and from 48 to 6.7 in group II. Maneuver has decreased cuff volume and pressure in 100% of group I patients, and in 97.3% of group II patients. CONCLUSIONS Both groups had intra-cuff pressures higher than necessary to keep ventilator cycling with no tidal volume leakage. Maneuver to keep intra-cuff pressure below 30 cmH2O was simple and cheap.JUSTIFICATIVA Y OBJETIVOS: Como no es de rutina el control de la presion en el interior de los balones de tubos traqueales, y como tambien no hay descripcion detallada en la literatura de como mantenerla abajo de los 30 cmH2O sin utilizacion de manometro, se decidio confirmar las presiones en el interior de los balones de tubos traqueales en pacientes bajo intubacion traqueal en la unidad de terapia intensiva y en el centro quirurgico, ensayando maniobras para mantener la presion en el balon abajo de 30 cmH2O, mas en niveles minimos necesarios para el ciclo del ventilador sin perdida del volumen corriente. METODO: Se estudiaron las presiones en el interior de balones de tubos traqueales de 50 pacientes bajo intubacion traqueal en la unidad de terapia intensiva (Grupo I) y 72 pacientes bajo intubacion traqueal en el centro quirurgico (Grupo II). Se experimento una maniobra para obtener la presion minima en el interior del balon del tubo traqueal, necesaria para una adecuada ventilacion, sin vaciamiento de aire. Se registro la presion inicial (P1) en el interior de los balones de los tubos traqueales utilizandose un manometro digital graduado en centimetros de agua, acoplado a una jeringa de 15 ml. Fue aspirada secrecion de la orofaringe. Con el meato acustico externo del examinador proximo de la boca del paciente entre 10 y 20 cm, se conecto el manometro al balon, que fue vaciado lentamente, hasta escucharse ruido en soplo, por el vaciamiento del volumen corriente en el periodo inspiratorio de la ventilacion artificial. En este momento, se lleno lentamente el balon hasta el desaparecimiento del ruido. Se anoto la presion final (P2) del balon y el volumen de aire que quedo en la jeringa del manometro (V). RESULTADOS: Las medias de las presiones P1 en los grupos I y II fueron 85,3 y 56,2 cmH2O, respectivamente. Las medias de presiones P2 en los grupos I y II fueron 26,7 y 15,5 cmH2O respectivamente. Despues de la maniobra hecha, el desvio patron bajo de 56,3 para 8,2 en el grupo I, y de 48 para 6,7 en el grupo II. En el grupo I, la maniobra redujo el volumen y la presion del balon en 100% de los pacientes y en el grupo II, en 97,3 %. CONCLUSIONES: Los dos grupos presentaron presiones en el interior de los balones en niveles arriba de lo necesario para el ciclo del ventilador sin perdida del volumen corriente. La maniobra para mantener la presion en el interior del balon en niveles inferiores a 30 cmH2O fue simples y de pequeno costo.