Healing of tumor-induced osteomalacia as assessed by high-resolution peripheral quantitative computed tomography is not similar across the skeleton in the first years following complete tumor excision.

Tumor-induced osteomalacia is caused by excessive fibroblast growth factor 23 production mainly from phosphaturic mesenchymal tumors. Surgical excision or tumor ablation are the preferred treatment. Information on bone microarchitecture parameters assessed by high-resolution peripheral quantitative computed tomography is limited. We report a woman with hypophosphatemic osteomalacia with generalized pain, weakness and recurrent fractures, and a large thoracic vertebral mass extending to the posterior mediastinum. Detailed radiologic and histopathologic evaluation revealed a phosphaturic mesenchymal tumor. Two surgeries were necessary for complete removal of the mass. Clinical symptoms improved after attaining normophosphatemia. Four-year post-surgical HR-pQCT parameters, compared to baseline, showed in the left distal radius, stable trabecular and cortical volumetric bone mineral density although below reference range. There was stability of trabecular number and thickness. Both stiffness and failure load decreased. A shift in cortical parameters was noted in year 2. In the left distal tibia, trabecular volumetric bone mineral density decreased whereas cortical volumetric bone mineral density markedly increased, as did cortical area. There was stability in the trabecular number and thickness. Both stiffness and failure load improved. Findings from HR-pQCT measurements in this patient disclosed that the healing of osteomalacia is not similar across the peripheral skeletal sites in the first years following tumor removal. Results contrasted low but stable volumetric bone mineral density in the distal radius with increase in the distal tibia at the expense of cortical bone. Our report helps further delineate the pattern of bone healing after treatment of this rare bone disorder.

Evaluation of compensatory hyperhidrosis after sympathectomy: The use of an objective method.

OBJECTIVE: To investigate the prevalence of compensatory hyperhidrosis following videothoracic sympathectomy to treat palmoplantar hyperhidrosis and its effect on sweating in the chest, abdomen, back and thighs. Furthermore, to evaluate the concordance between a subjective and an objective method of assessment for compensatory hyperhidrosis. METHODS: Forty patients with combined palmar and plantar hyperhidrosis who underwent video-assisted thoracoscopic sympathectomy (15 women and 25 men, with a mean age of 25 years) were prospectively followed for 1 year. Subjective and objective parameters were evaluated, using respectively a questionnaire and a sudorometer (Vapometer). RESULTS: In the subjective analysis, in the first month, only 10% of patients did not have compensatory hyperhidrosis, and 70% continued to report it at 1 or more sites after 1 year. In the objective analysis, 35% of the patients did not present compensatory hyperhidrosis after 1 month, and this number persisted stable, with 30% of patients remaining free of compensatory hyperhidrosis after 1 year. The most frequent area affected by compensatory hyperhidrosis was the back in both assessments. There was no positive concordance between the results of the objective and subjective analysis at any time in any of the 4 regions studied. CONCLUSIONS: Compensatory hyperhidrosis is a very common postoperative side effect after videothoracic sympathectomy, occurring early after the procedure and persisting for prolonged periods of time. The most frequently affected body area is the back, and no concordance between objective and subjective assessments was observed.

Objective evaluation of plantar hyperhidrosis after sympathectomy.

OBJECTIVE: The aim of the present study was to prospectively, randomly, blindly, and objectively investigate how surgery affects plantar sudoresis in patients with palmar and plantar hyperhidrosis over a one-year period using a sudorometer (VapoMeter). METHODS: From February 2007 to May 2009, 40 consecutive patients with combined palmar hyperhidrosis and plantar hyperhidrosis underwent video-assisted thoracic sympathectomy at the T3 or T4 ganglion level (15 women and 25 men, with a mean age of 25 years). RESULTS: Immediately after the operation and during the one-year follow-up, all of the patients were free from palmar hyperhidrosis episodes. Compensatory hyperhidrosis of varying degrees was observed in 35 (87.5%) patients after one year. Only two (2.5%) patients suffered from severe compensatory hyperhidrosis. There was a large initial improvement in plantar hyperhidrosis in 46.25% of the cases, followed by a progressive regression of that improvement, such that only 30% continued to show this improvement after one year. The proportion of patients whose condition worsened increased progressively (from 21.25% to 47.50%), and the proportion of stable patients decreased (32.5% to 22.50%). This was not related to resection level; however, a lower intensity of plantar hyperhidrosis prior to sympathectomy correlated with worse evolution. CONCLUSION: Patients with palmar hyperhidrosis and plantar hyperhidrosis who underwent video-assisted thoracic sympathectomy to treat their palmar hyperhidrosis exhibited good initial improvement in plantar hyperhidrosis, which then decreased to lesser degrees of improvement over a one-year period following the surgery. For this reason, video-assisted thoracic sympathectomy should not be performed when only plantar hyperhidrosis is present.

Objective evaluation of plantar hyperhidrosis after sympathectomy

OBJECTIVE: The aim of the present study was to prospectively, randomly, blindly, and objectively investigate how surgery affects plantar sudoresis in patients with palmar and plantar hyperhidrosis over a one-year period using a sudorometer (VapoMeter). METHODS: From February 2007 to May 2009, 40 consecutive patients with combined palmar hyperhidrosis and plantar hyperhidrosis underwent video-assisted thoracic sympathectomy at the T3 or T4 ganglion level (15 women and 25 men, with a mean age of 25 years). RESULTS: Immediately after the operation and during the one-year follow-up, all of the patients were free from palmar hyperhidrosis episodes. Compensatory hyperhidrosis of varying degrees was observed in 35 (87.5%) patients after one year. Only two (2.5%) patients suffered from severe compensatory hyperhidrosis. There was a large initial improvement in plantar hyperhidrosis in 46.25% of the cases, followed by a progressive regression of that improvement, such that only 30% continued to show this improvement after one year. The proportion of patients whose condition worsened increased progressively (from 21.25% to 47.50%), and the proportion of stable patients decreased (32.5% to 22.50%). This was not related to resection level; however, a lower intensity of plantar hyperhidrosis prior to sympathectomy correlated with worse evolution. CONCLUSION: Patients with palmar hyperhidrosis and plantar hyperhidrosis who underwent video-assisted thoracic sympathectomy to treat their palmar hyperhidrosis exhibited good initial improvement in plantar hyperhidrosis, which then decreased to lesser degrees of improvement over a one-year period following the surgery. For this reason, video-assisted thoracic sympathectomy should not be performed when only plantar hyperhidrosis is present.

Quantitative assessment of the intensity of palmar and plantar sweating in patients with primary palmoplantar hyperhidrosis.

OBJECTIVE: To compare individuals with and without hyperhidrosis in terms of the intensity of palmar and plantar sweating. METHODS: We selected 50 patients clinically diagnosed with palmoplantar hyperhidrosis and 25 normal individuals as controls. We quantified sweating using a portable noninvasive electronic device that has relative humidity and temperature sensors to measure transepidermal water loss. All of the individuals had a body mass index of 20-25 kg/cm². Subjects remained at rest for 20-30 min before the measurements in order to reduce external interference. The measurements were carried out in a climate-controlled environment (21-24ºC). Measurements were carried out on the hypothenar region on both hands and on the medial plantar region on both feet. RESULTS: In the palmoplantar hyperhidrosis group, the mean transepidermal water loss on the hands and feet was 133.6 ± 51.0 g/m²/h and 71.8 ± 40.3 g/m²/h, respectively, compared with 37.9 ± 18.4 g/m²/h and 27.6 ± 14.3 g/m²/h, respectively, in the control group. The differences between the groups were statistically significant (p < 0.001 for hands and feet). CONCLUSIONS: This method proved to be an accurate and reliable tool to quantify palmar and plantar sweating when performed by a trained and qualified professional.

Avaliação quantitativa da intensidade da transpiração palmar e plantar em pacientes portadores de hiperidrose palmoplantar primária / Quantitative assessment of the intensity of palmar and plantar sweating in patients with primary palmoplantar hyperhidrosis

OBJETIVO: Comparar a intensidade de transpiração em palmas das mãos e planta dos pés de indivíduos portadores de hiperidrose com a de um grupo controle. MÉTODOS: Foram selecionados 50 pacientes com diagnóstico clínico de hiperidrose palmoplantar e 25 indivíduos controles. Um método objetivo de quantificação da transpiração foi utilizado com um aparelho eletrônico portátil, não invasivo, com sensores de umidade relativa e de temperatura capazes de quantificar a perda de água transepidérmica. Todos os indivíduos apresentavam índice de massa corpórea de 20-25 kg/cm² e permaneceram em repouso por 20-30 min antes das medições para reduzir a interferência externa. A mensuração foi realizada em sala climatizada com a temperatura de 21-24ºC. Os locais determinados para a aferição foram região hipotenar da face palmar e região medial da face plantar. RESULTADOS: No grupo com hiperidrose palmoplantar, as médias da intensidade de transpiração nas mãos e nos pés foram de, respectivamente, 133,6 ± 51,0 g/m²/h e 71,8 ± 40,3 g/m²/h, enquanto, no grupo controle, essas foram de 37,9 ±18,4 g/m²/h e 27,6 ± 14,3 g /m²/h. As diferenças das médias entre os grupos foram estatisticamente significativas (p < 0,001). CONCLUSÕES: Este método de quantificação mostrou-se uma ferramenta precisa e confiável na avaliação da transpiração palmar e plantar, quando operado por um profissional treinado e capacitado.

OBJECTIVE: To compare individuals with and without hyperhidrosis in terms of the intensity of palmar and plantar sweating. METHODS: We selected 50 patients clinically diagnosed with palmoplantar hyperhidrosis and 25 normal individuals as controls. We quantified sweating using a portable noninvasive electronic device that has relative humidity and temperature sensors to measure transepidermal water loss. All of the individuals had a body mass index of 20-25 kg/cm². Subjects remained at rest for 20-30 min before the measurements in order to reduce external interference. The measurements were carried out in a climate-controlled environment (21-24ºC). Measurements were carried out on the hypothenar region on both hands and on the medial plantar region on both feet. RESULTS: In the palmoplantar hyperhidrosis group, the mean transepidermal water loss on the hands and feet was 133.6 ± 51.0 g/m²/h and 71.8 ± 40.3 g/m²/h, respectively, compared with 37.9 ± 18.4 g/m²/h and 27.6 ± 14.3 g/m²/h, respectively, in the control group. The differences between the groups were statistically significant (p < 0.001 for hands and feet). CONCLUSIONS: This method proved to be an accurate and reliable tool to quantify palmar and plantar sweating when performed by a trained and qualified professional.

Pleural effusion following ovarian hyperstimulation.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.

Derrame pleural secundário à hiperestimulação ovariana / Pleural effusion following ovarian hyperstimulation

A síndrome de hiperestimulação ovariana (SHEO) é uma complicação iatrogênica que ocorre na fase lútea de um ciclo hormonal induzido. Na maioria dos casos, os sintomas são autolimitados e regridem espontaneamente. Entretanto, casos graves comumente cursam com desconforto respiratório agudo. O objetivo deste estudo foi descrever a apresentação clínica, o tratamento e os desfechos de derrame pleural associado a SHEO em três pacientes submetidas a fertilização in vitro. A idade das pacientes variou de 27 a 33 anos, e o aparecimento do derrame pleural sintomático (bilateral em todos os casos) ocorreu, em média, 43 dias (variação: 27-60 dias) após o início da terapia hormonal para a indução da ovulação. Todas as pacientes necessitaram de internação hospitalar para reposição volêmica maciça, e duas delas necessitaram de ventilação mecânica não invasiva. Embora todas as pacientes tenham sido inicialmente submetidas à toracocentese, a recidiva precoce dos sintomas e do derrame pleural fez com que se optasse pela drenagem pleural com cateter do tipo pigtail. Apesar do alto débito de drenagem (média de 1.000 mL/dia na primeira semana) e do tempo de drenagem prolongado (9-22 dias), os desfechos foram excelentes (alta hospitalar). Embora o derrame pleural secundário a SHEO seja provavelmente subdiagnosticado, a morbidade associada não deve ser subestimada, principalmente devido a seus efeitos em pacientes potencialmente gestantes. Nesta série de casos, o diagnóstico precoce e as medidas de suporte clínico adequadas permitiram uma evolução favorável, limitando a abordagem cirúrgica a uma drenagem pleural adequada.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.

Objective evaluation of patients with palmar hyperhidrosis submitted to two levels of sympathectomy: T3 and T4.

This study compares the results obtained of video-assisted sympathectomy performed on two distinct ganglion levels (third vs. fourth thoracic ganglion) in the treatment of palmar hyperhidrosis (PH), through a blind randomized clinical trial. All participants were randomized into two groups of 20 patients (G3 and G4) and underwent the operation, and were followed for 12 months. We used an objective method for measuring sweat, checking the transepidermal water loss (TEWL), and evaluated the quality-of-life (QoL) before and after the operation. All patients (n=40) ceased suffering from PH after surgery, with statistical difference when we compared the values of TEWL palmar preoperatively with their respective values at one week, one month, six months and 12 months. The main side effect observed was compensatory hyperhidrosis (CH), which was most frequent in G3 after 12 months of follow-up. There was an improvement in QoL since the first evaluation of the postoperative period with no difference between groups. Both techniques were effective in the treatment of PH, generating objective reduction of TEWL regardless of the ganglion operated. Sympathectomy G3 had a higher incidence of CH, yet the improvement in QoL was similar in both groups.

Tratamento da hiperidrose palmo-plantar pela simpatectomia videotoracoscópica: terceiro versus quarto gânglio torácico / Treatment of palmoplantar hyperhidrosis by video-assisted thoracoscopic sympathectomy: third versus fourth thoracic ganglion

Introdução: Atualmente, a simpatectomia torácica videoassistida tornou-se o tratamento de escolha para hiperidrose palmar. O principal efeito colateral após operação é a hiperidrose compensatória (HC), sendo considerada a maior causa de insatisfação pelos pacientes. Objetivo: Comparar os resultados obtidos com a simpatectomia torácica videotoracoscópica realizada em dois níveis ganglionares distintos (terceiro versus quarto gânglio torácico) no tratamento da hiperidrose palmo-plantar, por meio de um ensaio clínico randomizado e cego. Método: Foram selecionados 40 pacientes entre fevereiro de 2007 e maio de 2009. Os participantes foram aleatorizados em dois grupos de 20 pacientes (G3 e G4) e submetidos à operação com seguimento de 12 meses (1ª semana, 1° mês, 6° mês e 12° mês). Utilizamos um método objetivo para mensuração do suor, aferindo a TEWL (transepidermal water loss) pelo VapoMeter, além da avaliação da qualidade de vida antes e após a operação. Também foram estudados: resolução da hiperidrose palmar, incidência e intensidade da HC. Resultados: Todos os pacientes apresentaram resolução da hiperidrose palmar após a operação, com diferença estatística em relação ao fator tempo, quando comparados os valores da TEWL palmar no pré-operatório com os seus respectivos valores na 1ª semana, 1° mês, 6° mês e 12° mês. O principal efeito colateral observado foi a hiperidrose compensatória, incidindo com maior frequência no grupo G3 após 12 meses de seguimento; apesar disto, não houve diferença estatística em relação à intensidade (gravidade) da HC nos grupos estudados. Verificou-se melhora da qualidade de vida desde a primeira avaliação do pós-operatório, sem diferença entre os grupos, que assim se manteve até o fim do estudo. As regiões mais acometidas pela HC foram dorso, tórax, abdome e coxas; no entanto, não houve diferença estatística da TEWL mensurada nessas regiões após 12 meses de acompanhamento. Conclusão: Ambas as técnicas foram efetivas no tratamento...

Introduction: Currently, video-assisted thoracic sympathectomy has become the preferred treatment for palmar hyperhidrosis. The main side effect after surgery remains compensatory hyperhidrosis (CH), considered the major cause of dissatisfaction for patients. Objective: To compare the results obtained of video-assisted sympathectomy performed on two distinct ganglion levels (third versus fourth thoracic ganglion) in the treatment of palmo-plantar hyperhidrosis, through a blind randomized clinical trial. Method: We selected 40 patients from February 2007 to May 2009. All participants were randomized into two groups of 20 patients (G3 and G4) and underwent the operation, being followed for 12 months (1 week, 1 month, 6 months and 12th month). We used an objective method for measuring sweat, checking the "TEWL (transepidermal water loss) measured by the"VapoMeter", and evaluated the quality of life before and after the operation. Also studied were: palmar hyperhidrosis, incidence and intensity of the CH. Results: All patients ceased suffering from palmar hyperhidrosis after surgery, with statistical difference regarding the time factor when we compared the values of "TEWL" palmar preoperatively with their respective values at 1 week, 1 month, 6 months and 12th month. The main side effect observed was compensatory sweating, most frequent in G3 after 12 months of follow-up; despite this, there was no statistical difference regarding the intensity (severity) of CH in both groups. There was an improvement in quality of life since the first evaluation of the postoperative period, with no difference between groups, and so it remained until the end of follow-up. The areas most affected by CH were back, chest, abdomen and thighs; however, there was no statistical difference in the "TEWL" measured in these areas after 12 months of follow-up. Conclusion: Both techniques were effective in the treatment of palmar hyperhidrosis, generating objective reduction...

Is sympathectomy at T4 level better than at T3 level for treating palmar hyperhidrosis?

PURPOSE: We compared the results from a video-assisted thoracoscopic sympathectomy (VTS) at the T4 denervation level with those from a VTS at the T3 level for the treatment of palmar hyperhydrosis (PH). METHODS: Seventy patients with PH were prospectively followed for VTS at the T3 or T4 denervation levels for 6 months. The end points of this study were: absence of PH, compensatory hyperhydrosis (CH), and quality-of-life assessment. RESULTS: Sixty-seven patients reported a complete resolution of PH after surgery. One failure occurred in the T3 group and 2 in the T4 group. When anhydrosis was obtained, we noticed totally dry hands in 26 patients in the T3 group and 6 patients in the T4 group. The other 27 patients in the T4 group and 8 in the T3 group maintained a small level of sweating and were also considered to be therapeutic successes. At 6 months, 25 patients in the T4 group had some degree of CH (71.42%) and all patients in the T3 group (100%), though the T4 group had a lower degree of severity of CH at the 6-month follow-up (P < 0.05). After the operation, quality of life was improved similarly in both groups. CONCLUSIONS: VTS at either the T3 or T4 level provides an effective treatment for PH. VTS at the T4 level is associated with a less severe form of CH. Despite the occurrence of CH, patients' quality of life is significantly improved following VTS at the T3 or T4 levels. For this reason, the T4 resection can now be used as a treatment for PH.

[Pneumothorax after acupuncture: clinical presentation and management]. / Pneumotórax pós-acupuntura: apresentação clínica e tratamento.

INTRODUCTION: Pneumothorax is a rare but dangerous complication of acupuncture. Because of its rarity, there are few reports in literature and, therefore little information regarding clinical and therapeutic aspects. This article aims to analyze the clinical presentation, management and follow-up of patients with pneumothorax after acupuncture. METHODS: Retrospective study of patients with post-acupuncture pneumothorax evaluated in a tertiary hospital during a five-year period (2001-2006). RESULTS: Five patients (3 male and 2 female), mean age 46 years (30-73) were included. All patients but one (who had a bilateral pneumothorax) had left-sided pneumothorax . Chest pain, which was the initial symptom in all patients was severe in three cases and mild in two. Four patients underwent tube thoracostomy (pig-tail catheter), three of them immediately after admission and the other after a failed 12-hour conservative treatment period. One patient had a successful conservative management. All had an excellent outcome and were asymptomatic and exhibited a normal chest X-ray at 6-month follow-up CONCLUSION: In all patients, the initial symptom was chest pain, of varying intensity. Tube thoracostomy was the therapeutic modality most frequently employed. All patients had a successful outcome with no further complications.

Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation.

BACKGROUND: Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. OBJECTIVE: To determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications. METHOD: Retrospective medical chart review of all patients that underwent elective tracheostomy between April 1999 and December 2005 at ICU of three private hospitals. RESULTS: The study group comprised 552 patients with a mean age of 69.6 +/- 15.8 years. The incidence of significant complications (until 30 days after the procedure) was 4.34% (24 cases): 9 minor bleeding, 9 major bleeding, 2 subcutaneous emphysema, 4 stomal infections. Late complications were: laryngotracheal stenosis in 2 and tracheoinomminate fistula in 1 patient. CONCLUSIONS: OBT seems to be a safe and simple procedure, when performed by a team of experienced physicians under controlled circumstances, and should be considered as an option for ICU patients.

Evaluation of plantar hyperhidrosis in patients undergoing video-assisted thoracoscopic sympathectomy.

BACKGROUND: Sympathectomy is the treatment of choice for primary hyperhidrosis. One curious occurrence that is difficult to explain from an anatomophysiological point of view in cases of video-assisted thoracoscopic sympathectomy (VATS) for the treatment of palmar hyperhidrosis (PH) is the observed improvement in plantar hyperhidrosis (PLH). Nevertheless, current reports on VATS rarely describe the effect on PLH or just give superficial data. The aim of this study was to prospectively investigate, how surgery affects PLH in patients with PH and PLH over one-year period. METHODS: From May 2003 to January 2004, 70 consecutive patients with combined PH and PLH underwent VATS at the T2, T3, or T4 ganglion level (47 women and 23 men, with mean age of 23 years). RESULTS: Immediately after the operation, all the patients said they were free from PH episodes, except for two patients (2.8%) who suffered from continued PH. Compensatory hyperhidrosis (CH) of various degrees was observed in 58 (90.6%) patients after one year. Only 13 (20.3%) suffered from severe CH. There was a great initial improvement in PLH in 50% of the cases, followed by progressive regression, such that only 23.4% still presented that improvement after one year. The number of cases without overall improvement increased progressively (from 17.1% to 37.5%) and the numbers with slight improvement remained stable (32.9-39.1%). Of the 24 patients with no improvement after one year, 6 patients graded plantar sweating worse. CONCLUSION: Patients with PH and PLH who undergo VATS to treat their PH present a good initial improvement in PLH that reduces to a lower level of improvement after the one-year period.

Pneumotórax pós-acupuntura: apresentação clínica e tratamento / Pneumothorax after acupuncture: clinical presentation and management

OBJETIVOS: Apesar de raro, o pneumotórax é um evento adverso da acupuntura potencialmente grave. Visto sua baixa freqüência, apenas relatos de casos são disponíveis e faltam informações quanto os seus aspectos clínicos e terapêuticos. O objetivo deste trabalho é avaliar apresentação clínica, tratamento e evolução do pneumotórax pós-acupuntura. MÉTODOS: Análise retrospectiva de pacientes com pneumotórax pós-acupuntura tratados em hospital terciário no período 2001 2006. RESULTADOS: Cinco pacientes (Três homens e duas mulheres) com idade média de 46 anos (30 73) foram incluídos. Com exceção de um caso em que houve pneumotórax bilateral, em todos houve perfuração pleural à esquerda. Dor torácica foi o sintoma inicial em todos os pacientes, sendo intensa em três casos, levando a procura imediata por serviço de emergência; e leve em dois casos. Quatro pacientes foram tratados com drenagem pleural (três imediatamente após a admissão e uma após falha de tratamento conservador), devido à sintomatologia exuberante e/ou volume do pneumotórax, e um paciente foi tratado conservadoramente. Todos os pacientes apresentaram evolução clínica satisfatória após resolução do pneumotórax e, em seguimento de 6 meses após o evento, apresentavam-se assintomáticos e sem alterações significativas à radiografia de tórax. CONCLUSÃO: Dor torácica ocorreu em todos os casos, em intensidade variável; a drenagem pleural foi a terapêutica mais frequentemente instituída; e todos os casos evoluíram satisfatoriamente, sem complicações.

INTRODUCTION: Pneumothorax is a rare but dangerous complication of acupuncture. Because of its rarity, there are few reports in literature and, therefore little information regarding clinical and therapeutic aspects. This article aims to analyze the clinical presentation, management and follow-up of patients with pneumothorax after acupuncture. METHODS: Retrospective study of patients with post-acupuncture pneumothorax evaluated in a tertiary hospital during a five-year period (2001-2006). RESULTS: Five patients (3 male and 2 female), mean age 46 years (30 73) were included. All patients but one (who had a bilateral pneumothorax) had left-sided pneumothorax . Chest pain, which was the initial symptom in all patients was severe in three cases and mild in two. Four patients underwent tube thoracostomy (pig-tail catheter), three of them immediately after admission and the other after a failed 12-hour conservative treatment period. One patient had a successful conservative management. All had an excellent outcome and were asymptomatic and exhibited a normal chest X-ray at 6-month follow-up CONCLUSION: In all patients, the initial symptom was chest pain, of varying intensity. Tube thoracostomy was the therapeutic modality most frequently employed. All patients had a successful outcome with no further complications.

Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation

BACKGROUND: Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. OBJECTIVE: To determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications. METHOD: Retrospective medical chart review of all patients that underwent elective tracheostomy between April 1999 and December 2005 at ICU of three private hospitals. RESULTS: The study group comprised 552 patients with a mean age of 69.6 ± 15.8 years. The incidence of significant complications (until 30 days after the procedure) was 4.34 percent (24 cases): 9 minor bleeding, 9 major bleeding, 2 subcutaneous emphysema, 4 stomal infections. Late complications were: laryngotracheal stenosis in 2 and tracheoinomminate fistula in 1 patient. CONCLUSIONS: OBT seems to be a safe and simple procedure, when performed by a team of experienced physicians under controlled circumstances, and should be considered as an option for ICU patients.

INTRODUÇÃO: A traqueostomia é um procedimento eletivo realizado em pacientes de unidades de terapia intensiva sob ventilação mecânica prolongada. O risco associado ao transporte, custos e dificuldades de agendamento cirúrgico são alguns obstáculos para uma maior aceitação da traqueostomia. O uso de rígidos critérios de seleção para a realização deste procedimento a beira do leito exclui muitos pacientes que se beneficiariam deste método. OBJETIVO: Determinar à segurança da traqueostomia convencional a beira do leito como procedimento de rotina (sem a utilização dos critérios de seleção) em unidades de terapia intensiva, considerando as complicações intra e pós-operatórias. MÉTODO: Revisão retrospectiva de prontuários de pacientes submetidos à traqueostomia eletiva nas unidades de terapia intensiva de três hospitais privados no período de abril de 1999 a dezembro de 2005. RESULTADOS: Foram incluídos 552 pacientes com idade media de 69.6 ± 15.8 anos. A incidência de complicações pós-operatórias (até o 30° pós-operatório) foi 4.34 por cento (24 casos): 9 sangramentos leves, 9 sangramentos importantes, 2 enfisemas subcutâneos, 4 infecções do estoma. As complicações tardias observadas foram: estenose laringotraqueal em 2 pacientes e fistula traqueo-inominada em 1 paciente. CONCLUSÃO: A traqueostomia convencional a beira do leito parece ser um procedimento simples e seguro quando realizado por equipe experiente em condições controladas, deve, portanto ser considerada como uma opção para pacientes em terapia intensiva sob ventilação prolongada.

Palmar hyperhidrosis--which is the best level of denervation using video-assisted thoracoscopic sympathectomy: T2 or T3 ganglion?

PURPOSE: This study compares early results of video-assisted thoracoscopic sympathectomy (VTS) at the thoracic T2 versus T3 ganglion denervation levels for the treatment of palmar hyperhidrosis (PH). METHODS: Sixty patients with PH were prospectively randomized for VTS at the thoracic T2 or T3 ganglion denervation levels. The patients underwent postoperative evaluation on three occasions: before surgery, and 1 and 6 months after the operation. Endpoints included the absence of PH, the presence, location, and severity of compensatory hyperhidrosis (CH), and a quality-of-life assessment. RESULTS: Fifty-nine of 60 patients reported complete resolution of PH after surgery. One failure occurred in the T3 group. CH was observed in 26 patients (86.66%) in the T2 group and in 27 patients (90%) in the T3 group at 1 month. At 6 months, 30 of 30 patients in the T2 group and 29 of 30 in the T3 group experienced CH, although in the T3 group, CH was less severe at both 1 and 6 months (P < .05). Quality of life was very poor in both groups before surgery. One month after operation, quality of life was improved similarly in both groups. This improvement was maintained at 6 months in both groups. CONCLUSION: PH is well treated by VTS at either the T2 or T3 levels. Denervation at the T3 level appears associated with less severe CH in the early postoperative period. Quality of life improved significantly in both groups.