Does videothoracoscopy improve clinical outcomes when implemented as part of a pleural empyema treatment algorithm?

OBJECTIVE: We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients. METHODS: This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications. RESULTS: Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p < 0.01). The patients in the new algorithm group were older (41 +/- 1 vs. 46.3 +/- 16.7 years, p=0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p= 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04). CONCLUSIONS: The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery.

Resultados maternos e neonatais em centro de parto normal peri-hospitalar e hospital

OBJETIVO: Comparar os resultados maternos e neonatais em mulheres de baixo risco atendidas em centro de parto normal peri-hospitalar e hospital. MÉTODOS: Estudo transversal com amostra representativa de mulheres de baixo risco atendidas em São Paulo, SP, de 2003 a 2006. Foram incluídas 991 mulheres que tiveram o parto no centro de parto normal e 325 que deram à luz no hospital. Os dados foram obtidos dos prontuários. A análise comparativa foi realizada para o total de mulheres e estratifi cada segundo a paridade. Foram aplicados os testes qui-quadrado e exato de Fisher. RESULTADOS: Houve distribuição homogênea das mulheres segundo a paridade (45,4% nulíparas e 54,6% mulheres com um ou mais partos anteriores). Foram encontradas diferenças estatisticamente signifi cantes em relação às seguintes intervenções: amniotomia (mais freqüente entre nulíparas do hospital); utilização de ocitocina no trabalho de parto e utilização de analgésico no pós-parto (mais freqüentes no hospital entre as mulheres de todas as paridades). A taxa de episiotomia foi maior entre as nulíparas, tanto no centro de parto como no hospital. Houve maior freqüência de intervenções com o neonato no hospital: aspiração das vias aéreas superiores, aspiração gástrica, lavagem gástrica, oxigênio por máscara aberta. Também ocorreram com mais freqüência no hospital bossa serossanguínea, desconforto respiratório e internação na unidade neonatal. Não houve diferença nos valores de Apgar no quinto minuto nem casos de morte materna ou perinatal. CONCLUSÕES: A assistência no centro de parto normal foi realizada com menos intervenções e com resultados maternos e neonatais semelhantes aos do hospital.

Educational levels and the functional dependence of ischemic stroke survivors

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. >= 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.

Selection of Top 10 Quality Indicators for Nutrition Therapy

Background: The identification of useful quality indicators for nutrition therapy (QINTs) is of great interest and a challenge. This study attempted to identify the 10 QINTs that best suit the practice of quality control in nutrition therapy (NT) by evaluating the opinion of experts in NT with the use of psychometric techniques and statistical tools. Methods: Thirty-six QINTs available for clinical application in Brazil were assessed in 2 distinct phases. In phase 1, 26 nutrition experts ranked QINTs by scoring 4 attributes (utility, simplicity, objectivity, low cost) to assess each QINT on a 5-point Likert scale. The top 10 QINTs were identified from the 10 best scores obtained, and the reliability of expert opinion for each indicator was assessed by Cronbach's alpha. In phase 2, experts provided feedback regarding the selected top 10 QINTs by answering 2 closed questions. Results: The top 10 QINTs, in descending order, are the frequency of nutrition screening of hospitalized patients, diarrhea, involuntary withdrawal of enteral feeding tubes, feeding tube obstruction, fasting longer than 24 hours, glycemic dysfunction, estimated energy expenditure and protein needs, central venous catheter infection, compliance of NT indication, and frequency of application of subjective global assessment. Opinions were consistent among the interviewed experts. During feedback, 96% of experts were satisfied with the top 10 QINTs, and 100% had considered them in accordance with their previous opinion. Conclusion: The top 10 QINTs were identified according to their usefulness in clinical practice by obtaining adequate agreement and representativeness of opinion of nutrition experts. (Nutr Clin Pract. 2012;27:261-267)

Anatrophic Nephrotomy as Nephron-Sparing Approach for Complete Removal of Intraparenchymal Renal Tumors

Objective: Partial nephrectomy for small kidney tumors has increased in the last decades, and the approach to non-palpable endophytic tumors became a challenge, with larger chances of positive margins or complications. The aim of this study is to describe an alternative nephron-sparing approach for small endophytic kidney tumors through anatrophic nephrotomy. Patients and Methods: A retrospective analysis of patients undergoing partial nephrectomy at our institution was performed and the subjects with endophytic tumors treated with anatrophic nephrotomy were identified. Patient demographics, perioperative outcomes and oncological results were evaluated. Results: Among the partial nephrectomies performed for intraparenchymal tumors between 06/2006 and 06/2010, ten patients were submitted to anatrophic nephrotomy. The mean patient age was 42 yrs, and the mean tumor size was 2.3 cm. Mean warm ischemia time was 22.4 min and the histopathological analysis showed 80% of clear cell carcinomas. At a mean follow-up of 36 months, no significant creatinine changes or local or systemic recurrences were observed. Conclusion: The operative technique described is a safe and effective nephron-sparing option for complete removal of endophytic renal tumors.

Resultados da ressecção de hemangiomas infantis nasais em fase proliferativa: abordagem segura para os tumores centrais da face

INTRODUÇÃO: O hemangioma infantil é o tumor benigno mais comum da infância, predominando na região cervicofacial. É caracterizado por apresentar 3 fases distintas, observando-se frequentemente regressão espontânea dessas lesões. No entanto, sequelas residuais ou deformidades das estruturas anatômicas em crescimento podem ocorrer. A abordagem cirúrgica precoce e definitiva é indicada, em decorrência da localização dos hemangiomas nasais e seu potencial desfigurante, visando à obtenção de bons resultados estéticos e preservação anatômica. O objetivo do presente estudo foi analisar os resultados da abordagem cirúrgica definitiva para hemangiomas proliferativos nasais, com base em uma avaliação objetiva. MÉTODO: No período de 1997 a 2009, 20 pacientes portadores de hemangiomas nasais em fase proliferativa foram submetidos a tratamento cirúrgico. As lesões foram avaliadas segundo local de acometimento e tratamento realizado. Foram analisados índices de complicações e necessidade de procedimentos adicionais. Os resultados estéticos foram avaliados por avaliadores independentes. RESULTADOS: As lesões estavam localizadas na ponta nasal em 50% dos pacientes; no dorso, em 20%; em todas as subunidades, em 15%; nas áreas paranasais, em 10%; e na unidade alar, em 5%. A ressecção foi total em 60% dos pacientes e subtotal em 40%. O período médio de acompanhamento foi de 42,6 meses. A média de procedimentos cirúrgicos por paciente foi de 1,3 + 0,7. Nenhuma complicação importante foi observada. Os resultados foram positivamente avaliados quanto a redução do volume da lesão e melhora do contorno facial, corroborando a conduta proposta. CONCLUSÕES: No manejo dos hemangiomas nasais, o tratamento cirúrgico definitivo pode ser considerado uma alternativa segura e eficaz, com baixas taxas de complicação.

Idade e indicações de osteotomias para avanço frontofacial em pacientes com craniossinostoses sindrômicas

INTRODUÇÃO: Desde o início da Cirurgia Craniofacial, muitos desafios foram ultrapassados. Problemas operatórios técnicos e de infraestrutura básica de atendimento especializado foram solucionados. Agora, 25 anos após as publicações iniciais dos avanços frontofaciais, há ainda algumas dúvidas quanto às indicações precisas da idade e do tipo de cirurgia a ser realizada. O objetivo deste estudo foi avaliar a evolução de pacientes submetidos a tratamento de craniossinostoses sindrômicas operados nos últimos 10 anos em nossa instituição. MÉTODO: Todos os pacientes sindrômicos submetidos a avanço frontofacial em monobloco ou somente facial isolado foram selecionados no período de 2001 a 2011. Foram selecionados 70 pacientes, 56 submetidos a avanço frontofacial em monobloco e 14, a avanço facial após remodelagem frontorbitária prévia. Todos os dados referentes a esses pacientes foram correlacionados, avaliando a idade e o resultado final. Os pacientes foram selecionados de acordo com idade à época da cirurgia, complicações existentes e resultados finais correlacionados com os principais problemas existentes previamente. RESULTADOS: Os pacientes sindrômicos apresentaram graus variados de resultados finais, dependendo da síndrome e da idade de realização do procedimento. Os avanços frontofaciais em monobloco apresentaram baixo índice de complicações pós-operatórias imediatas, porém ficou demonstrada a necessidade de procedimentos futuros ao final do crescimento facial. Nos pacientes submetidos a cirurgias mais tardiamente, o índice de resultados positivos foi maior. CONCLUSÕES: Nos casos de craniossinostoses graves, com problemas funcionais, a indicação de avanço frontofacial em monobloco continua sendo a melhor opção terapêutica.

Cross-cultural adaptation and assessment of the reliability and validity of the Core Outcome Measures Index (COMI) for the Brazilian-Portuguese language

The use of patient-orientated questionnaires is of utmost importance in assessing the outcome of spine surgery. Standardisation, using a common set of outcome measures, is essential to aid comparisons across studies/in registries. The Core Outcome Measures Index (COMI) is a short, multidimensional outcome instrument validated for patients with spinal disorders. This study aimed to produce a Brazilian-Portuguese version of the COMI. A cross-cultural adaptation of the COMI into Brazilian-Portuguese was carried out using established guidelines. 104 outpatients with chronic LBP (> 3 months) were recruited from a Public Health Spine Medical Care Centre. They completed a questionnaire booklet containing the newly translated COMI, and other validated symptom-specific questionnaires: Oswestry Disability Index (ODI) and Roland Morris disability scale (RM), and a pain visual analogue scale. All patients completed a second questionnaire within 7-10 days to assess reproducibility. The COMI summary score displayed minimal floor and ceiling effects. On re-test, the responses for each individual domain of the COMI were within 1 category in 98% patients for the domain 'function', 96% for 'symptom-specific well-being', 97% for 'general quality of life', 99% for 'social disability' and 100% for 'work disability'. The intraclass correlation coefficients (ICC2,1) for COMI pain and COMI summary scores were 0.91-0.96, which compared favourably with the corresponding values for the RM (ICC, 0.99) and ODI (ICC, 0.98). The standard error of measurement for the COMI was 0.6, giving a "minimum detectable change" (MDC95%) of approximately 1.7 points i.e., the minimum change to be considered "real change" beyond measurement error. The COMI scores correlated as hypothesised (Rho, 0.4-0.8) with the other symptom-specific questionnaires. The reproducibility of the Brazilian-Portuguese version of the COMI was comparable to that of other language versions. The COMI scores correlated in the expected manner with existing but longer symptom-specific questionnaires suggesting good convergent validity for the COMI. The Brazilian-Portuguese COMI represents a valuable tool for Brazilian study-centres in future multicentre clinical studies and surgical registries.

Assessment of the role of transcript for GATA-4 as a marker of unfavorable outcome in human adrenocortical neoplasms

Abstract Background Malignant neoplasia of the adrenal cortex is usually associated with very poor prognosis. When adrenocortical neoplasms are diagnosed in the early stages, distinction between carcinoma and adenoma can be very difficult to accomplish, since there is yet no reliable marker to predict tumor recurrence or dissemination. GATA transcription factors play an essential role in the developmental control of cell fate, cell proliferation and differentiation, organ morphogenesis, and tissue-specific gene expression. Normal mouse adrenal cortex expresses GATA-6 while its malignant counterpart only expresses GATA-4. The goal of the present study was to assess whether this reciprocal change in the expression of GATA factors might be relevant for predicting the prognosis of human adrenocortical neoplasms. Since human adrenal cortices express luteinizing hormone (LH/hCG) receptor and the gonadotropins are known to up-regulate GATA-4 in gonadal tumor cell lines, we also studied the expression of LH/hCG receptor. Methods We conducted a study on 13 non-metastasizing (NM) and 10 metastasizing/recurrent (MR) tumors obtained from a group of twenty-two adult and pediatric patients. The expression of GATA-4, GATA-6, and LH/hCG receptor (LHR) in normal and tumoral human adrenal cortices was analysed using reverse transcriptase-polymerase chain reaction (RT-PCR) complemented by dot blot hybridization. Results Messenger RNA for GATA-6 was detected in normal adrenal tissue, as well as in the totality of NM and MR tumors. GATA-4, by its turn, was detected in normal adrenal tissue, in 11 out of 13 NM tumors, and in 9 of the 10 MR tumors, with larger amounts of mRNA found among those presenting aggressive clinical behavior. Transcripts for LH receptor were observed both in normal tissue and neoplasms. A more intense LHR transcript accumulation was observed on those tumors with better clinical outcome. Conclusion Our data suggest that the expression of GATA-6 in human adrenal cortex is not affected by tumorigenesis. GATA-4 expression is more abundant in MR tumors, while NM tumors express more intensely LHR. Further studies with larger cohorts are needed to test whether relative expression levels of LHR or GATA-4 might be used as prognosis predictors.

Clinical, histopathological and immunohistochemical assessment of human skin field cancerization before and after photodynamic therapy

Background The field cancerization concept in photodamaged patients suggests that the entire sun-exposed surface of the skin has an increased risk for the development of (pre)-malignant lesions, mainly epithelial tumours. Topical photodynamic therapy (PDT) is a noninvasive therapeutic method for multiple actinic keratosis (AK) with excellent outcome. Objectives To evaluate the clinical, histological and immunohistochemical changes in human skin with field cancerization after multiple sessions of PDT with methyl-aminolaevulinate (MAL). Methods Twenty-six patients with photodamaged skin and multiple AK on the face received three consecutive sessions of MAL-PDT with red light (37 J cm(-2)), 1 month apart. Biopsies before and 3 months after the last treatment session were taken from normal-appearing skin on the field-cancerized area. Immunohistochemical stainings were performed for TP-53, procollagen-I, metalloproteinase-1 (MMP-1) and tenascin-C (Tn-C). Results All 26 patients completed the study. The global score for photodamage improved considerably in all patients (P < 0.001). The AK clearance rate was 89.5% at the end of the study. Two treatment sessions were as effective as three MAL-PDT sessions. A significant decrease in atypia grade and extent of keratinocyte atypia was observed histologically (P < 0.001). Also, a significant increase in collagen deposition (P = 0.001) and improvement of solar elastosis (P = 0.002) were noticed after PDT. However, immunohistochemistry showed only a trend for decreased TP-53 expression (not significant), increased procollagen-I and MMP-1 expressions (not significant) and an increased expression of Tn-C (P = 0.024). Conclusions Clinical and histological improvement in field cancerization after multiple sessions of MAL-PDT is proven. The decrease in severity and extent of keratinocyte atypia associated with a decreased expression of TP-53 suggest a reduced carcinogenic potential of the sun-damaged area. The significant increase of new collagen deposition and the reduction of solar elastosis explain the clinical improvement of photodamaged skin.