Milena Carlos Vidotto

Equações de referência para os testes de caminhada de campo em adultos saudáveis

OBJECTIVE: To develop regression equations for predicting six-minute and incremental shuttle walk distances (6MWD and ISWD, respectively), based on demographic characteristics, anthropometric variables, and grip strength. METHODS: We evaluated 6MWD and ISWD in 98 healthy adults. Height, weight, and grip strength were also assessed. Using data from 90 of the participants (40 males; 60 ± 9 years of age), we devised linear equations adjusted for age, gender, height, and weight, and we developed alternate models that included grip strength. We prospectively applied the equations in the 8 remaining participants (4 males; 59 ± 10 years), who had been randomly separated from the initial sample. RESULTS: Age, gender, height, and weight collectively explained 54.5% and 64.9% of the variance in 6MWD and ISWD, respectively, whereas age, height, weight, and grip strength collectively explained 54.4% and 69.0% of the respective variances. There was no significant difference between the measured and predicted 6MWD using equations with and without grip strength (14 ± 57 vs. 13 ± 67 m). Similar results were observed for ISWD (25 ± 104 vs. 25 ± 93 m). CONCLUSIONS: Grip strength is a determinant of ISWD and 6MWD; however, it could not improve the power of equations adjusted by demographic and anthropometric variables. The validity of our models including grip strength should be further evaluated in patients with skeletal muscle dysfunction.

Incidence and risk factors for postoperative pulmonary complications in elective intracranial surgery

OBJECT It has been shown that craniotomy may lead to a decrease in lung volumes and arterial blood gas tensions as well as a change in the respiratory pattern. The purpose of this study was to determine the incidence of postoperative pulmonary complications (PPCs) and the mortality rate in patients who have undergone elective craniotomy and to evaluate the associations between preoperative and postoperative variables and PPCs in this population. METHODS Two hundred thirty-six patients were followed up based on a protocol including a clinical questionnaire, physical examination and observation of clinical characteristics in the preoperative period, type of surgery performed, duration of surgery, time spent in the intensive care unit (ICU) and hospital, and the occurrence of any PPCs. RESULTS Postoperative pulmonary complications occurred in 58 patients (24.6%) and 23 other patients (10%) died. Predicting factors for PPCs according to multivariate analyses were as follows: type of surgery performed (p < 0.0001), prolonged mechanical ventilation >or= 48 hours (p < 0.0001), time spent in the ICU > 3 days (p < 0.0001), decrease in level of consciousness (p < 0.002), duration of surgery >or= 300 minutes (p < 0.01), and previous chronic lung disease (p < 0.04). CONCLUSIONS The incidence from March 2003 to March 2005 of PPCs in patients who had undergone craniotomy was 25% and death occurred in 10%. Some risk factors for PPCs may be predicted such as the type of surgery performed, prolonged mechanical ventilation, a longer time in the ICU, a decreased level of consciousness, duration of surgery, and previous chronic lung disease.

Functional aerobic exercise capacity limitation in adolescent idiopathic scoliosis

BACKGROUND CONTEXT Exercise limitation has been described in patients with adolescent idiopathic scoliosis (AIS); however, whether the walking performance is impaired in these patients should be elucidated. PURPOSE Thus, we aimed to evaluate the physiologic responses to the incremental shuttle walk test (ISWT) in patients with AIS. STUDY DESIGN/SETTING Cross-sectional study. PATIENT SAMPLE Twenty-nine patients with AIS and 20 healthy adolescents aged between 11 and 18 years old. OUTCOME MEASURES Oxygen uptake (VO₂), incremental shuttle walk distance (ISWD), ΔVO₂/Δwalking velocity, ΔHR/ΔVO₂, ΔVE/ΔVCO₂, and linearized Δtidal volume (VT)/ΔlnVE, forced expiratory volume in the first second of expiration (FEV1), and forced vital capacity (FVC). METHODS We performed two ISWTs, and the data used were acquired in the second test. We also evaluated the lung function and respiratory muscle strength through spirometry test and manovacuometry, respectively. All authors confirm that there are no conflicts of interest. To compare the means or medians of variables between patients and healthy subjects, we used the unpaired t test or Mann-Whitney U test, respectively. The correlations were assessed by Pearson or Spearman coefficients according to the distribution of the studied variables. The probability of alpha error was set at 5% for all analyses. RESULTS Adolescent idiopathic scoliosis patients showed significant lower values of ISWD, VO₂, and ventilation at the end of the ISWT, as well as lower FEV₁ and FVC; they also presented significantly shallower slope of ΔVT/ΔlnVE, whereas VO₂ related significantly with ISWD (r=0.80), FVC (r=0.78), FEV₁ (r=0.73), and ΔVT/ΔlnVE (r=0.58). CONCLUSIONS Adolescent idiopathic scoliosis correlated to walking limitation and was associated to reduced pulmonary function and worse breathing pattern during exercise. Our results suggest that walking-based aerobic exercises should be encouraged in these patients.

Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery

Patients undergoing neurosurgery are predisposed to a variety of complications related to mechanical ventilation (MV). There is an increased incidence of extubation failure, pneumonia, and prolonged MV among such patients. The aim of the present study was to assess the influence of extubation failure and prolonged MV on the following variables: postoperative pulmonary complications (PPC), mortality, reoperation, tracheostomy, and duration of postoperative hospitalization following elective intra-cranial surgery. The study involved a prospective observational cohort of 317 patients submitted to elective intracranial surgery for tumors, aneurysms and arteriovenous malformation. Preoperative assessment was performed and patients were followed up for the determination of extubation failure and prolonged MV (>48 h) until discharge from the hospital or death. The occurrence of PPC, incidence of death, the need for reoperation and tracheostomy, and the length of hospitalization were assessed during the postoperative period. Twenty-six patients (8.2%) experienced extubation failure and 30 (9.5%) needed prolonged MV after surgery. Multivariate analysis showed that extubation failure was significant for the occurrence of death (OR = 8.05 [1.88; 34.36]), PPC (OR = 11.18 [2.27; 55.02]) and tracheostomy (OR = 7.8 [1.12; 55.07]). Prolonged MV was significant only for the occurrence of PPC (OR = 4.87 [1.3; 18.18]). Elective intracranial surgery patients who experienced extubation failure or required prolonged MV had a higher incidence of PPC, reoperation and tracheostomy and required a longer period of time in the ICU. Level of consciousness and extubation failure were associated with death and PPC. Patients who required prolonged MV had a higher incidence of extubation failure.

Postoperative study of vital capacity and ventilation measurements following elective craniotomy

CONTEXT AND OBJECTIVE Changes in pulmonary function commonly occur after general surgery. The aims were to evaluate vital capacity, tidal volume and respiratory frequency among patients undergoing elective craniotomy and to determine possible correlations of these parameters with surgery duration and etiology for neurosurgery. DESIGN AND SETTING Prospective, open study at a tertiary university hospital. METHODS Twenty-six patients underwent elective craniotomy for aneurysm clipping (11) or tumor resection (15). Vital capacity (VC), tidal volume (TV), minute volume (VE) and respiratory rate were determined before the operation and on the first to fourth postoperative days. RESULTS There were significant decreases of 25% in VC, 22% in TV and 12% in VE (p < 0.05) and no significant increase in respiratory frequency (5%) on the first postoperative day. VE returned to baseline on the second postoperative day and TV on the third postoperative day, while VC was 8% lower on the fourth postoperative day, compared with before the operation (p < 0.05). VC reduction was significantly greater in patients undergoing aneurysm clipping (43%) than in patients undergoing tumor resection (14%) when surgery duration was more than four hours (p < 0.05), with no significant change when surgery duration was less than four hours. CONCLUSION Reductions in VC, TV and VE were observed during the postoperative period in patients undergoing aneurysm clipping or tumor resection. The reductions in VC and TV were greater in patients undergoing craniotomy due to aneurysm and with longer surgery duration.

Quality of life and physical limitations in primary brain tumor patients

ObjectiveTo correlate quality of life (QoL) and physical limitations in histological proven primary brain tumor patients using a battery of generic, disease-specific and symptom questionnaires.MethodsThirty patients with primary brain tumors were selected from a neuro-oncology outpatient clinic. The FACT-Br Functional Assessment of Cancer Therapy-Brain (specific quality of life questionnaire for patients with brain tumors), SF-36 (generic quality of life questionnaire), HADS (anxiety and depression), and Barthel Index (functionality scale) were answered by the patients at the same interview.ResultsThe Barthel index did not demonstrate correlation with any subscale of the FACT-Br questionnaire. The HADS had a negative correlation with all FACT-Br subscales and its total score. The SF-36 had a significant weak to moderate correlation with the FACT-Br questionnaire.ConclusionConsidering that the FACT-Br is a quick specific questionnaire, it can be a valuable and simple option in evaluating QoL in brain tumor patients with good functional capacity.

Analysis of Risk Factors for Extubation Failure in Subjects Submitted to Non-Emergency Elective Intracranial Surgery

BACKGROUND: Extubation failure is defined as the re-institution of respiratory support ranging from 24 to 72 hours following scheduled extubation and occurs in 2% to 25% of extubated patients. The aim of this study was to determine clinical and surgical risk factors that may predict extubation failure in patients submitted to non-emergency intracranial surgery. METHODS: This was a prospective observational cohort study. The study was carried out on 317 subjects submitted to non-emergency intracranial surgery for tumors, aneurysms, and arteriovenous malformation. Preoperative assessment was performed and subjects were followed up for the determination of extubation failure until either discharge from hospital or death. RESULTS: Twenty-six (8.2%) of the 317 subjects experienced extubation failure following surgery. The following variables were considered for the multivariate analysis: level of consciousness at the time of extubation, duration of mechanical ventilation prior to extubation, sex and the use of intraoperative mannitol. The multivariate analysis determined that the most important variable for extubation failure was the level of consciousness at the time of extubation (P = .001), followed by female sex, which also showed to be significant (P = .006). CONCLUSIONS: Lower level of consciousness (GCS 8T-10T) and female sex were considered risk factors for extubation failure in subjects submitted to elective intracranial surgery.

Incidence, indication and complications of postoperative reintubation after elective intracranial surgery

CONTEXT AND OBJECTIVE There are no reports on reintubation incidence and its causes and consequences during the postoperative period following elective intracranial surgery. The objective here was to evaluate the incidence of reintubation and its causes and complications in this situation. DESIGN AND SETTING Prospective cohort study, using data obtained at a tertiary university hospital between 2003 and 2006. METHODS 169 patients who underwent elective intracranial surgery were studied. Preoperative assessment was performed and the patients were followed up until hospital discharge or death. The rate of reintubation with its causes and complications was ascertained. RESULTS The incidence of reintubation was 12.4%, and the principal cause was lowered level of consciousness (71.5%). There was greater incidence of reintubation among females (P = 0.028), and greater occurrence of altered level of consciousness at the time of extubation (P < 0.0001). Reintubated patients presented longer duration of mechanical ventilation (P < 0.0001), longer stays in the intensive care unit (ICU) and in the hospital (P < 0.0001), greater incidence of pulmonary complications (P < 0.0001), greater need for reoperation and tracheostomy, and higher mortality (P < 0.0001). CONCLUSION The incidence of reintubation in these patients was 12.4%. The main cause was lowering of the level of consciousness. Female gender and altered level of consciousness at the time of extubation correlated with higher incidence of reintubation. Reintubation was associated with pulmonary complications, longer durations of mechanical ventilation, hospitalization and stay in the ICU, greater incidence of tracheostomy and mortality.

Pleural subxyphoid drain confers better pulmonary function and clinical outcomes in chronic obstructive pulmonary disease after off-pump coronary artery bypass grafting: a randomized controlled trial

OBJECTIVE To evaluate the lung function and clinical outcome in severe chronic obstructive pulmonary disease in patients undergoing off-pump coronary artery bypass grafting with left internal thoracic artery graft, comparing the pleural drain insertion in the intercostal versus subxyphoid region. METHODS A randomized controlled trial. Chronic obstructive pulmonary disease patients were randomized into two groups according pleural drain site: II group (n=27) - pleural drain in intercostal space; SI group (n=29) - pleural drain in the subxyphoid region. Spirometry values (Forced Vital Capacity - and Forced expiratory volume in 1 second) were obtained on preoperative and 1, 3 and 5 postoperative days. Chest x-ray from preoperative until postoperative day 5 (POD5) was performed for monitoring respiratory events, such as atelectasis and pleural effusion. Pulmonary shunt fraction and pain score was evaluate preoperatively and on postoperative day 1. RESULTS In both groups there was a significant decrease of the spirometry values (Forced Vital Capacity and Forced expiratory volume in 1 second) until POD5 (P<0.05). However, when compared, SI group presented less decrease in these parameters (P<0.05). Pulmonary shunt fraction was significantly lower in SI group (P<0.05). Respiratory events, pain score, orotracheal intubation time and postoperative length of hospital stay were lower in the SI group (P<0.05). CONCLUSION Subxyphoid pleural drainage in severe Chronic obstructive pulmonary disease patients determined better preservation and recovery of pulmonary capacity and volumes with lower pulmonary shunt fraction and better clinical outcomes on early postoperative off-pump coronary artery bypass grafting.

Functional Assessment of Cancer Therapy-Brain questionnaire: translation and linguistic adaptation to Brazilian Portuguese

CONTEXT AND OBJECTIVE Quality of life assessment among patients with brain tumors is important, given that new treatments have increased patient survival. The aim of this study was to translate the Functional Assessment of Cancer Therapy-Brain (FACT-Br) questionnaire (version 4) into Portuguese, carry out cross-cultural adaptation and assess its reproducibility. DESIGN AND SETTING Cohort at the Universidade Federal de São Paulo (Unifesp). METHODS Forty patients with a brain tumor seen at the neuro-oncology outpatient clinic participated in the study. The process of translation and back-translation was carried out, along with adaptation to the Portuguese language and Brazilian culture. The intraclass correlation coefficient (ICC) was used to test the reproducibility of the FACT-Br (version 4). RESULTS The reproducibility of the questionnaire was excellent (ICC = 0.95; 95% confidence interval, CI: 0.89-0.97). The ICC with a mean interval of 15 days between applications of the questionnaire was very good in all domains (ICC = 0.87 to 0.95). The mean time taken to answer the questionnaire was 6.27 ± 2.26 minutes, ranging from 3 to 11 minutes. CONCLUSION The translated version of the FACT-Br questionnaire (version 4) adapted to the Portuguese language and Brazilian culture proved to be easily understood and achieved very good reproducibility among patients with diagnoses of brain tumors.