Minimally invasive interventions for biopsy of malignancy-suspected pulmonary nodules: a systematic review and meta-analysis.

BACKGROUND: Imaging tests are important for diagnosis during the management of pulmonary nodules; however, biopsy is required to confirm the malignancy. OBJECTIVES: To compare the effects of different techniques used for the biopsy of a pulmonary nodule. DESIGN AND SETTING: Systematic review and meta-analysis were conducted using Cochrane methodology in São Paulo, São Paulo, Brazil. METHODS: We conducted a systematic review of randomized controlled trials (RCTs) on minimally invasive techniques, including tomography-guided percutaneous biopsy (PERCUT), transbronchial biopsies with fluoroscopy (FLUOR), endobronchial ultrasound (EBUSR), and electromagnetic navigation (NAVIG). The primary outcomes were diagnostic yield, major adverse events, and need for another approach. RESULTS: Seven RCTs were included (913 participants; 39.2% female, mean age: 59.28 years). Little to no increase was observed in PERCUT over FLUOR (P = 0.84), PERCUT over EBUSR (P = 0.32), and EBUSR over NAVIG (P = 0.17), whereas a slight increase was observed in NAVIG over FLUOR (P = 0.17); however, the evidence was uncertain. EBUSR may increase the diagnostic yield over FLUOR (P = 0.34). PERCUT showed little to no increase in all bronchoscopic techniques, with uncertain evidence (P = 0.02). CONCLUSION: No biopsy method is definitively superior to others. The preferred approach must consider availability, accessibility, and cost, as safety and diagnostic yield do not differ. Further RCTs planned, conducted, and reported with methodological rigor and transparency are needed, and additional studies should assess cost and the correlation between nodule size and location, as well as their association with biopsy results. SYSTEMATIC REVIEW REGISTRATION: PROSPERO database, CRD42018092367 -https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=92367.

Minimally invasive interventions for biopsy of malignancy-suspected pulmonary nodules: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Imaging tests are important for diagnosis during the management of pulmonary nodules; however, biopsy is required to confirm the malignancy. OBJECTIVES: To compare the effects of different techniques used for the biopsy of a pulmonary nodule. DESIGN AND SETTING: Systematic review and meta-analysis were conducted using Cochrane methodology in São Paulo, São Paulo, Brazil. METHODS: We conducted a systematic review of randomized controlled trials (RCTs) on minimally invasive techniques, including tomography-guided percutaneous biopsy (PERCUT), transbronchial biopsies with fluoroscopy (FLUOR), endobronchial ultrasound (EBUSR), and electromagnetic navigation (NAVIG). The primary outcomes were diagnostic yield, major adverse events, and need for another approach. RESULTS: Seven RCTs were included (913 participants; 39.2% female, mean age: 59.28 years). Little to no increase was observed in PERCUT over FLUOR (P = 0.84), PERCUT over EBUSR (P = 0.32), and EBUSR over NAVIG (P = 0.17), whereas a slight increase was observed in NAVIG over FLUOR (P = 0.17); however, the evidence was uncertain. EBUSR may increase the diagnostic yield over FLUOR (P = 0.34). PERCUT showed little to no increase in all bronchoscopic techniques, with uncertain evidence (P = 0.02). CONCLUSION: No biopsy method is definitively superior to others. The preferred approach must consider availability, accessibility, and cost, as safety and diagnostic yield do not differ. Further RCTs planned, conducted, and reported with methodological rigor and transparency are needed, and additional studies should assess cost and the correlation between nodule size and location, as well as their association with biopsy results. SYSTEMATIC REVIEW REGISTRATION: PROSPERO database, CRD42018092367 -https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=92367.

Traditional chest drainage versus drainage by thoracotomy: a prospective randomized study.

OBJECTIVE: To compare the chest tube drainage by the same thoracotomy intercostal space with the traditional approach in patients undergoing muscle-sparing thoracotomy. METHODS: We evaluated 40 patients aged ≥18 years who underwent elective muscle sparing thoracotomies. Patients were divided into two groups of 20 patients. One group underwent thoracic drainage by the same intercostal space of thoracotomy and the other by traditional chest drainage approach. RESULTS: The mean length of hospital stay for the intercostal drainage group in the intensive care unit was 1.5 day (1.0 to 2.0 days) and 2.0 days (25.1 to 3.0 days) for the traditional chest drainage group (p=0.060). The intercostal drainage group had mean length of hospital stay (p=0.527) and drainage (p=0.547) of 4 days, and the traditional chest drainage group and 2 and 5.5 days, respectively. Dipirona and tramadol doses did not differ between groups (p=0.201 and p=0.341). The mean pain scale values on first postoperative was 4.24 in the drainage by the same intercostal group and 3.95 in the traditional chest drainage (p=0.733). In third postoperative day, mean was 3.18 for the first group and 3.11 for the traditional group (p=0.937). In the 15th day after surgery, drainage by the incision was 1.53 and the traditional chest drainage was 2.11 (p=0.440), 30th days after drainage by incision was 0.71 and traditional chest drainage was 0.84 (p=0.787). Complications, for both groups were similar with 30% in proposed drainage and 25% in traditional approach (p=0.723). CONCLUSION: Drainage by the same thoracotomy intercostal space was feasible and results 30 days after surgery were not inferior to those of the traditional chest drainage approach.

Traditional chest drainage versus drainage by thoracotomy: a prospective randomized study / Drenagem torácica tradicional versus drenagem pela toracotomia: estudo prospectivo randomizado

ABSTRACT Objective To compare the chest tube drainage by the same thoracotomy intercostal space with the traditional approach in patients undergoing muscle-sparing thoracotomy. Methods We evaluated 40 patients aged ≥18 years who underwent elective muscle sparing thoracotomies. Patients were divided into two groups of 20 patients. One group underwent thoracic drainage by the same intercostal space of thoracotomy and the other by traditional chest drainage approach. Results The mean length of hospital stay for the intercostal drainage group in the intensive care unit was 1.5 day (1.0 to 2.0 days) and 2.0 days (25.1 to 3.0 days) for the traditional chest drainage group (p=0.060). The intercostal drainage group had mean length of hospital stay (p=0.527) and drainage (p=0.547) of 4 days, and the traditional chest drainage group and 2 and 5.5 days, respectively. Dipirona and tramadol doses did not differ between groups (p=0.201 and p=0.341). The mean pain scale values on first postoperative was 4.24 in the drainage by the same intercostal group and 3.95 in the traditional chest drainage (p=0.733). In third postoperative day, mean was 3.18 for the first group and 3.11 for the traditional group (p=0.937). In the 15th day after surgery, drainage by the incision was 1.53 and the traditional chest drainage was 2.11 (p=0.440), 30th days after drainage by incision was 0.71 and traditional chest drainage was 0.84 (p=0.787). Complications, for both groups were similar with 30% in proposed drainage and 25% in traditional approach (p=0.723). Conclusion Drainage by the same thoracotomy intercostal space was feasible and results 30 days after surgery were not inferior to those of the traditional chest drainage approach.

RESUMO Objetivo Comparar a drenagem torácica pela mesma intercostotomia à drenagem tradicional em pacientes submetidos à toracotomia poupadora lateral. Métodos Foram avaliados 40 pacientes maiores de 18 anos submetidos a toracotomias poupadoras laterais eletivas. Eles foram separados em dois grupos de 20 pacientes cada, sendo um submetido à drenagem torácica pelo mesmo espaço intercostal da toracotomia e o outro à drenagem tradicional. Resultados No grupo da drenagem pela mesma intercostotomia, a mediana de tempo de internação em unidade de terapia intensiva foi de 1,5 dia (1,0 a 2,0 dias) e de 2,0 dias (1,25 a 3,0 dias) na drenagem tradicional (p=0,060). As medianas do tempo de internação (p=0,527) e de drenagem (p=0,547) foram ambas de 4 dias, no primeiro grupo, e de 2 e 5,5 dias, no grupo com drenagem tradicional. As doses utilizadas de dipirona e de tramadol não apresentaram diferenças estatísticas entre os grupos (p=0,201 e p=0,341). As médias da escala de dor foram 4,24 no primeiro dia pós-operatório do grupo com a drenagem proposta e 3,95 nos drenados da forma tradicional (p=0,733); no terceiro pós-operatório, foi de 3,18 para o grupo drenado pela incisão e de 3,11 nos drenados da forma tradicional (p=0,937). No 15º dia após a cirurgia, a drenagem pela incisão foi de 1,53 e a tradicional de 2,11 (p=0,440); no 30º pós-operatório, foi de 0,71 e 0,84, respectivamente, para a incisão e a forma tradicional (p=0,787). Em relação às complicações, os grupos foram semelhantes, com 30% na drenagem proposta e 25% na drenagem tradicional (p=0,723). Conclusão A drenagem pelo mesmo espaço intercostal foi exequível e não apresentou inferioridade à técnica tradicional no período pós-operatório estudado de 30 dias.

Comparative study of transepidermal water loss in patients with and without hyperhidrosis by closed-chamber measurer in an air-conditioned environment.

OBJECTIVE: To evaluate the difference in transepidermal water loss in patients diagnosed with hyperhidrosis and healthy subjects, in an air-conditioned environment. METHODS: Twenty patients diagnosed with hyperhidrosis and 20 healthy subjects were subjected to quantitative assessment using a closed-chamber device, in six previously established sites. RESULTS: The measurements showed different transepidermal water loss values for healthy subjects and patients with hyperhidrosis, especially in the hands and feet. In the Control Group, the median for the hands was 46.4g/m2/hour (p25: 36.0; p75: 57.6), while in the Hyperhidrosis Group, the median was 123.5g/m2/hour (p25: 54.3; p75: 161.2) - p<0.001. For the feet, the Control Group had a median of 41.5g/m2/hour (p25: 31.3; p75: 63.5) and the Hyperhidrosis Group, 61.2g/m2/hour (p25: 32.3; p75: 117) - p<0.02. Measurements of the axillas also showed differences. In the Control Group, the median was 14.8g/m2/hour (p25: 11.8; p75: 19.0) and, in the Hyperhidrosis Group, 83.5g/m2/hour (p25: 29.5; p75: 161.7) - p<0.001. CONCLUSION: Measuring transepidermal water loss is sufficient for diagnosis and follow-up of patients with hyperhidrosis.

Comparative study of transepidermal water loss in patients with and without hyperhidrosis by closed-chamber measurer in an air-conditioned environment / Estudo comparativo da perda transepidérmica de água em pacientes com e sem hiperidrose por mensurador de câmara fechada em ambiente climatizado

ABSTRACT Objective To evaluate the difference in transepidermal water loss in patients diagnosed with hyperhidrosis and healthy subjects, in an air-conditioned environment. Methods Twenty patients diagnosed with hyperhidrosis and 20 healthy subjects were subjected to quantitative assessment using a closed-chamber device, in six previously established sites. Results The measurements showed different transepidermal water loss values for healthy subjects and patients with hyperhidrosis, especially in the hands and feet. In the Control Group, the median for the hands was 46.4g/m2/hour (p25: 36.0; p75: 57.6), while in the Hyperhidrosis Group, the median was 123.5g/m2/hour (p25: 54.3; p75: 161.2) - p<0.001. For the feet, the Control Group had a median of 41.5g/m2/hour (p25: 31.3; p75: 63.5) and the Hyperhidrosis Group, 61.2g/m2/hour (p25: 32.3; p75: 117) - p<0.02. Measurements of the axillas also showed differences. In the Control Group, the median was 14.8g/m2/hour (p25: 11.8; p75: 19.0) and, in the Hyperhidrosis Group, 83.5g/m2/hour (p25: 29.5; p75: 161.7) - p<0.001. Conclusion Measuring transepidermal water loss is sufficient for diagnosis and follow-up of patients with hyperhidrosis.

RESUMO Objetivo Avaliar a diferença entre a perda transepidérmica de água aferida entre pacientes com e sem diagnóstico de hiperidrose, em ambiente climatizado. Métodos Foram selecionados 20 pacientes com diagnóstico de hiperidrose e 20 hígidos, submetidos à aferição de maneira quantitativa, com mensurador de câmara fechada, em seis locais previamente estabelecidos. Resultados As medidas realizadas mostraram valores diferentes de perda transepidérmica de água em pessoas hígidas e naquelas com hiperidrose, principalmente em mãos e pés. No Grupo Controle, a mediana das aferições em mãos foi 46,4g/m2/hora (p25: 36,0; p75: 57,6), enquanto, no Grupo Hiperidrose, obtivemos a mediana de 123,5g/m2/hora (p25: 54,3; p75: 161,2) - p<0,001. Já nos pés, a mediana no Grupo Controle foi 41,5g/m2/hora (p25: 31,3; p75: 63,5) e, no Grupo Hiperidrose, foi 61,2g/m2/hora (p25: 32,3; p75: 117) - p<0,02. As medidas das regiões axilares também mostraram diferença. No Grupo Controle, obtivemos mediana 14,8g/m2/hora (p25: 11,8; p75: 19,0) e, no Hiperidrose, 83,5g/m2/hora (p25: 29,5; p75: 161,7) - p<0,001. Conclusão A mensuração da perda transepidérmica de água é suficiente para diagnóstico e acompanhamento de pacientes com hiperidrose.

Preoperative predictive factors for intensive care unit admission after pulmonary resection.

OBJECTIVE: To determine whether the use of a set of preoperative variables can predict the need for postoperative ICU admission. METHODS: This was a prospective observational cohort study of 120 patients undergoing elective pulmonary resection between July of 2009 and April of 2012. Prediction of ICU admission was based on the presence of one or more of the following preoperative characteristics: predicted pneumonectomy; severe/very severe COPD; severe restrictive lung disease; FEV1 or DLCO predicted to be < 40% postoperatively; SpO2 on room air at rest < 90%; need for cardiac monitoring as a precautionary measure; or American Society of Anesthesiologists physical status ≥ 3. The gold standard for mandatory admission to the ICU was based on the presence of one or more of the following postoperative characteristics: maintenance of mechanical ventilation or reintubation; acute respiratory failure or need for noninvasive ventilation; hemodynamic instability or shock; intraoperative or immediate postoperative complications (clinical or surgical); or a recommendation by the anesthesiologist or surgeon to continue treatment in the ICU. RESULTS: Among the 120 patients evaluated, 24 (20.0%) were predicted to require ICU admission, and ICU admission was considered mandatory in 16 (66.6%) of those 24. In contrast, among the 96 patients for whom ICU admission was not predicted, it was required in 14 (14.5%). The use of the criteria for predicting ICU admission showed good accuracy (81.6%), sensitivity of 53.3%, specificity of 91%, positive predictive value of 66.6%, and negative predictive value of 85.4%. CONCLUSIONS: The use of preoperative criteria for predicting the need for ICU admission after elective pulmonary resection is feasible and can reduce the number of patients staying in the ICU only for monitoring.

OBJETIVO: Avaliar se a utilização de um conjunto de variáveis pré-operatórias é capaz de antever a necessidade de internação em UTI no pós-operatório. MÉTODOS: Estudo de coorte observacional prospectivo, com 120 pacientes submetidos à ressecção pulmonar eletiva entre julho de 2009 e abril de 2012. A previsão de indicação de internação em UTI indicação foi baseada na presença de uma ou mais das seguintes condições pré-operatórias: previsão de pneumonectomia; DPOC grave/muito grave; doença restritiva grave; VEF1 ou DLCO previstos para o pós-operatório < 40% do previsto; SpO2 em repouso e ar ambiente < 90%; necessidade de monitorização cardíaca profilática; classificação da American Society of Anesthesiologists ≥ 3. O padrão ouro para internação justificada em UTI foi baseado na presença de uma ou mais das seguintes condições pós-operatórias: manutenção de ventilação mecânica ou reintubação; insuficiência respiratória aguda ou necessidade de ventilação não invasiva; instabilidade hemodinâmica ou choque; intercorrências intraoperatórias ou no pós-operatório imediato (cirúrgicas ou clínicas); indicação do anestesiologista ou cirurgião para a manutenção de tratamento na UTI. RESULTADOS: Dos 120 pacientes avaliados, houve previsão de necessidade de internação em UTI em 24 (20,0%), sendo essa considerada justificada em 16 deles (66,6%) desses 24, ao passo que dos 96 pacientes sem previsão de necessidade de internação em UTI, essa foi necessária em 14 (14,5%). A utilização dos critérios preditivos para a internação em UTI mostrou boa acurácia (81,6%), sensibilidade de 53,3%, especificidade de 91%, valor preditivo positivo de 66,6% e valor preditivo negativo de 85,4%. CONCLUSÕES: A utilização de critérios pré-operatórios para a indicação de internação em UTI após ressecção pulmonar eletiva é factível e é capaz de reduzir o número de pacientes que aí permanecem apenas para vigilância.

Preoperative predictive factors for intensive care unit admission after pulmonary resection / Fatores preditivos pré-operatórios de internação em unidade de terapia intensiva após ressecção pulmonar

Objective: To determine whether the use of a set of preoperative variables can predict the need for postoperative ICU admission. Methods: This was a prospective observational cohort study of 120 patients undergoing elective pulmonary resection between July of 2009 and April of 2012. Prediction of ICU admission was based on the presence of one or more of the following preoperative characteristics: predicted pneumonectomy; severe/very severe COPD; severe restrictive lung disease; FEV1 or DLCO predicted to be < 40% postoperatively; SpO2 on room air at rest < 90%; need for cardiac monitoring as a precautionary measure; or American Society of Anesthesiologists physical status ≥ 3. The gold standard for mandatory admission to the ICU was based on the presence of one or more of the following postoperative characteristics: maintenance of mechanical ventilation or reintubation; acute respiratory failure or need for noninvasive ventilation; hemodynamic instability or shock; intraoperative or immediate postoperative complications (clinical or surgical); or a recommendation by the anesthesiologist or surgeon to continue treatment in the ICU. Results: Among the 120 patients evaluated, 24 (20.0%) were predicted to require ICU admission, and ICU admission was considered mandatory in 16 (66.6%) of those 24. In contrast, among the 96 patients for whom ICU admission was not predicted, it was required in 14 (14.5%). The use of the criteria for predicting ICU admission showed good accuracy (81.6%), sensitivity of 53.3%, specificity of 91%, positive predictive value of 66.6%, and negative predictive value of 85.4%. Conclusions: The use of preoperative criteria for predicting the need for ICU admission after elective pulmonary resection is feasible and can reduce the number of patients staying in the ICU only for monitoring. .

Objetivo: Avaliar se a utilização de um conjunto de variáveis pré-operatórias é capaz de antever a necessidade de internação em UTI no pós-operatório. Métodos: Estudo de coorte observacional prospectivo, com 120 pacientes submetidos à ressecção pulmonar eletiva entre julho de 2009 e abril de 2012. A previsão de indicação de internação em UTI indicação foi baseada na presença de uma ou mais das seguintes condições pré-operatórias: previsão de pneumonectomia; DPOC grave/muito grave; doença restritiva grave; VEF1 ou DLCO previstos para o pós-operatório < 40% do previsto; SpO2 em repouso e ar ambiente < 90%; necessidade de monitorização cardíaca profilática; classificação da American Society of Anesthesiologists ≥ 3. O padrão ouro para internação justificada em UTI foi baseado na presença de uma ou mais das seguintes condições pós-operatórias: manutenção de ventilação mecânica ou reintubação; insuficiência respiratória aguda ou necessidade de ventilação não invasiva; instabilidade hemodinâmica ou choque; intercorrências intraoperatórias ou no pós-operatório imediato (cirúrgicas ou clínicas); indicação do anestesiologista ou cirurgião para a manutenção de tratamento na UTI. Resultados: Dos 120 pacientes avaliados, houve previsão de necessidade de internação em UTI em 24 (20,0%), sendo essa considerada justificada em 16 deles (66,6%) desses 24, ao passo que dos 96 pacientes sem previsão de necessidade de internação em UTI, essa foi necessária em 14 (14,5%). A utilização dos critérios preditivos para a internação em UTI mostrou boa acurácia (81,6%), sensibilidade de 53,3%, especificidade de 91%, valor preditivo positivo de 66,6% e valor preditivo negativo de 85,4%. Conclusões: A utilização de critérios pré-operatórios para a indicação de internação em UTI após ressecção pulmonar eletiva é factível e é capaz de reduzir o número de pacientes que aí permanecem apenas para vigilância. .

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.

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.

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. .

Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients / Mortalidade, morbidade e categorização de risco para complicações perioperatórias em pacientes com câncer de pulmão

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. .

OBJETIVO: Determinar as taxas de morbidade e mortalidade por categoria de risco conforme as diretrizes do American College of Chest Physicians, verificar como exames funcionais participaram dessa categorização e identificar fatores de risco para complicações perioperatórias (CPOs). MÉTODOS: Estudo de coorte histórica a partir de avaliações pré e pós-operatórias de casos diagnosticados ou suspeitos de câncer de pulmão avaliados entre 2001 e 2010. RESULTADOS: Dos 239 pacientes avaliados, apenas 13 (5,4%) foram considerados como de alto risco para CPOs. O cálculo do VEF1 previsto para o pós-operatório (VEF1ppo) foi suficiente para a estratificação do risco em 156 pacientes (65,3%); entretanto, o teste de exercício cardiopulmonar (TECP) foi necessário para a identificação de alto risco. Foram operados 145 pacientes, e as taxas globais de morbidade e mortalidade encontradas foram semelhantes às de outros estudos. Entretanto, as taxas de morbidade e mortalidade para aqueles com risco aceitável foram de 31,6% e 4,3%, respectivamente, enquanto as taxas para aqueles com alto risco foram de 83,3% e 33,3%. Idade mais avançada, presença da DPOC, ressecção de um ou mais lobos e VEF1ppo mais baixo estiveram relacionados à ocorrência de CPOs. CONCLUSÕES: Embora a espirometria tenha sido suficiente para a determinação de risco na maioria da população estudada, o TECP teve papel fundamental na identificação de pacientes com risco alto, que apresentaram uma taxa de mortalidade sete vezes maior que os de risco aceitável. Os fatores de risco relacionados a CPOs coincidiram aos relatados em outros estudos. .

Analysis and validation of probabilistic models for predicting malignancy in solitary pulmonary nodules in a population in Brazil.

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.

Análise e validação de modelos probabilísticos de malignidade de nódulo pulmonar solitário em uma população no Brasil / Analysis and validation of probabilistic models for predicting malignancy in solitary pulmonary nodules in a population in Brazil

OBJETIVO: Analisar características clínicas e radiográficas que influenciaram o diagnóstico anatomopatológico de nódulo pulmonar solitário (NPS) e comparar/validar dois modelos probabilísticos de malignidade do NPS em pacientes com NPS no Brasil. MÉTODOS: Análise retrospectiva de 110 pacientes com diagnóstico de NPS submetidos à ressecção em um hospital terciário no período entre 2000 e 2009. As características clínicas estudadas foram gênero, idade, presença de comorbidades sistêmicas, história de neoplasia maligna ao diagnóstico de NPS, diagnóstico histopatológico do NPS, tabagismo, carga tabágica e tempo de cessação do tabagismo. As características radiográficas avaliadas em relação ao NPS foram presença de margens espiculadas, tamanho do maior diâmetro transversal e localização anatômica do NPS. Foram utilizados dois modelos matemáticos, criados em 1997 e 2007, respectivamente, para determinar a probabilidade de malignidade do NPS. RESULTADOS: Houve associações significantes entre malignidade do NPS e idade (p = 0,006; OR = 5,70 para idade >70 anos), presença de margens espiculadas (p = 0,001) e diâmetro maior do NPS (p = 0,001; OR = 2,62 para diâmetro >20 mm). O modelo probabilístico de 1997 mostrou-se superior ao de 2007 - área sob a curva [ASC] ROC = 0,79 ± 0,44 (IC95%: 0,70-0,88) vs. ASC = 0,69 ± 0,50 (IC95%: 0,59-0,79). CONCLUSÕES: Idade elevada, maior diâmetro do NPS e presença de margens espiculadas tiveram associações significantes ao diagnóstico de malignidade do NPS. Nossa análise mostrou que, embora os dois modelos matemáticos sejam eficazes na determinação de malignidade do NPS nessa população, o modelo de 1997 mostrou-se superior.

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.

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.

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 percent) and 802 non-entrapped consecutive controls (66.7 percent). 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 percent), aged 32±13.1 years, with immediate mortality of 10.2 percent and overall mortality of 11.7 percent. 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 percent) and trauma for non-entrapped victims. Of the entrapped victims who survived, 18.7 percent had a severe GCS (OR = 10.62), 12 percent a severe RTS (OR = 9.78) and 23.7 percent 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.

Immunohistochemical analysis of the COX-2 marker in acute pulmonary injury in rats.

Acute inflammatory response is one of the main defensive mechanisms of the lungs. This work tried to assess this response through an immunohistochemical analysis of rat lungs mechanically injured by open manipulation, analyzing the COX-2 inflammatory marker, in addition to performing a microscopic histological analysis using the hematoxylin and eosin stain. The correlation between this response and the degree of manipulation over different lengths of time and degrees of injury was also investigated. Sixteen rats were divided into four groups and subjected to anterior thoracotomy. The upper lobe of the right lung was compressed using a plastic Bulldog clamp for different time length according to group (5 minutes, 2 minutes, and three 10-second compressions with 10 second intervals). The control group was subjected to thoracotomy but their lungs were not compressed. The injured lobes were analyzed histologically and subjected to immunohistochemistry and the results were compared. There were no differences in the immunohistochemical patterns between the control and injured rats, but the histological patterns between them differed. In conclusion, the histological analysis shows that the degree of injury caused by clamping the pulmonary parenchyma increases as the time length of compression increases but this inflammatory response is not paralleled by modifications of the COX-2 marker at immunohistochemistry.

Surgical treatment of 60 patients with pulmonary malformations: what have we learned?

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.

Tratamento operatório de 60 pacientes com malformações pulmonares: o que aprendemos? / Surgical treatment of 60 patients with pulmonary malformations: what have we learned?

OBJETIVO: Analisar retrospectivamente os prontuários de pacientes com malformações pulmonares submetidos a tratamento operatório e verificar a evolução clínica até o diagnóstico definitivo. MÉTODOS:Analisamos os prontuários dos pacientes com malformações pulmonares operados no Hospital São Paulo-Universidade Federal de São Paulo/Escola Paulista de Medicina-de 1969 a 2004. Cada prontuário foi analisado quanto aos seguintes aspectos: quadro clínico, diagnóstico, tratamento prévio, tratamento operatório e complicações hospitalares. Os critérios de inclusão foram os seguintes: ter diagnóstico de malformação pulmonar, ter sido submetido à ressecção pulmonar e ter prontuário com dados completos. RESULTADOS: A análise dos prontuários revelou que 60 pacientes com diagnóstico de malformações pulmonares foram operados-27 casos de cisto broncogênico, 14 de ensifema lobar congênito, 10 de seqüestro pulmonar e 9 de malformação adenomatóide cística. A idade variou de 4 dias a 62 anos (média de 17,9 anos). Houve predominância do sexo masculino (55 por cento). Noventa e dois por cento dos pacientes apresentavam sintomas (média de duração, 15,37 meses). Dos 60 pacientes operados, 27 (45 por cento) receberam tratamento domiciliar ou hospitalar com antibiótico antes da operação. Quanto às complicações, observamos morbidade de 23 por cento e mortalidade de 3,3 por cento. A duração dos procedimentos operatórios realizados em nossos pacientes variou de 1 a 8 h (média, 3,2 h). CONCLUSÕES: A falha ou atraso no diagnóstico das malformações pulmonares resultou em tratamentos e hospitalizações desnecessárias e em complicações infecciosas recorrentes e freqüentes. Acreditamos que o tratamento definitivo é a operação, a qual é curativa e tem baixa morbidade e mortalidade.

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 percent). Ninety-two percent of the patients presented symptoms (mean duration: 15.37 months). Of the 60 patients undergoing surgery, 27 (45 percent) received preoperative home or hospital treatment with antibiotics. Regarding complications, we observed that morbidity was 23 percent, and mortality was 3.3 percent. 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.

[Development and assessment of a multimedia computer program to teach pleural drainage techniques]. / 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 São 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.