Augmented Reality in Orthopedic Surgery Is Emerging from Proof of Concept Towards Clinical Studies: a Literature Review Explaining the Technology and Current State of the Art.

PURPOSE OF REVIEW: Augmented reality (AR) is becoming increasingly popular in modern-day medicine. Computer-driven tools are progressively integrated into clinical and surgical procedures. The purpose of this review was to provide a comprehensive overview of the current technology and its challenges based on recent literature mainly focusing on clinical, cadaver, and innovative sawbone studies in the field of orthopedic surgery. The most relevant literature was selected according to clinical and innovational relevance and is summarized. RECENT FINDINGS: Augmented reality applications in orthopedic surgery are increasingly reported. In this review, we summarize basic principles of AR including data preparation, visualization, and registration/tracking and present recently published clinical applications in the area of spine, osteotomies, arthroplasty, trauma, and orthopedic oncology. Higher accuracy in surgical execution, reduction of radiation exposure, and decreased surgery time are major findings presented in the literature. In light of the tremendous progress of technological developments in modern-day medicine and emerging numbers of research groups working on the implementation of AR in routine clinical procedures, we expect the AR technology soon to be implemented as standard devices in orthopedic surgery.

[Transdermal buprenorphine for acute postoperative pain: a systematic review]. / Uso da buprenorfina transdérmica na dor aguda pós­operatória: revisão sistemática.

BACKGROUND AND OBJECTIVES: Postoperative pain is still a major concern in several surgical procedures. Multimodal analgesia is best for postoperative pain management; however, opioid therapy is still the main treatment for pain after surgical procedures. Transdermal buprenorphine is a partial µ agonist opioid widely used for chronic pain syndromes, with limited evidence for acute postoperative pain. A systematic review of studies examining transdermal buprenorphine for acute pain management after surgery was conducted. CONTENTS: Data from PubMed, Embase, The Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL via EBSCOhost, and LILACS were reviewed, including randomized clinical trials that evaluated total postoperative pain, postoperative analgesic consumption, drug-related side effects and patient satisfaction with analgesia regimen. Data from nine studies (615 patients) were included in this review. Most studies initiated transdermal buprenorphine use 6 to 48 hours before surgery, maintaining use from 1 to 8 days after the procedure. Most studies showed lower or similar postoperative pain scores, postoperative analgesic consumption and patient satisfaction comparing buprenorphine to placebo, tramadol, celecoxib, flurbiprofen and parecoxib. The incidence of side effects varied between studies, with most showing no increase in drug-related side effects with buprenorphine use, except one study, which compared buprenorphine to oral tramadol, and one to transdermal fentanyl. However, most results were derived from evidence with an overall high or unclear risk of bias. CONCLUSIONS: Although more studies are necessary, initial results show that transdermal buprenorphine seems to be an effective and safe opioid choice for management of acute postoperative pain.

Transdermal buprenorphine for acute postoperative pain: a systematic review / Uso da buprenorfina transdérmica na dor aguda pós-operatória: revisão sistemática

Background and objectives: Postoperative pain is still a major concern in several surgical procedures. Multimodal analgesia is best for postoperative pain management; however, opioid therapy is still the main treatment for pain after surgical procedures. Transdermal buprenorphine is a partial µ-agonist opioid widely used for chronic pain syndromes, with limited evidence for acute postoperative pain. A systematic review of studies examining transdermal buprenorphine for acute pain management after surgery was conducted. Contents: Data from PubMed, Embase, The Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL via EBSCOhost, and LILACS were reviewed, including randomized clinical trials that evaluated total postoperative pain, postoperative analgesic consumption, drug-related side effects and patient satisfaction with analgesia regimen. Data from nine studies (615 patients) were included in this review. Most studies initiated transdermal buprenorphine use 6 to 48 hours before surgery, maintaining use from 1 to 28 days after the procedure. Most studies showed lower or similar postoperative pain scores, postoperative analgesic consumption and patient satisfaction comparing buprenorphine to placebo, tramadol, celecoxib, flurbiprofen and parecoxib. The incidence of side effects varied between studies, with most showing no increase in drug-related side effects with buprenorphine use, except one study, which compared buprenorphine to oral tramadol, and one to transdermal fentanyl. However, most results were derived from evidence with an overall high or unclear risk of bias. Conclusions: Although more studies are necessary, initial results show that transdermal buprenorphine seems to be an effective and safe opioid choice for management of acute postoperative pain

Justificativa e objetivos: A dor pós-operatória ainda é uma queixa importante em vários procedimentos cirúrgicos. A analgesia multimodal é a melhor conduta para a dor pós-operatória, embora a terapia com opioides ainda seja o principal tratamento para a dor após procedimentos cirúrgicos. A buprenorfina transdérmica é um opioide agonista µ amplamente prescrito nas síndromes de dor crônica, mas com limitada evidência do seu uso para dor aguda no pós-operatório. Realizamos revisão sistemática de estudos que examinaram o papel da buprenorfina transdérmica no tratamento da dor aguda pós-operatória. Conteúdo: Revisamos os dados de PubMed, Embase, Registro Central de Ensaios Controlados Cochrane (CENTRAL), CINAHL via EBSCOhost e LILACS, incluindo estudos clínicos randomizados que avaliaram a dor pós-operatória total, consumo de analgésicos pós-operatórios, efeitos colaterais relacionados a medicamentos e satisfação do paciente com esquema de analgesia. Dados de nove estudos (615 pacientes) foram incluídos nesta revisão. A maioria dos estudos iniciou o uso transdérmico de buprenorfina 6 a 48 horas antes da cirurgia, mantendo o uso de 1 a 28 dias após o procedimento. A maioria dos estudos encontrou valores semelhantes ou menores para o escore de dor pós-operatória, consumo pós-operatório de analgésicos e satisfação do paciente quando a buprenorfina foi comparada ao placebo, tramadol, celecoxibe, flurbiprofeno e parecoxibe. A incidência de efeitos colaterais oscilou nos estudos, e a maioria não mostrou aumento de efeito colateral relacionado ao uso de buprenorfina, exceto em dois estudos, um que comparou buprenorfina ao tramadol oral e outro ao fentanil transdérmico. No entanto, a maioria dos resultados foi obtida a partir de evidências com um risco geral alto ou risco de viés impreciso. Conclusões: Embora sejam necessários mais estudos, os resultados iniciais mostram que a buprenorfina transdérmica parece ser uma forma de administração segura e efetiva de opioide no tratamento da dor aguda pós-operatória

Fatores Preditores de Complicações após Radioterapia Conformacional 3D em Pacientes com Adenocarcinoma de Próstata / Predictors of Complications following 3D Conformational Radiotherapy in Patients with Prostate Adenocarcinoma / Factores Predictores de Complicaciones después de la Radioterapia Conformacional 3D en Pacientes con Adenocarcinoma de Próstata

Introdução: O câncer de próstata é considerado a neoplasia maligna mais comum que acomete homens em todas as Regiões do país, à exceção do câncer de pele não melanoma. Se diagnosticado e tratado precocemente, o câncer de próstata tem alta taxa de cura; contudo, terapêuticas como a radioterapia podem gerar complicações agudas que podem impactar as atividades cotidianas. Apesar das complicações no pós-tratamento, a radioterapia tem sido um método bastante praticado e que apresenta resultados positivos, ocasionando melhoria da sobrevida livre de doença. Objetivo: Avaliar os principais fatores preditores de complicações agudas que acometem pacientes em tratamento radioterápico para câncer de próstata. Método: Para identificação de fatores preditores de complicações agudas pós-radioterapia, avaliaram-se, consecutiva e prospectivamente, 208 pacientes diagnosticados com adenocarcinoma de próstata tratados com radioterapia conformacional 3D em um centro referência vinculado ao SUS entre os anos 2016 e 2017. Realizou-se ainda avaliação retrospectiva de prontuários para coleta de dados adicionais. A análise estatística foi realizada por meio dos testes qui-quadrado, exato de Fisher, Anova e regressão logística ordinal. Resultados: Após análise da amostra, evidenciou-se que, entre as complicações agudas, as de maior incidência foram radiodermite, cistite e enterite/retite, de forma que tais complicações tiveram como fatores associados volume irradiado, tratamento prévio e sintomas prévios ao tratamento. Conclusão: O estudo sugere que, apesar da existência de complicações ao final do tratamento, a grande maioria é de baixa complexidade e que pacientes submetidos a procedimentos cirúrgicos prévios podem evoluir com presença de complicações mais graves.

Introduction: Prostate cancer is considered the most common malignancy that affects men in all regions of the country, except for non-melanoma skin cancer. If diagnosed and treated early, prostate cancer has a high cure rate; however, therapies such as radiotherapy can generate acute complications that can impact daily activities. Despite post-treatment complications, radiotherapy has been a widely practiced method and has shown positive results, leading to improved disease-free survival. Objective: To evaluate the main predictive factors for acute complications that affect patients undergoing radiotherapy for prostate cancer. Method: To identify predictive factors for acute post-radiotherapy complications, 208 patients diagnosed with prostate adenocarcinoma treated with 3D conformational radiotherapy were consecutively and prospectively evaluated at a referral center linked to SUS between the years 2016 and 2017. It was carried out retrospective evaluation of medical records to collect additional data. Statistical analysis was performed using the chi-square test, Fisher's exact, Anova and ordinal logistic regression. Results: After analyzing the sample, it was evidenced that among the acute complications, those with the highest incidence were radiodermatitis, cystitis, enteritis/rectitis, so that these complications had associated predictive factors as irradiated volume, previous treatment and symptoms. Conclusion: The study suggests that despite the existence of complications at the end of the treatment, the vast majority are of low complexity and that the patients submitted to previous surgical procedures can evolve with the presence of more severe complications.

Introducción: El cáncer de próstata se considera la neoplasia maligna más común que afecta a los hombres en todas las regiones del país, con la excepción del cáncer de piel no melanoma. Si se diagnostica y trata temprano, el cáncer de próstata tiene una alta tasa de curación; sin embargo, las terapias como la radioterapia pueden generar complicaciones agudas que pueden afectar las actividades diarias. A pesar de las complicaciones posteriores al tratamiento, la radioterapia ha sido un método ampliamente practicado y ha mostrado resultados positivos, lo que lleva a una mejor supervivencia libre de enfermedad. Objetivo: Evaluar los principales predictores de complicaciones agudas que afectan a los pacientes sometidos a radioterapia para el cáncer de próstata. Método: Para identificar los factores predictivos de complicaciones agudas posteriores a la radioterapia, 208 pacientes diagnosticados con adenocarcinoma de próstata tratados con radioterapia conformacional 3D fueron evaluados consecutiva y prospectivamente en un centro de referencia vinculado al SUS entre los años 2016 y 2017. Se realizó evaluación retrospectiva de registros médicos para recopilar datos adicionales. El análisis estadístico se realizó utilizando la prueba de chi-cuadrado, exacta de Fisher, de Anova y la regresión logística ordinal. Resultados: Después de analizar la muestra, se evidenció que, entre las complicaciones agudas, las de mayor incidencia fueron radiodermatitis, cistitis, enteritis/retitis y síntomas obstructivos, por lo que estas complicaciones tenían factores predictivos asociados, como el volumen irradiado, el tratamiento previo y los síntomas. Conclusión: El estudio sugiere que a pesar de la existencia de complicaciones al final del tratamiento, la gran mayoría son de baja complejidad. Como factores predictivos encontrados, se puede mencionar el volumen irradiado, la existencia de tratamiento previo y los síntomas en la consulta inicial.

Haptic interaction for needle insertion training in medical applications: The state-of-the-art.

Computer-based simulation for medical procedures training has been gaining relevance, as well the use of haptic devices for developing fine motor skills in such simulations. The purpose of this paper is to present a review of the state-of-the-art in virtual needle insertion training simulation based on haptic interaction. A systematic review method was applied to gather documentation that enables a rigorous audit of the process stages and results. We established a classification system based on certain characteristics of the studies analyzed, including: main procedures and target body regions in medical applications; ways to generate haptic feedback; devices; types of environment; and user validation. In addition, the review aimed to identify challenges and trends in the field, indicating research opportunities. Results showed the predominance of Virtual Reality and commercial haptic devices in simulations. Since most studies are based on subjective tests, finding ways to objectively evaluate haptic interaction perception represents a promising research field. We also found that devices and ways to generate haptic feedback and to represent tissue and needle behavior pose limitations and challenges for computer simulation. Finally, the realism provided is a constant concern in the validation process, which brings another problem: defining and performing suitable user tests.

Radiodermatites: Análise dos Fatores Preditivos em Pacientes com Câncer de Mama / Radiodermatitis: Analysis of Predictive Factors in Breast Cancer Patients / Radiodermatitis: Análisis de Factores Predictivos en Pacientes con Cáncer de Mama

Introdução: A radioterapia é uma das modalidades terapêuticas de escolha para os tratamentos adjuvante e neoadjuvante, em pacientes com câncer de mama. Tal modalidade provoca reação de pele dolorosa conhecida como radiodermatite. Objetivo: Avaliar os fatores associados com o aparecimento de radiodermite após radioterapia e a sua associação com o maior grau de toxicidade nesses pacientes. Método: Estudo retrospectivo, com 117 pacientes com de câncer de mama submetidos à radioterapia conformacional 3D, entre 2016 a 2018, em doses variáveis. Dados pessoais foram coletados a partir de prontuário, e o grau de radiodermite estabelecido segundo os critérios do grupo de oncologia radioterápica. O total de 15 potenciais preditivos foram elencados e analisados por estatísticas univariada e multivariada. Resultados: A população do estudo apresentou uma média de 50 anos, 47% relataram alguma comorbidade, 59,83% realizaram cirurgia radical e 81,19% desenvolveram radiodermite. Observou-se, em análise multivariada, associação do desenvolvimento de radiodermite com maiores doses da radiação (p=0,011) e com uso de bólus diário (p=0,009). Conclusão: As principais variáveis que culminaram em maiores graus de radiodermite foram a dose da radiação e o uso de bólus diário. Categorizando os fatores preditivos, identificam-se o paciente com maior risco de lesões graves e a possibilidade da criação de protocolos mais eficazes na prevenção das radiodermatites.

Introduction: Radiotherapy is one of the therapeutic modalities chosen for adjuvant and neoadjuvant treatment in patients with breast cancer. This modality causes a painful skin reaction known as radiodermatitis. Objective:To evaluate the factors related with the appearance of radiodermatitis after radiotherapy and their relationship with the highest degree of toxicity in patients with breast cancer. Method: Retrospective study, with 117 patients with breast cancer submitted to 3D conformational radiotherapy between 2016 and 2018, at variable doses. Personal data were collected from medical records, and the degree of radiodermatitis established according to the criteria of the Radiation Oncology Group. The total of 15 predictive factors in potential were listed and later analyzed by univariate and multivariate statistics. Results: The study population presented an average of 50 years, 47% reported some comorbidities, 59.83% underwent radical surgery and 81.19% developed radiodermatitis. In a multivariate analysis, there was an association between development of radiodermatitis and higher doses of radiation (p=0.011) and daily bolus use (p=0.009). Conclusion:The main elements that culminated in higher degrees of radiodermatitis were the dose of radiation and the use of daily bolus. By categorizing the predictive factors, we can identify the patient with the highest risk of severe skin lesions and enables the creation of more effective protocols for the prevention of radiodermatitis.

Introducción: La radioterapia es una modalidad terapéutica para tratamiento adyuvante y neoadyuvante, en pacientes con cáncer de mama. Tal modalidad provoca reacción de piel dolorosa conocida como radiodermatitis. Objetivo: Evaluar factores conexos con la aparición de radiodermatitis tras la radioterapia y su asociación con el mayor grado de toxicidad. Método: Estudio retrospectivo, con 117 pacientes con cáncer de mama sometidos a la Radioterapia Conformacional 3D entre 2016 a 2018. Los datos personales fueron recolectados a partir de prontuario, así como el grado de radiodermatitis establecido según los criterios del grupo de oncología radioterápica. El total de 15 potencial predictivos fueron enumerados y posteriormente analizados por estadística univariana y multivariada. Resultados: La población del estudio presentó un promedio de 50 años, el 47% informó de algunas comorbilidades, el 59,83% se sometió a cirugía radical y el 81,19% desarrolló radiodermatitis. En un análisis multivariado, hubo una asociación entre el desarrollo de radiodermatitis y dosis más altas de radiación (p=0.011) y el uso diario de bolos (p=0.009). Conclusión: Las principales variables que culminaron en mayores grados de radiodermatitis fueron la dosis de radiación y el uso de bolos diarios. Al categorizar los factores predictivos, podemos identificar al paciente con el mayor riesgo de lesiones cutáneas graves y permitir la creación de protocolos más efectivos para la prevención de la radiodermatitis.

Erector spinae plane block for perioperative analgesia in cardiac surgery. Case report / Bloqueio do plano eretor espinhal para analgesia perioperatória em cirurgia cardíaca. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: The anesthetic management has evolved with the use of alternative techniques that promote greater safety, quick recovery and comfort in the perioperative period. The erector spinae plane block emerges as a promising alternative that can be employed as a simple analgesic technique for thoracic analgesia, acute post-surgical, post-traumatic and chronic neuropathic thoracic pain. CASE REPORT: Female patient, 72-year-old, undergoing aortic valve replacement surgery under general anesthesia associated with an erector spinae plane block as a technique for perioperative pain management. CONCLUSION: We demonstrate with this case report that the erector spinae plane block can be a suitable option as a regional analgesia technique for cardiac surgery, used perioperatively as a regional block for multimodal analgesia. Further research and studies are needed to address its efficacy and safety for multiple cardiac and aortic surgery techniques.

RESUMO JUSTIFICATIVA E OBJETIVOS: O manuseio anestésico evoluiu com o uso de técnicas alternativas que promovem maior segurança, rápida recuperação e conforto no período perioperatório. O bloqueio do plano eretor espinhal surge como uma alternativa promissora que pode ser empregada como uma técnica analgésica simples para analgesia torácica, dor torácica aguda pós-cirúrgica, pós-traumática e crônica neuropática. RELATO DO CASO: Paciente do sexo feminino, 72 anos, submetida à cirurgia de troca valvar aórtica sob anestesia geral associada ao bloqueio do plano eretor espinhal, como técnica para o manuseio da dor no período perioperatório. CONCLUSÃO: O presente relato demonstrou que o bloqueio do plano eretor espinhal pode ser uma opção adequada como uma técnica de analgesia regional para cirurgia cardíaca, usada no perioperatório como um bloqueio regional para analgesia multimodal. Mais pesquisas e estudos são necessários para abordar sua eficácia e segurança para múltiplas técnicas de cirurgia cardíaca e aórtica.

The aplication of cyanoacrilate surgical glue on skin suture in rats.

PURPOSE:: To compare the use of a new cyanoacrylate-based surgical glue and suture with sepa-rate points in skin wounds closure. METHODS:: Thirty-six rats were subjected to a 4cm dorsal longitudinal incision. Twelve were sub-jected to simple suture with polyamide 6-0, 12 rats underwent wall synthesis using Dermabond(r) and 12 was performed cutaneous synthesis with N-2-Butyl-Cyanoacrylate. Twelve of each group was euthanized on the seventh postoperative day, their blood was taken to biochemical tests and a layer of skin and subcutaneous tissue surrounding the surgical scar was randomly divided in two segments, to the submission of tension tests and to histological study. RESULTS:: There were no significant difference between groups (p>0.05). In the soft dermis there was more type I collagen production in group I (p<0.05), group II and III was similar re-sults (p>0.05). In the compact dermis, all 3 groups showed similar results (p>0.05). The biomechanical study was similarity between the glue groups (p>0.05) but the group III proved to be different from the others having a higher resistance (p>0.05) . CONCLUSION:: This glue does not cause any inflammation or kidney and hepatic toxicity. Polyamide sutures are more resistant and the glue should be used alone only in less tension are-as.

The aplication of cyanoacrilate surgical glue on skin suture in rats

Abstract Purpose: To compare the use of a new cyanoacrylate-based surgical glue and suture with sepa-rate points in skin wounds closure. Methods: Thirty-six rats were subjected to a 4cm dorsal longitudinal incision. Twelve were sub-jected to simple suture with polyamide 6-0, 12 rats underwent wall synthesis using Dermabond(r) and 12 was performed cutaneous synthesis with N-2-Butyl-Cyanoacrylate. Twelve of each group was euthanized on the seventh postoperative day, their blood was taken to biochemical tests and a layer of skin and subcutaneous tissue surrounding the surgical scar was randomly divided in two segments, to the submission of tension tests and to histological study. Results: There were no significant difference between groups (p>0.05). In the soft dermis there was more type I collagen production in group I (p<0.05), group II and III was similar re-sults (p>0.05). In the compact dermis, all 3 groups showed similar results (p>0.05). The biomechanical study was similarity between the glue groups (p>0.05) but the group III proved to be different from the others having a higher resistance (p>0.05) . Conclusion: This glue does not cause any inflammation or kidney and hepatic toxicity. Polyamide sutures are more resistant and the glue should be used alone only in less tension are-as.

Very short cycles of postconditioning have no protective effect against reperfusion injury. Experimental study in rats / Ciclos muito curtos de pós-condicionamento não protegem contra lesão de reperfusão. Estudo experimental em ratos

Introduction: Ischemic postconditioning has been recognized as effective in the prevention of reperfusion injury in situations of ischemia and reperfusion in various organs and tissues. However, it remains unclear what would be the best way to accomplish it, since studies show great variation in the method of their application. Objective: To assess the protective effect of ischemic postconditioning on ischemia and reperfusion in rats undergoing five alternating cycles of reperfusion and ischemia of 30 seconds each one. Methods: We studied 25 Wistar rats distributed in three groups: group A (10 rats), which underwent mesenteric ischemia (30 minutes) and reperfusion (60 minutes); Group B (10 rats), undergoing ischemia (30 minutes) and reperfusion (60 minutes), intercalated by postconditioning (5 alternating cycles of reperfusion and ischemia of 30 seconds each one); and group C - SHAM (5 rats), undergoing only laparotomy and manipulation of mesenteric artery. All animals underwent resection of an ileum segment for histological analysis. Results: The mean lesions degree according to Chiu et al. were: group A, 2.77, group B, 2.67 and group C, 0.12. There was no difference between groups A and B (P>0.05). Conclusion: Ischemic postconditioning was not able to minimize or prevent the intestinal tissue injury in rats undergoing ischemia and reperfusion process when used five cycles lasting 30 seconds each one. .

Introdução: O pós-condicionamento isquêmico tem sido reconhecido como eficaz na prevenção das lesões de reperfusão em situações de isquemia e reperfusão em vários órgãos e tecidos. Entretanto, não está ainda claro qual seria a melhor maneira de realizá-lo, já que as publicações mostram grande variação de método no seu emprego. Objetivo: Avaliar o efeito protetor do pós-condicionamento isquêmico na isquemia e reperfusão intestinal em ratos, através de cinco ciclos alternados de 30 segundos de isquemia e 30 segundos de reperfusão. Métodos: Foram estudados 25 ratos Wistar, distribuídos em três grupos: grupo A (10 ratos), em que se realizou isquemia (30 minutos) e reperfusão (60 minutos) mesentérica; grupo B (10 ratos), isquemia e reperfusão, seguidos de pós-condicionamento isquêmico com 5 ciclos alternados de reperfusão e reoclusão, de 30 segundos cada; e grupo C (5 ratos), controle (SHAM). Ao final, ressecou-se um segmento do intestino delgado para análise histológica. Avaliaram-se os resultados pela classificação de Chiu et al. e procedeu-se ao tratamento estatístico. Resultados: As médias dos graus de lesão tecidual segundo a classificação de Chiu et al. foram: no grupo A, 2,77; no grupo B, 2,67; e no grupo C, 0,12. A diferença entre o resultado do grupo A com o resultado do grupo B não teve significância estatística (P>0,05). Conclusão: O pós-condicionamento isquêmico não foi capaz de minimizar ou prevenir a lesão tecidual intestinal de ratos submetidos ao processo de isquemia e reperfusão mesentérica quando utilizados cinco ciclos com duração de 30 segundos cada. .

Very short cycles of postconditioning have no protective effect against reperfusion injury. Experimental study in rats.

INTRODUCTION: Ischemic postconditioning has been recognized as effective in the prevention of reperfusion injury in situations of ischemia and reperfusion in various organs and tissues. However, it remains unclear what would be the best way to accomplish it, since studies show great variation in the method of their application. OBJECTIVE: To assess the protective effect of ischemic postconditioning on ischemia and reperfusion in rats undergoing five alternating cycles of reperfusion and ischemia of 30 seconds each one. METHODS: We studied 25 Wistar rats distributed in three groups: group A (10 rats), which underwent mesenteric ischemia (30 minutes) and reperfusion (60 minutes); Group B (10 rats), undergoing ischemia (30 minutes) and reperfusion (60 minutes), intercalated by postconditioning (5 alternating cycles of reperfusion and ischemia of 30 seconds each one); and group C - SHAM (5 rats), undergoing only laparotomy and manipulation of mesenteric artery. All animals underwent resection of an ileum segment for histological analysis. RESULTS: The mean lesions degree according to Chiu et al. were: group A, 2.77, group B, 2.67 and group C, 0.12. There was no difference between groups A and B (P>0.05). CONCLUSION: Ischemic postconditioning was not able to minimize or prevent the intestinal tissue injury in rats undergoing ischemia and reperfusion process when used five cycles lasting 30 seconds each one.

Experimental model of anal fistula in rats / Modelo experimental de fistula anal em ratos

INTRODUCTION: the management of anal fistula remains debatable. The lack of a standard treatment free of complications stimulates the development of new options. OBJECTIVE: to develop an experimental model of anal fistula in rats. METHODS: to surgically create an anal fistula in 10 rats with Seton introduced through the anal sphincter musculature. The animals were euthanized for histological fistula tract assessment. RESULTS: all ten specimens histologically assessed had a lumen and surrounding granulation tissue. There was complete epithelialization of the tract in two samples, halfway epithelialization in one sample and epithelialization of only the outer portion in six samples. Epithelialization was not evident in one tract. CONCLUSION: anal fistulas in rats were histologically proved. (AU)

INTRODUÇÃO: o manejo da fístula anal ainda permanece um debate. A ausência de um tratamento ideal isento de complicações estimula o desenvolvimento de novas modalidades terapêuticas. OBJETIVO: desenvolver um modelo experimental de fístula anal em ratos. METODOLOGIA: criação de fístula anal cirúrgica em 10 ratos por meio de passagem de fio de aço através da musculatura do esfíncter anal. Os animais foram submetidos a eutanásia para comprovação histológica do trajeto fistuloso. RESULTADOS: todos os segmentos analisados histologicamente apresentaram lúmen e tecido de granulação. Houve epitelização completa do trajeto em dois espécimes, epitelização até a metade do trajeto em um, e epitelização somente da porção externa em seis. Um trajeto não apresentou área de epitelização. CONCLUSÃO: o desenvolvimento de fístula anal em ratos foi comprovado histologicamente. (AU)

Radiotherapy for pain management of bone metastases

PURPOSE: This is the first Brazilian study intended to evaluate the response of pain relief with radiotherapy in three different fractionations and the clinical differences in managing pain in patients with painful bone metastases. METHODS: Prospective study of patients with painful bone metastases referred to the Radiotherapy Sector of the Hospital de Câncer de Barretos for pain-relieving radiotherapy between March and December 2010. It is known that radiotherapy seems to alter the activation of osteoclast-mediated bone resorption, relieving pain in cases of painful bone metastases. Patients were assessed in relation to the status of pain intensity before and after the initiation of radiotherapy. Either a single fraction of 8Gy, five fractions of 4Gy or ten fractions of 3Gy were given. A visual analog scale (VAS) was applied by doctors, nurses and nursing technicians to assess pain intensity at each session of radiotherapy, and follow-up at 8, 30 and 90 days from the end of treatment. RESULTS: We evaluated 92 consecutive patients, 48 male and 44 female, with a median age of 58 years. We found that 14% of patients referred from the Palliative Care or Clinical Oncology sectors need better pharmacological analgesia due to severe pain, compared with 40.5% of patients from the other sectors (p = 0.004). We also found that the onset of pain relief to patients receiving 10 fractions of 300cGy analgesia without changing the pre-radiotherapy analgesia occurred with significance after the fifth fraction. Improvement in pain experienced within 90 days of follow-up was found in eighty percent of patients, independent of fractionated radiotherapy, site of metastases and the clinical condition of the patient. ISCUSSION/CONCLUSION: The Palliative Care and Clinical Oncology sectors expressed greater concern in regards to analgesia for the patient with painful bone metastases...

Radioterapia externa conformada 3D para o carcinoma de próstata: experiência do Instituto do Radium de Campinas com 285 pacientes / 3D conformal external beam radiation therapy for prostate carcinoma: an experiment of Instituto do Radium de Campinas with 285 patients

OBJETIVO: Reportar resultados de tratamentos do câncer de próstata com radioterapia conformada 3D realizadosem uma única instituição. MATERIAIS E MÉTODOS: De julho de 1997 a janeiro de 2002, 285 pacientes consecutivos com câncer de próstata foram submetidos a radioterapia conformada 3D com dose mediana de 7.920 cGy na próstata e analisados retrospectivamente. A distribuição segundo o grupo de risco foi a seguinte: baixo risco ù 95 (33,7%); risco intermediário ù 66 (23,4%); alto risco ù 121 (42,9%) pacientes. RESULTADOS: Em seguimento mediano de 53,6 meses (3,6û95,3 meses), sobrevidas atuariais global, causa específica, livre de metástases a distância e livre de recidiva bioquímica em cinco anos foram de 85,1%, 97,0%, 94,2% e 75,8%, respectivamente. Sobrevidas atuariais livre de toxicidade retal e urinária tardias em cinco anos foram de 96,4% e 91,1%, respectivamente. Ressecção transuretral pré-radioterapia conformada 3D e doses > 70 Gy em 30% do volume da bexiga implicaram maior toxicidade urinária tardia grau 2-3 em cinco anos (p = 0,0002 e p = 0,0264, respectivamente). CONCLUSÃO: A primeira experiência relatada de radioterapia conformada 3D no Brasil permitiu altas doses de radiação, com toxicidades retal e urinária aceitáveis. A existência de ressecção transuretral de próstata pré-radioterapia conformada 3D pode sinalizar maior risco de toxicidade urinária tardia grau 2-3 após irradiação. Restrição da dose ≤ 70 Gy em 30% do volume da bexiga à tomografia de planejamento pode reduzir complicações urinárias tardias.

OBJECTIVE: To report the outcomes of 3D conformal radiation therapy for prostate cancer in a single institution.MATERIALS AND METHODS: From July 1997 to January 2002, 285 consecutive patients with prostate cancer were submitted to 3D conformal radiation therapy receiving a median dose of 7,920 cGy to the prostate, and were retrospectively evaluated. The patients distribution according to the level of risk was the following: low risk û 95 (33.7%); intermediate risk û 66 (23.4%); high risk û 121 (42.9%) patients. RESULTS: Median follow-up of 53.6 months (3.6û95.3 months) demonstrated 85.1% actuarial five-year overall survival, 97.0% specific cause survival, 94.2% five-year distant metastasis-free survival, and 75.8% five-year biochemical recurrence-free survival. Rates of five-year actuarial survival free from late rectal and urinary toxicity were 96.4% and 91.1% respectively. Pre-3D conformal radiation therapy transurethral resection of the prostate and doses > 70 Gy in 30% of the bladder volume implied a higher grade 2-3 late urinary toxicity in five years (p = 0.0002 and p = 0.0264, respectively). CONCLUSION: The first experiment with 3D conformalradiation therapy reported in Brazil allowed high radiation doses with acceptable levels of urinary and rectaltoxicity. Pre-3D conformal radiation therapy transurethral resection of prostate may determine a higher riskfor post-irradiation grade 2-3 late urinary toxicity. At the tomography planning, the reduction of the radiationdose to ≤ 70 Gy in 30% of the bladder volume may reduce the risk for late urinary complications.

Prognostic factors for late urinary toxicity grade 2-3 after conformal radiation therapy on patients with prostate cancer.

OBJECTIVE: Identify prognostic factors associated to late urinary toxicity in patients with prostate cancer submitted to radical conformal radiotherapy (3DCRT). MATERIALS AND METHODS: From July 1997 to January 2002, 285 patients with localized prostate cancer were consecutively treated with 3DCRT and retrospectively analyzed. Thirty seven (13%) patients were submitted to transurethral prostate resection previously to 3DCRT. The median dose delivered to the prostate was 7920 cGy (7020-8460). Patient and treatment characteristics were analyzed and correlated to late urinary toxicity grade 2-3, especially whether certain radiation doses applied to certain bladder volumes, when visualized through computerized tomography (CT) planning, correlated with the observed actuarial incidences of late urinary complications, using bladder volume as a continuous variable. RESULTS: On a median follow-up of 53.6 months (3.6-95.3), the 5-year actuarial free from late urinary toxicity grade 2-3 survival was 91.1%. Seven and fifteen patients presented late urinary toxicity grades 2 and 3, respectively. Prior transurethral resection of prostate and radiation dose over 70 Gy on 30% of initial bladder volume were independent prognostic factors for late urinary toxicity grade 2-3. CONCLUSIONS: This study suggests that restricting radiation doses to 70 Gy or less on 30% of bladder volume, visualized through CT planning, may reduce late urinary complications. It furthermore suggests that patients with prior transurethral resection of prostate may indicate a group of patients with a greater risk for late urinary toxicity grade 2-3 after 3DCRT.

Prognostic factors for late urinary toxicity grade 2-3 after conformal radiation therapy on patients with prostate cancer

OBJECTIVE: Identify prognostic factors associated to late urinary toxicity in patients with prostate cancer submitted to radical conformal radiotherapy (3DCRT) MATERIALS AND METHODS: From July 1997 to January 2002, 285 patients with localized prostate cancer were consecutively treated with 3DCRT and retrospectively analyzed. Thirty seven (13 percent) patients were submitted to transurethral prostate resection previously to 3DCRT. The median dose delivered to the prostate was 7920 cGy (7020-8460). Patient and treatment characteristics were analyzed and correlated to late urinary toxicity grade 2-3, especially whether certain radiation doses applied to certain bladder volumes, when visualized through computerized tomography (CT) planning, correlated with the observed actuarial incidences of late urinary complications, using bladder volume as a continuous variable RESULTS: On a median follow-up of 53.6 months (3.6-95.3), the 5-year actuarial free from late urinary toxicity grade 2-3 survival was 91.1 percent. Seven and fifteen patients presented late urinary toxicity grades 2 and 3, respectively. Prior transurethral resection of prostate and radiation dose over 70 Gy on 30 percent of initial bladder volume were independent prognostic factors for late urinary toxicity grade 2-3 CONCLUSIONS: This study suggests that restricting radiation doses to 70 Gy or less on 30 percent of bladder volume, visualized through CT planning, may reduce late urinary complications. It furthermore suggests that patients with prior transurethral resection of prostate may indicate a group of patients with a greater risk for late urinary toxicity grade 2-3 after 3DCRT.

Salvage conformal radiotherapy for biochemical recurrent prostate cancer after radical prostatectomy.

OBJECTIVE: Assess the results of salvage conformal radiotherapy in patients with biochemical failure after radical prostatectomy and identify prognostic factors for biochemical recurrence and toxicity of the treatment. MATERIALS AND METHODS: From June 1998 to November 2001, 35 patients were submitted to conformal radiotherapy for PSA > or = 0.2 ng/mL in progression after radical prostatectomy and were retrospectively analyzed. The mean dose of radiation in prostatic bed was of 77.4 Gy (68-81). Variables related to the treatment and to tumor were assessed to identify prognostic factors for biochemical recurrence after salvage radiotherapy. RESULTS: The median follow-up was of 55 months (17-83). The actuarial survival rates free of biochemical recurrence and free of metastasis at a distance of 5 years were 79.7% e 84.7%, respectively. The actuarial global survival rate in 5 years was 96.1%. The actuarial survival rate free of biochemical recurrence in 5 years was 83.3% with PSA pre-radiotherapy < or = 1, 100% when > 1 and < or = 2, and 57.1% when > 2 (p = 0.023). Dose > 70 Gy in 30% of the bladder volume implied in more acute urinary toxicity (p = 0.035). The mean time for the development of late urinary toxicity was 21 months (12-51). Dose > 55 Gy in 50%bladder volume implied in more late urinary toxicity (p = 0.018). A patient presented late rectal toxicity of 2nd grade. CONCLUSIONS: Conformal radiotherapy showed to be effective for the control of biochemical recurrence after radical prostatectomy. Patients with pre-therapy PSA < or = 2 ng/mL have more biochemical control.

Salvage conformal radiotherapy for biochemical recurrent prostate cancer after radical prostatectomy

OBJECTIVE: Assess the results of salvage conformal radiotherapy in patients with biochemical failure after radical prostatectomy and identify prognostic factors for biochemical recurrence and toxicity of the treatment. MATERIALS AND METHODS: From June 1998 to November 2001, 35 patients were submitted to conformal radiotherapy for PSA > 0.2 ng/mL in progression after radical prostatectomy and were retrospectively analyzed. The mean dose of radiation in prostatic bed was of 77.4 Gy (68-81). Variables related to the treatment and to tumor were assessed to identify prognostic factors for biochemical recurrence after salvage radiotherapy. RESULTS: The median follow-up was of 55 months (17-83). The actuarial survival rates free of biochemical recurrence and free of metastasis at a distance of 5 years were 79.7 percent e 84.7 percent, respectively. The actuarial global survival rate in 5 years was 96.1 percent.The actuarial survival rate free of biochemical recurrence in 5 years was 83.3 percent with PSA pre-radiotherapy < 1, 100 percent when > 1 and < 2, and 57.1 percent when > 2 (p = 0.023). Dose > 70 Gy in 30 percent of the bladder volume implied in more acute urinary toxicity (p = 0.035). The mean time for the development of late urinary toxicity was 21 months (12-51). Dose > 55 Gy in 50 percent bladder volume implied in more late urinary toxicity (p = 0.018). A patient presented late rectal toxicity of 2nd grade. CONCLUSIONS: Conformal radiotherapy showed to be effective for the control of biochemical recurrence after radical prostatectomy. Patients with pre-therapy PSA < 2 ng/mL have more biochemical control.

Whole brain radiation therapy in management of brain metastasis: results and prognostic factors.

PURPOSE: To evaluate the prognostic factors associated with overall survival in patients with brain metastasis treated with whole brain radiotherapy (WBRT) and estimate the potential improvement in survival for patients with brain metastases, stratified by the Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) class. PATIENTS AND METHODS: From January 1996 to December 2000, 270 medical records of patients with diagnosis of brain metastasis, who received WBRT in the Hospital do Cancer Sao Paulo A.C. Camargo in the period, were analyzed. The surgery followed by WBRT was used in 15% of patients and 85% of others patients were submitted at WBRT alone; in this cohort 134 patients (50%) received the fractionation schedule of 30 Gy in 10 fractions. The most common primary tumor type was breast (33%) followed by lung (29%), and solitary brain metastasis was present in 38.1% of patients. The prognostic factors evaluated for overall survival were: gender, age, Karnofsky Performance Status (KPS), number of lesions, localization of lesions, primary tumor site, surgery, chemotherapy, absence extracranial disease, RPA class and radiation doses and fractionation. RESULTS: The OS in 1, 2 and 3 years was 25.1%, 10.4% and 4.3% respectively, and the median survival time was 4.6 months. The median survival time in months according to RPA class after WBRT was: 6.2 class I, 4.2 class II and 3.0 class III (p < 0.0001). In univariate analysis, the significant prognostic factors associated with better survival were: KPS higher than 70 (p < 0.0001), neurosurgery (p < 0.0001) and solitary brain metastasis (p = 0.009). In multivariate analysis, KPS higher than 70 (p < 0.001) and neurosurgery (p = 0.001) maintained positively associated with the survival. CONCLUSION: In this series, the patients with higher perform status, RPA class I, and treated with surgery followed by whole brain radiotherapy had better survival. This data suggest that patients with cancer and a single metastasis to the brain may be treated effectively with surgical resection plus radiotherapy. The different radiotherapy doses and fractionation schedules did not altered survival.