External validation of the parsimonious EuroLung risk models: analysis of the Brazilian Lung Cancer Registry.

OBJECTIVE: The purpose of this study was to assess performance in the Brazilian Lung Cancer Registry Database by using the parsimonious EuroLung risk models for morbidity and mortality. METHODS: The EuroLung1 and EuroLung2 models were tested and evaluated through calibration (calibration plot, Brier score, and the Hosmer-Lemeshow test) and discrimination (ROC AUCs), in a national multicenter registry of 1,031 patients undergoing anatomic lung resection. RESULTS: The evaluation of performance in Brazilian health care facilities utilizing risk-adjustment models, specifically EuroLung1 and EuroLung2, revealed substantial miscalibration, as evidenced by calibration plots and Hosmer-Lemeshow tests in both models. In terms of calibration, EuroLung1 exhibited a calibration plot with overlapping points, characterized by a slope of 1.11 and a Brier score of 0.15; the Hosmer-Lemeshow test yielded a statistically significant p-value of 0.015; and the corresponding ROC AUC was 0.678 (95% CI: 0.636-0.721). The EuroLung2 model displayed better calibration, featuring fewer overlapping points in the calibration plot, with a slope of 1.22, with acceptable discrimination, as indicated by a ROC AUC of 0.756 (95% CI: 0.670-0.842). Both models failed to accurately predict morbidity and mortality outcomes in this specific health care context. CONCLUSIONS: Discrepancies between the EuroLung model predictions and outcomes in Brazil underscore the need for model refinement and for a probe into inefficiencies in the Brazilian health care system.

Ultrasound evaluation in the postoperative period for surgical treatment of thoracic infectious and inflammatory diseases.

OBJECTIVE: This study aims to evaluate the role of TUSG in the postoperative period and the detection of early complications after surgical treatment, pulmonary resection, or decortication for infectious and inflammatory thoracic diseases, comparing with the standard method (Chest Radiography ‒ CXR). METHODS: Prospective non-randomized self-controlled study. Twenty-one patients over 16 years of age have undergone surgical treatment of inflammatory and infectious lung diseases. These patients were followed up with CXR and TUSG (performed on the 1st and 3rd postoperative days and/or after the chest tube removal). RESULTS: Both exams demonstrated similar results regarding their ability to safely predict the adequate moment for chest drain removal. TUSG allowed chest drain removal in 30% of cases and CXR in 34%. Statistical analysis demonstrates that both exams have similar capabilities in detecting postoperative changes in the pleural space. However, the authors report that TUSG is statistically more accurate in detecting subcutaneous emphysema than CXR (p = 0.037, Kappa [κ = 0.3068]). The analysis of other parameters showed no statistical difference. CONCLUSION: The authors conclude that TUSG in trained hands is equivalent to CXR in searching for postoperative complications regarding the surgical treatment of infectious and inflammatory thoracic diseases and can be used as a complement, and not a substitute, to CXR, when CCT is not feasible, or a more urgent diagnosis is needed.

Resident physician training in bedside pleural procedures: A one-year experience at a teaching hospital.

BACKGROUND AND OBJECTIVE: This study aims to quantify bedside pleural procedures performed at a quaternary teaching hospital describing technical and epidemiological aspects. MATERIALS AND METHODS: The authors retrospectively reviewed consecutive patients who underwent invasive thoracic bedside procedures between March 2022 and February 2023. RESULTS: 463 chest tube insertions and 200 thoracenteses were performed during the study period. Most procedures were conducted by 1st-year Thoracic Surgery residents, with Ultrasound Guidance (USG). There was a notable preference for small-bore pigtail catheters, with a low rate of immediate complications. CONCLUSION: Bedside thoracic procedures are commonly performed in current medical practice and are significant in surgical resident training. The utilization of pigtail catheters and point-of-care ultrasonography by surgical residents in pleural procedures is increasingly prevalent and demonstrates high safety.

Evaluation of the RAPID score as a predictor of postoperative morbidity and mortality in patients undergoing pulmonary decortication for stage III pleural empyema.

OBJECTIVE: This study aims to correlate the RAPID score with the 3-month survival and surgical results of patients undergoing lung decortication with stage III pleural empyema. METHODS: This was a retrospective study with the population of patients with pleural empyema who underwent pulmonary decortication between January 2019 and June 2022. Data were collected from the institution's database, and patients were classified as low, medium, and high risk according to the RAPID score. The primary outcome was 3-month mortality. Secondary outcomes were the length of hospital stay, readmission rate, and the need for pleural re-intervention. RESULTS: Of the 34 patients with pleural empyema, according to the RAPID score, patients were stratified into low risk (23.5 %), medium risk (47.1 %), and high risk (29.4 %). The high-risk group had a 3-month mortality of 40 %, while the moderate-risk group had a 6.25 % and the low-risk group had no deaths within 90 days, confirming a good correlation with the RAPID score (p < 0.05). Sensitivity and specificity for the primary outcome in the high-risk score were 80.0 % and 79.3 %, respectively. The secondary outcomes did not reach statistical significance. CONCLUSIONS: In this retrospective series, the RAPID score had a good correlation with 3-month mortality in patients undergoing lung decortication. The morbidity indicators did not reach statistical significance. The present data justifies further studies to explore the capacity of the RAPID score to be used as a selection tool for treatment modality in patients with stage III pleural empyema.

The association of visceral pleural invasion with skip N2 metastasis on clinical stage IA NSCLC.

BACKGROUND: Lung lymphatic drainage occurs mainly through a peribronchial path, but it is hypothesized that visceral pleural invasion could alter this path. This study aims to investigate the association between visceral pleural invasion, node upstaging, and N2 skip metastasis and the impact on survival in a population of patients with non-small cell lung cancer of 3 cm or smaller. METHODS: We retrospectively queried our institutional database of lung cancer resection for all patients with clinical stage IA NSCLC between June 2009 and June 2022. We collected baseline characteristics and clinical and pathological staging data. Patients were classified into two groups: The non-VPI group with negative visceral pleural invasion and the VPI group with positive. The primary results analyzed were the occurrence of nodal upstaging, skip N2 metastasis and recurrence. RESULTS: There were 320 patients analyzed. 61.3 % were women; the median age was 65.4 years. The pleural invasion occurred in 44 patients (13.7 %). VPI group had larger nodules (2.3 vs. 1.7 cm; p < 0.0001), higher 18F-FDG uptake (7.4 vs. 3.4; p < 0.0001), and lymph-vascular invasion (35.7 % vs. 13.5 %, p = 0.001). Also, the VPI group had more nodal disease (25.6 % vs. 8.7 %; p = 0.001) and skip N2 metastasis (9.3 % vs. 1.8 %; p = 0.006). VPI was a statistically independent factor for skip N2 metastasis. Recurrence occurred in 17.2 % of the population. 5-year disease-free and overall survival were worse in the VPI group. CONCLUSIONS: The visceral pleural invasion was an independent factor associated with N2 skip metastasis and had worse disease-free and overall survival.

Prolonged survival after thoracic metastasectomy in patients with nonseminomatous testicular cancer.

INTRODUCTION: Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates. METHODS: Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method. RESULTS: Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality. CONCLUSION: Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors.

Practice patterns and trends in surgical treatment for chronic lung infections: a survey from the Brazilian Society of Thoracic Surgery.

Background: Chronic lung infections represent a diversity of clinical entities that combined respond to significant public health, particularly in developing countries. However, there is no data regarding the practice patterns, surgeons' preferences, and technological usage, especially among Brazilian surgeons, in the setting of the surgical treatment of chronic lung infections. We, therefore, surveyed Brazilian thoracic surgeons from the Brazilian Society of Thoracic Surgery (SBCT) about practice patterns and trends in surgical treatment for chronic lung infections. Methods: A cross-sectional anonymous survey of all thoracic surgeons from the Brazilian Society was conducted in 2019. As the study was purely descriptive no further statistical evaluation was performed. Results: The responsive rate was 34% (259/766) from 23 of the 26 states in Brazil. A total of 141 (54.4%) participants reported their institution as a surgical reference for chronic infection lung disease, only 13.1% of surgeons have a high-volume service (more than 11 cases operated annually). The majority (76.2%) of respondents performed 1-5 surgical resection to treat tuberculosis (TB) sequelae, but only 62 (30.1%) had performed more than one resection to treat active TB. Chronic lung infection (76%) and hemoptysis (66%) were the most common symptoms as surgical indications. A proportion of 42.2% of the respondents do not have and/or perform routine drug sensitivity tests. In addition, 19.3% of respondents were not familiar with the recommendations of surgery in the treatment of pulmonary TB. Video-assisted thoracoscopic surgery (VATS) is available for 80% of respondents, while robotic surgery is for only 10%. Most (86%) surgeons have access to surgical staplers. Among the structural resources, respiratory isolation beds in the intensive care unit (ICU) (80%) and ward (79%) are frequently available resources. However, less than 12% of surgeons have in their institution a specific operating room for sputum-positive patients. Conclusions: Lung resection for chronic infectious disease is an essential area of activity for thoracic surgeons in Brazil, which occurs mainly in the public sphere, with no concentration of cases per surgeon or institution. The lack of adequate resources in many centers justifies the creation of reference centers for improving care for these patients.

Current morbimortality and one-year survival after pneumonectomy for infectious diseases.

OBJECTIVE: Identify the one-year survival rate and major complications in patients submitted to pneumonectomy for infectious disease. METHODS: Retrospective data from all cases of infectious disease pneumonectomy over the past 10 years were collected from two reference centers. The authors analyzed: patient demographics, etiology, laterality, bronchial stump treatment, presence of previous pulmonary resection, postoperative complications in the first 30 days, the treatment used in pleural complications, and one-year survival rate. RESULTS: 56 procedures were performed. The average age was 44 years, with female predominance (55%). 29 cases were operated on the left side (51%) and the most frequent etiology was post-tuberculosis (51.8%). The overall incidence of complications was 28.6% and the most common was empyema (19.2%). Among empyema cases, 36.3% required pleurostomy, 27.3% required pleuroscopy and 36.3% underwent thoracoplasty for treatment. Bronchial stump fistula was observed in 10.7% of cases. From all cases, 16.1% were completion pneumonectomies and 62.5% of these had some complication, a significantly higher incidence than patients without previous surgery (p = 0.0187). 30-day in-hospital mortality was (7.1%) with 52 cases (92.9%) and 1-year survival. The causes of death were massive postoperative bleeding (1 case) and sepsis (3 cases). CONCLUSIONS: Pneumonectomy for benign disease is a high-risk procedure performed for a variety of indications. While morbidity is often significant, once the perioperative risk has passed, the one-year survival rate can be very satisfying in selected patients with benign disease.

Risk factors related to pleural empyema after talc slurry pleurodesis.

OBJECTIVE: Empyema is a complication of talc-pleurodesis that may lead to further surgical intervention and death. Therefore, the present study's objective was to identify the risk factors for the development of post-pleurodesis empyema after talc slurry pleurodesis in order to better select patients for this procedure and minimize its morbidity. METHODS: Patients with malignant pleural effusion who underwent talc slurry pleurodesis at the present institution from January 2018 to January 2020 were retrospectively analyzed. Post-pleurodesis empyema was defined as pleural infection up to 30 days after pleurodesis. Using Cox regression analysis, significant prognostic factors for the development of empyema were examined. RESULTS: Of the 86 patients identified for inclusion in the study, 62 were women (72%). Their mean age was 56.3±12.6 years. The median pleural drainage time was 9 days, and 20 patients (23.3%) developed empyema. In the univariate analysis, both drainage time (p = 0.038) and the use of antibiotics prior to pleurodesis (p < 0.001) were risk factors for pleural empyema. Multivariate analysis also identified the use of antibiotics as an independent risk factor (Odds Ratio [OR] 9.81; 95% Confidence Interval [95% CI] 2.87‒33.54). Although the pulmonary expansion was not associated with empyema in the multivariate analysis, patients with less than 50% pulmonary expansion had a 4.5-times increased risk of empyema (95% CI 0.90‒22.86; p = 0.067), and patients with 50‒70% pulmonary expansion had a 3.8-times increased risk of empyema (95% CI 0.98‒15; p = 0.053) after pleurodesis. CONCLUSION: The study suggests that antibiotic therapy prior to talc slurry pleurodesis may increase the risk of developing empyema. Furthermore, pleurodesis should be considered with caution in patients with long-duration chest tube placement and incomplete lung expansion.

Quality of life in patients with malignant pleural effusion treated with an indwelling pleural catheter in an emerging country.

BACKGROUND: The use of Indwelling Pleural Catheter (IPC) in the care of patients with Malignant Pleural Effusion (MPE) is well established, however studies involving public health systems of low and middle-income countries are still lacking. This study aimed to determine the effect of IPC on the respiratory symptoms and Quality of Life (QoL) of patients with MPE in the setting of a Brazilian public health system. METHODS: From August 2015 to November 2019, patients with MPE underwent IPC placement and were prospectively followed. QoL and respiratory symptoms were assessed by the EORTC questionnaires (QLQ-30; LC13) and Visual Analogue Scale (VAS), respectively, at pre-treatment, 30 , and 60 days after IPC placement. RESULTS: 56 patients were enrolled with 57 catheters inserted. The mean age was 63 (23‒88) years, of which 17 (30%) were men and 39 (70%) were women. Breast 24 (42%) and lung 21 (37%) were the main primary neoplasms. Cellulitis was the most common complication and all patients recovered with appropriate antimicrobial therapy. QoL did not change significantly over time, however, the VAS showed a significant improvement in dyspnea (+1.2: -0.5; p = 0.001). CONCLUSION: IPC relieves respiratory symptoms without compromising the QoL, with a low complication rate. It represents a suitable option for patients with MPE and short LE in an emerging country.

Conservative Management of Asymptomatic Adnexal Masses Classified as Benign by the IOTA ADNEX Model: A Prospective Multicenter Portuguese Study.

This prospective multicentric study aiming to determine the incidence of complications (malignant transformation, torsion or rupture) during conservative management of adnexal masses was performed in two Portuguese tertiary referral hospitals. It included ≥18-year-old, non-pregnant patients with asymptomatic adnexal masses (associated IOTA ADNEX risk of malignancy < 10%) sonographically diagnosed between January 2016 and December 2020. Conservative patient management consisted of serial clinical and ultrasound assessment up to 60 months of follow-up, spontaneous resolution of the formation or surgical excision (median follow-up: 17.8; range 9-48 months). From the 573 masses monitored (328 premenopausal and 245 postmenopausal adnexal masses), no complications were observed in 99.5%. The annual lesion growth rates and increases in morphological complexity were similar in the premenopausal and postmenopausal patients. Spontaneous resolution, evidenced in 16.4% of the patients, was more common in the premenopausal group (p < 0.05). Surgical intervention was performed in 18.4% of the cases; one borderline and one invasive FIGO IA stage cancer were diagnosed. There was an isolated case of ovary torsion (0.17%). These data support conservative management as a safe option for sonographically benign, stable and asymptomatic adnexal masses before and after menopause and highlight the need for expedite treatment of symptomatic or increased-morphological-complexity lesions.

Pneumomediastinum in COVID-19 disease: Outcomes and relation to the Macklin effect.

AIM: Pneumomediastinum (PM) is associated with several etiologies and mechanisms. Although it has been described more than 100 years ago, the literature is limited to small retrospective studies. This study aimed to follow patients with coronavirus disease (COVID-19) that developed PM during hospitalization and describe their clinical and radiological evolution. METHODS: A prospective cohort was developed with patients with PM, excluding those with aerodigestive trauma, inside a hospital COVID-19 dedicated hospital. Clinical variables including onset of symptoms, hemodynamic instability, associated complications, the need of interventions, and disease course were all recorded. Also, radiological findings such as the presence of the Macklin effect, extension of lung involvement by COVID-19, and characteristics of the PM were analyzed. RESULTS: Twenty-one patients with non-traumatic PM were followed, resulting in an overall incidence of 0.5% during the study period. Seven (33%) patients had associated pneumothorax and malignant/tension PM was observed in three (14%) cases. The Macklin effect could be found in 11 patients (52%) and the majority of them had more than 50% of lung involvement due to COVID-19. The mortality rate was 49%; however, no deaths were directly related to the PM. CONCLUSIONS: PM incidence is probably increased in the severe acute respiratory syndrome caused by COVID-19, especially in those with greater involvement of the lungs, and the Macklin effect may be an important underlying mechanism of this complication. Usually, PM has a benign course, but complications like tension/malignant PM may occur requiring prompt detection and intervention.

Floating aquatic macrophytes for the treatment of aquaculture effluents.

Aquaculture is an activity with economic and social importance since it generates food, employment, and income. However, like other human activities, it negatively impacts the environment, in this respect mainly due to the production of effluents rich in sedimentable solids, organic matter, phosphorus, and nitrogen. These last two are responsible for the eutrophication of water courses, causing changes in the aquatic biota. Hence, there is a need to adopt strategies to improve the efficiency of wastewater reuse. In this sense, the objective of this work was to evaluate the efficiency of using the floating aquatic macrophytes Eichhornia crassipes, Pistia stratiotes, and Salvinia molesta for the treatment of aquaculture effluents. The experiment was conducted in a completely randomized design, with seven treatments and three repetitions; the treatments were the following: T1, without plant, treated only with sedimentation; T2, Eichhornia crassipes; T3, Pistia stratiotes; T4, Salvinia molesta; T5, Eichhornia crassipes and Pistia stratiotes; T6, Eichhornia crassipes and Salvinia molesta; and T7, Pistia stratiotes and Salvinia molesta. The treatments were evaluated for a period of 168 h: the first collection of effluent allowed analysis of the raw effluent; the second occurred 24 h after the first collection and the others, on alternate days with 72, 120, and 168 h, totaling five collections in each experimental unit. The effluent used came from breeding tanks of Nile Tilapia (Oreochromis niloticus). The quality of the effluent was evaluated by the rate of removal of nutrients N-total, N-nitrite, N-nitrate, N-ammoniacal and Ptotal, temperature, pH, turbidity, dissolved oxygen, electrical conductivity, total alkalinity, BDO, and CDO. After the effluent was treated, the values of the parameters were compared with the maximum admissible values (MAVs), as specified by Brazil's National Environmental Council (CONAMA) in Resolutions 430/2011 and 357/2005. With the use of floating aquatic macrophytes, the concentrations of all evaluated limnology parameters improved significantly. There was also an improvement in the physical aspect of the effluent (transparency and turbidity). Thus, it can be concluded that the use of the macrophytes Eichhornia crassipes, Pistia stratiotes, and Salvinia molesta is effective in the treatment of effluents from fish farming.

Salinity tolerance of macroalgae Gracilaria birdiae / Tolerânciaà salinidade da macroalga Gracilaria birdiae

ABSTRACT: This study aimed to determining the manner in which salinity influenced the growth of the macroalgae Gracilaria birdiae, with the objective of identifying its tolerance limits to this abiotic variable. The specimens were submitted to nutrient-enriched water of varying salinities (0, 10, 20, 30, 40, 50, and 60 ppt) for a 30-day period. Initially, under extreme salinity conditions (0 and 60 ppt) the growth of the G. birdiae suffered a negative impact. The macroalgae biomass exposed to 0 and 10 ppt salinities showed a reduction from day six until the experiment was completed. The macroalgae biomass exposed to salinities 20, 30, 40, and 50 ppt showed an increase, with no significant differences between the four treatments. This suggested that this salinity range was comfortable for this species to develop. We concluded that salinity is a crucial parameter which controls the growth of the G. birdiae. This seaweed was negatively influenced when exposed to values equal to or below 10 ppt and equal to 60 ppt, demonstrating good tolerance to salinities of 20, 30, 40 and 50 ppt.

RESUMO: Objetivamos com o presente trabalho avaliar os efeitos da salinidade sobre o crescimento da macroalga Gracilaria birdiae, visando identificar os seus limites de tolerância a esta variável abiótica. Os exemplares foram submetidos a água com salinidades 0, 10, 20, 30, 40, 50 e 60 ppt enriquecida com nutrientes por um período de 30 dias. Inicialmente a G. birdiae foi negativamente afetada em condições de salinidades extremas (0 e 60 ppt). A biomassa das macroalgas expostas a salinidade 0 e 10 ppt declinou a partir do 6º dia até o final do experimento. Houve aumento na biomassa das macroalgas expostas as salinidades 20, 30, 40 e 50 ppt, não apresentando diferenças significativas entre estes quatro tratamentos, sugerindo este intervalo de salinidade como sendo ótimo para o desenvolvimento desta espécie. Concluímos que a salinidade é um parâmetro importante para controlar o crescimento da G. birdiae, sendo afetada negativamente quando exposta a valores igual ou menor que 10 ppt e igual a 60 ppt, possuindo tolerância às salinidades de 20, 30, 40 e 50 ppt.

Efeito do tipo de sedimento na eficiência alimentar, crescimento e sobrevivência de Litopenaeus vannamei (Boone, 1931) / Effect of sediment type on feed efficiency, growth and survival of Litopenaeus vannamei (Boone, 1931)

Este estudo avaliou o desempenho zootécnico do camarão marinho Litopenaeus vannamei em diferentes tipos de substratos não consolidados. Juvenis (0,97 ± 0,27 g) foram aclimatados na densidade de 52 m-2, em 21 caixas de polietileno com biofiltros individuais, em um sistema fechado de filtração contínua, sendo submetidos aos tratamentos: 1) A = 25% silte + 25% argila + 25% areia muito fina + 25% areia fina; 2) B = 50% areia fina + 50% areia muito fina e 3) Controle = sem substrato, em um delineamento experimental completamente casualizado, com três tratamentos e sete repetições cada. Os animais foram alimentados com 12% da biomassa/dia com ração peletizada (35% de proteína bruta), ofertada em bandejas e parcelada em duas ofertas diárias (8 e 16h). O estudo teve duração de 48 dias, sendo avaliados: consumo aparente de ração, eficiência alimentar, taxa de crescimento específico, sobrevivência e ganho de peso. Foram acompanhados diariamente salinidade, pH, amônia e temperatura da água. A análise estatística dos dados se deu por meio dos testes Anova ou Kuskal-Wallis, em função da sua parametricidade. Não foram observadas diferenças significativas com relação aos fatores avaliados nas diferentes granulometrias de sedimento testadas, indicando que estas não exerceram influência sobre o desempenho zootécnico de L. vannamei juvenil.

This study aimed to evaluate the zootechnical performance of Litopenaeus vannamei shrimp at different types of unconsolidated substrate. Juvenile shrimp (0.97 ± 0.27 g) were acclimatized, in a stocking density of 52 m-2, to 21 polyethylene boxes (50 L) connected individually to biofilters in a closed water exchange system. The animals were submitted to the treatments: 1) A = 25% silt + 25% clay + 25% very fine sand + 25% fine sand; 2) B = 50% fine sand + 50% very fine sand and 3) Control = no sediment, with seven replications each. Photoperiod was set on 12L: 12D. Shrimps were fed twice a day (at 08:00 and 16:00h) with 12% total biomass day-1. Food was offered in feeding trays 2 cm from the substrate. The experiment had a duration of 48 days, evaluating: apparent ration intake, food efficiency, specific growth rate, survival and weight gain. During this period, water quality was monitored daily. Data was analyzed by Anova or Kuskal-Wallis test, depending on normality (SigmaStat 3.1, 2004 and STATISTICA 6.0, 2001). There were no differences among groups regarding weight gain, food intake, SGR and survival, indicating that these did not exert influence on the zootechnical performance of L. vannamei juvenil.