Universidade Federal do Cearà / The demand for biodegradable materials extracted from renewable sources that have high performance and lower cost is increasingly growing. The galactomannan extracted from Cassia fistula seeds was characterized by several methodologies: Elemental Analysis; Protein content; Uronic acid content; Gel Permeation Chromatography (GPC); Intrinsic Viscosity; Rheological Studies;Turbidity; Thermogravimetry; Infrared and 1H, 13C NMR. The yield of the extraction was 26.5 % m/m. The values obtained for protein content, humidity and uronic acid content were: 2.5%, 11.9% and 3.6% respectively. The values of molar weight (Mw = 2.2 x106g/mol) and intrinsic viscosity (9.73 dL/g) found for GCF were close to those from locusta bean galactomannan. For galactomannan of locusta bean is the second galactomannan commercializes most in the world, for this reason a comparative between GCF was done andGLB. The rheological analysis showed that GCF solutions exhibited pseudoplastic behavior at concentrations higher than 1%. Thermogravimetry analysis for GCF showed three events: 1 related to water loss; 2 related to matter decomposition and the 3 related to loss of organic matter which is more resistant to degradation. The infrared spectrum showed characteristic bands for polysaccharide and the 1H and 13C NMR spectra showed galactomannan characteristic peaks. The ratio mannose/galactose of GCF determined by 1H NMR spectrum analysis was 3.2, value close to that one from locusta bean galactomannan. The GCF was modified by reacting with sodium periodate at several concentrations to obtain the modified polysaccharide with oxidation degrees of: 10%; 20%; 50%; 65% and 80% [(periodate molar rate/glycosidic unities) x100]. The yield values obtained for the reactions were around 70% w/w. The oxidated materials were characterized by Rheology; GPC and 1H ,13C NMR. It was observed a decrease of molar mass (Mw) of 2.3 x 106 g/mol (GCF) to 6.4 x 104 g/mol (GCFO10%). As the degree of oxidation increases there is a reduction of the molecular weight, confirming that there was a degradation of the polymeric chain by the oxidation reaction with sodium periodate. The rheological analysis for 1% (w/v) non-modified GCF solutions and of GCFOXâs showed a reduction of apparent viscosity with oxidation degree increase (at 596 s-1): of 60.0 mPa.s (GCF) to 14 and 1.7 mPa.s (GCFO10) and 80%, respectively. The 1H NMR spectra showed for samples until 20% a few signals on anomeric range, when compared with samples with oxidation degree higher than 50 %. The ratio Man/Gal increased from 3.2 for the original sample to 3.3 and 4.6 for those samples of 10 and 20%, respectively. That increase means that the oxidation takes place preferably at the galactose units. / A procura por materiais biodegradÃveis, extraÃdos de fontes enovÃveis que apresentem alto desempenho e um menor custo à cada vez mais rescente. A galactomanana extraida das sementes de Cassia fistula (GCF) foi caracterizada atravÃs das anÃlises elementar; teor de proteÃna; teor de Ãcido urÃnico;cromatografia de permeaÃÃo em gel; viscosidade intrinseca; estudos reolÃgicos; turbidez; anÃlise termogravimÃtrica; espectroscopica na regiÃo do infravermelho e RMN de 1H e 13C. O rendimento da extraÃÃo foi de 26,5 % em massa. Os valores de teor de proteÃna, umidade e Ãcido urÃnico obtidos foram de 2,5%, 11,9% e 3,6%, respectivamente. O valor da massa molar mÃdia (Mw) (2,2 x 106 g/mol) e viscosidade intrÃseca (9,73 dL/g) encontrado para GCF foram prÃximos aos valores encontrados para galactomanana de locusta bean. As anÃlises reolÃgicas mostraram que as soluÃÃes de GCF apresentam comportamento pseudoplÃtico em concentraÃÃes acima de 1% m/v. Na anÃlise termogravimÃtrica a amostra de GCF apresentou trÃs eventos, o 1 referente à perda de Ãgua; o 2 evento referente à decomposiÃÃo da matÃria e o 3 evento referente à perda da matÃria orgÃnica mais resistente a degradaÃÃo. O espectro de infravermelho mostrou bandas caracterÃsticas de polissacarÃdeo e os espectros de RMN de 1H e 13C mostraram picos caracterÃsticos de galactomanana. A razÃo manose/galactose da GCF determinado pelo espectro de RMN de 1H foi de 3,2 razÃo prÃxima a galactomanana de locusta bean (GL). A galactomanana da locusta bean à a segunda galactomanana mais comercializada no mundo, por essa razÃo foi feito um comparativo entre a GCF e a GL. A GCF foi modificada atravÃs da reaÃÃo com periodato de sÃdio em vÃrias concentraÃÃes para obter o polissacarÃdeo modificado com graus de oxidaÃÃo de 10%; 20%; 50%; 65% e 80% [(razÃo molar de periodato/unidades glicosÃdicas)x100]. Os valores obtidos do rendimento das reaÃÃes foram em torno de 70% em massa. Os materiais oxidados foram caracterizados atravÃs das anÃlises reolÃgicas, por GPC e RMN 1H e 13C. Observa-se uma diminuiÃÃo da massa molar (Mw) de 2,3 x 106 g/mol da GCF para 6,4 x 104 g/mol da galactomanana de Cassia fistula oxidada a 10% GCFO10%).A medida que aumenta o grau de oxidaÃÃo ocorre uma reduÃÃo da massa molar, confirmando que houve uma degradaÃÃo da cadeia polimÃrica pela reaÃÃo de oxidaÃÃo com o periodato de sÃdio. A anÃlise reolÃgica de soluÃÃes 1% (m/v) de GCF nÃo modificada e das galactomananas de Cassia fÃstula oxidadas (GCFOXâs) mostrou uma reduÃÃo da viscosidade aparente com o aumento do grau de oxidaÃÃo: de 60,0 mPa.s da GCF para 14 e 1,7 mPa.s da GCFO10% e GCFO80%, respectivamente. Os espectros de RMN 1H mostraram que para as amostras com o grau de oxidaÃÃo atà 20% aparecem poucos novos sinais na regiÃo de anomÃrico, quando comparados com as amostras com grau de oxidaÃÃo acima de 50%. A razÃo Man/Gal aumenta de 3,2 da amostra original para 3,3 e 4,6 nas amostras de 10 e 20%, respectivamente. Esse aumento indica que a oxidaÃÃo ocorre preferencialmente nas unidades de galactose.

Obstetric Fistulas have a high prevalence rate in developing countries where there is a lack of immediate access to maternal health care for women. Although Obstetric Fistulas are physical injuries, they affect women’s psychosocial health. This analysis aims to display the inefficiency of focusing on surgical repairs as the only treatment option and to demonstrate the need to integrate mental health treatment at different Obstetric Fistulas treatment stages. A total of 8 research articles from both Pub Med and Web of Science met the inclusion criteria, and the analysis was done by country. The results showed the presence of depressive symptoms, although there is an immediate improvement in quality of life after surgical repair. In some cases, there was worsening of psychological symptoms due to residual incontinence with or without successful fistula closure. These results suggested that whereas surgical repairs positively impact Obstetric Fistula patients, it does not solve the depressive symptoms, which cause women to self-isolate and have suicidal ideations. The mental sequelae caused by Obstetrical Fistulas can only be resolved using structured mental health care that should be started before surgical repair and continued after repair.

The purpose of this study was to identify factors that contribute to women delaying seeking treatment for obstetric fistula. A stratified random sampling technique was used to select 384 study participants. A cross sectional analytical research design was used; data was collected by structured, closed ended questionnaires. Bivariate and multivariate logistic regression models were applied. Results show a significant correlation between traditional treatment and delay in seeking treatment (P-Value = 0.012). The presence of parents has a significant correlation in reaching treatment centres (p-value = 0.013), those women who are speaking about their fistula have less chance of delay in seeking treatment (p-value = 0.008), having no income significantly associated with delay in seeking treatment (AOR = 0.28) and women living closer to the treatment centres have less chance of delay (p-value = 0.008). Therefore, there are a number of factors that significantly influence women from early seeking of treatment for their fistulae. / Health Studies / M.A. (Public Health)

The purpose of this study was to identify factors that contribute to women delaying seeking treatment for obstetric fistula. A stratified random sampling technique was used to select 384 study participants. A cross sectional analytical research design was used; data was collected by structured, closed ended questionnaires. Bivariate and multivariate logistic regression models were applied. Results show a significant correlation between traditional treatment and delay in seeking treatment (P-Value = 0.012). The presence of parents has a significant correlation in reaching treatment centres (p-value = 0.013), those women who are speaking about their fistula have less chance of delay in seeking treatment (p-value = 0.008), having no income significantly associated with delay in seeking treatment (AOR = 0.28) and women living closer to the treatment centres have less chance of delay (p-value = 0.008). Therefore, there are a number of factors that significantly influence women from early seeking of treatment for their fistulae. / Health Studies / M.A. (Public Health)

INTRODUÇÃO: A fistula esofagorrespiratória é complicação temida do câncer esofágico avançado. A paliação com prótese metálica autoexpansível é método amplamente empregado, porém com resultados conflitantes. OBJETIVO: Identificar fatores associados ao insucesso clínico do tratamento da fístula esofagorrespiratória maligna com prótese metálica autoexpansível. MÉTODOS: Estudo retrospectivo através da análise de banco de dados elaborado de forma prospectiva de pacientes submetidos ao tratamento da fístula esofagorrespiratória maligna com prótese metálica autoexpansível entre janeiro de 2009 e fevereiro de 2016 em hospital terciário dedicado ao tratamento do câncer. Foram coletados dados quanto à: características demográficas, nível de albumina sérica, capacidade funcional do paciente, doença pulmonar infecciosa em atividade no momento da passagem da prótese, tratamentos oncológicos prévios, momento do diagnóstico da fístula, tamanho e localização do trajeto fistuloso. RESULTADOS: Um total de 71 pacientes foram incluídos no estudo (55 homens, idade média de 59 anos). Insucesso clínico ocorreu em 44.3% dos pacientes. ECOG 3 ou 4, desenvolvimento da fístula durante o tratamento do câncer esofágico e diâmetro da fístula >= 1 cm foram fatores preditivos do insucesso clínico. ECOG 3 ou 4, doença pulmonar infecciosa em atividade no momento da passagem da prótese e tratamento oncológico prévio com radioterapia foram fatores preditivos de menor sobrevida. O grau de disfagia melhorou significativamente 15 dias após a passagem da prótese. A taxa total de eventos adversos foi de 30%. Migração da prótese e a oclusão da mesma por crescimento tumoral nas extremidades da prótese foram os eventos adversos mais comumente observados. CONCLUSÃO: A prótese metálica autoexpansível é um método terapêutico efetivo para o tratamento da fístula esofagorrespiratória maligna, no entanto, ECOG 3 ou 4, desenvolvimento da fístula durante o tratamento do câncer esofágico e diâmetro da fístula >= 1cm foram fatores preditivos do insucesso clínico após a passagem da prótese / INTRODUCTION: Malignant esophagorespiratory fistula is a serious and life-threatening complication of esophageal cancer. Self-expandable metal stents placement is a well accepted palliative treatment, however, with conflicting results. OBJECTIVE: To identify risk factors associated with clinical failure after self-expandable metal stents placement for the treatment of malignant esophagorespiratory fistula. METHODS: This was a retrospective analysis of a prospectively maintained database used at a tertiary cancer hospital, with patients treated with SEMS placement for MERF between January 2009 and February 2016. The following variables were collected: patient demographics, serum albumin level, Eastern Cooperative Oncology Group (ECOG) performance status, pulmonary infection, previous oncologic treatment, moment of diagnosis of the malignant esophagorespiratory fistula, size and classification of the fistulous tract. RESULTS: A total of 71 patients (55 males, mean age 59 years) were considered for the final analysis. Clinical failure occurred in 44.3% of the patients. ECOG 3 or 4, fistula development during esophageal cancer treatment and fistula diameter >= 1cm were factors associated with increased risk of clinical failure. ECOG 3 or 4, pulmonary infection at the time of SEMS placement and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse events rate was 30%. Stent migration and occlusion due to tumor overgrowth were the most commonly seen adverse events. CONCLUSION: SEMS placement is a reasonable treatment option for MERF, however, ECOG 3 or 4, fistula development during esophageal cancer treatment or large fistula diameter may be independent predictors of clinical failure after stenting

INTRODUÇÃO: A fistula esofagorrespiratória é complicação temida do câncer esofágico avançado. A paliação com prótese metálica autoexpansível é método amplamente empregado, porém com resultados conflitantes. OBJETIVO: Identificar fatores associados ao insucesso clínico do tratamento da fístula esofagorrespiratória maligna com prótese metálica autoexpansível. MÉTODOS: Estudo retrospectivo através da análise de banco de dados elaborado de forma prospectiva de pacientes submetidos ao tratamento da fístula esofagorrespiratória maligna com prótese metálica autoexpansível entre janeiro de 2009 e fevereiro de 2016 em hospital terciário dedicado ao tratamento do câncer. Foram coletados dados quanto à: características demográficas, nível de albumina sérica, capacidade funcional do paciente, doença pulmonar infecciosa em atividade no momento da passagem da prótese, tratamentos oncológicos prévios, momento do diagnóstico da fístula, tamanho e localização do trajeto fistuloso. RESULTADOS: Um total de 71 pacientes foram incluídos no estudo (55 homens, idade média de 59 anos). Insucesso clínico ocorreu em 44.3% dos pacientes. ECOG 3 ou 4, desenvolvimento da fístula durante o tratamento do câncer esofágico e diâmetro da fístula >= 1 cm foram fatores preditivos do insucesso clínico. ECOG 3 ou 4, doença pulmonar infecciosa em atividade no momento da passagem da prótese e tratamento oncológico prévio com radioterapia foram fatores preditivos de menor sobrevida. O grau de disfagia melhorou significativamente 15 dias após a passagem da prótese. A taxa total de eventos adversos foi de 30%. Migração da prótese e a oclusão da mesma por crescimento tumoral nas extremidades da prótese foram os eventos adversos mais comumente observados. CONCLUSÃO: A prótese metálica autoexpansível é um método terapêutico efetivo para o tratamento da fístula esofagorrespiratória maligna, no entanto, ECOG 3 ou 4, desenvolvimento da fístula durante o tratamento do câncer esofágico e diâmetro da fístula >= 1cm foram fatores preditivos do insucesso clínico após a passagem da prótese / INTRODUCTION: Malignant esophagorespiratory fistula is a serious and life-threatening complication of esophageal cancer. Self-expandable metal stents placement is a well accepted palliative treatment, however, with conflicting results. OBJECTIVE: To identify risk factors associated with clinical failure after self-expandable metal stents placement for the treatment of malignant esophagorespiratory fistula. METHODS: This was a retrospective analysis of a prospectively maintained database used at a tertiary cancer hospital, with patients treated with SEMS placement for MERF between January 2009 and February 2016. The following variables were collected: patient demographics, serum albumin level, Eastern Cooperative Oncology Group (ECOG) performance status, pulmonary infection, previous oncologic treatment, moment of diagnosis of the malignant esophagorespiratory fistula, size and classification of the fistulous tract. RESULTS: A total of 71 patients (55 males, mean age 59 years) were considered for the final analysis. Clinical failure occurred in 44.3% of the patients. ECOG 3 or 4, fistula development during esophageal cancer treatment and fistula diameter >= 1cm were factors associated with increased risk of clinical failure. ECOG 3 or 4, pulmonary infection at the time of SEMS placement and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse events rate was 30%. Stent migration and occlusion due to tumor overgrowth were the most commonly seen adverse events. CONCLUSION: SEMS placement is a reasonable treatment option for MERF, however, ECOG 3 or 4, fistula development during esophageal cancer treatment or large fistula diameter may be independent predictors of clinical failure after stenting

Submitted in fulfillment of the requirements for the degree of Master of Clinical Technology (Nephrology), Durban University of Technology, Durban, South Africa, 2013. / Diabetic nephropathy is a serious complication of diabetes that can lead to end stage renal failure (ESRF). It is now the most common cause of ESRF in patients accepted onto renal replacement therapy (RRT) programmes. Kidney disease is common in South Africa. 60-65% is due to inherited hypertension and 20-25% due to Type 2 diabetes (National Kidney Foundation of South Africa, 2002). The renal replacement therapies include haemodialysis, peritoneal dialysis and transplantation. Successful long-term haemodialysis in patients with end stage renal disease (ESRD) depends to a large extent upon a trouble- free vascular access. Achieving a successful vascular access remains a challenge especially in the diabetic population. Current Kidney Dialysis Outcome Quality Initiative (KDOQI) guidelines encourage placing Arterio-Venous Fistula (AVF) in more haemodialysis patients. While the upper limb is the preferred site for AVF creation, researchers are undecided on which is the ideal location (distal or proximal arm) in the diabetic population. Many new fistulae fail to mature sufficiently to be usable for haemodialysis. Pre-insertion work-up with regard to haemodialysis access is important in maintaining the most appropriate access in the growing diabetic population requiring haemodialysis. Pre-operative vascular mapping to identify suitable vessels has been reported to improve vascular access outcomes . In South Africa, duplex scanning is not routinely done, and a clinical judgement by the surgeon remains in most instances the deciding factor on the site of the AVF. Whilst conducting this research, it has been found that while diabetic patients may have AVF created, the maturation time is of a much extended period, and a challenge to achieve the desired dose of dialysis. This is a prospective, quantitative and qualitative study of 21 diabetic patients. These included patients that were starting on the chronic haemodialysis program and limited to patients that were having first attempt of AVF creation and aims to establish if sonogram testing provides a more accurate measure of the ideal location for the AVF, or if a clinical evaluation alone by the surgeon is sufficient. Surgical techniques are different amongst surgeons and clinical evaluation is more a subjective decision. By limiting the surgeons performing the AVF, a standardized surgical procedure was established. If an ideal AVF access for the patient is created, haemodialysis efficiency is increased and ultimately patient outcome improved. The AVF was created according to the clinical evaluation as is the current process, and the surgeons were not aware of the duplex sonogram results. Failure and success of AVF were analysed according to primary patency and functional success. A primary patency success of the AVF does not guarantee functional success. If an AVF is not able to complete an entire haemodialysis session trouble free at the prescribed dialysis dose, the AVF is considered a failure irrespective of primary patency success. This was evident with 10% of patients who had primary patency but functional success was not achieved. With a 55% functional success in this study with AVF created on clinical evaluation, there was no significance difference (p=0.795) if AVFs were based on duplex sonogram findings. However, there was evidence of increased AVF success in 33% of the failed AVFs when the new AVFs were created at the duplex sonogram site. 95% of patients in this study had commenced haemodialysis with a Central Venous Catheter (CVC). AVF success could be increased if early referral of diabetic patients for permanent access to the surgeon occurred. Maturation rate of AVF differed from KDOQI guidelines with AVF first cannulation only after 17 weeks, and not after the recommended time of 6 weeks. Blood flow rates on dialysis also varied with international standards, with only maximum of 400mls/min reached after one year. With distal arm AVF, diameter of radial artery of less than 2mm and cephalic vein less than 3mm was associated with AVF failure. This research study represents the first of its kind in Kwazulu Natal looking at vascular access sites in diabetic patients with End Stage Renal Disease on haemodialysis. / PDF Full-text unavailable. Please refer to hard copy for Full-text / M

O sucesso do tratamento cirúrgico no câncer de laringe não pode apenas dar atenção à taxa de sobrevida, está também relacionado com a rápida reabilitação da voz e da fala. Para compreender como as estruturas do trato digestivo participam da produção do som traqueoesofágico, a pressão aérea e o limiar de pressão fonatória podem ser utilizados como método de análise nos pacientes com vozes traqueoesofágica. O objetivo desse estudo foi comparar as medidas aerodinâmicas em laringectomizados totais falantes com prótese traqueoesofágica com indivíduos laríngeos. O estudo incluiu a análise de dois grupos, sendo o grupo de estudo (GE) composto por 28 indivíduos que se submeteram a laringectomia total e que optaram pela reabilitação da voz alaríngea por meio da prótese traqueoesofágica e o outro grupo, denominado grupo controle (GC), composto por 32 indivíduos laríngeos saudáveis. Ambos os grupos foram submetidos à avaliação das medidas aerodinâmicas, por meio do Sistema Aerodinâmico Fonatório (SAF) Modelo 6600 (Kaypentax®). Os resultados foram apresentados de forma descritiva e, posteriormente, foram realizadas as comparações entre os grupos (estudo e controle) com o teste t de student para amostras independentes. Foram apresentadas as diferenças estimadas da comparação entre o grupo estudo e o grupo controle com seus respectivos valores p e intervalos de confiança (95%). Para a comparação entre os grupos e as faixas etárias (40 a 59 anos e 60 a 89 anos) foi utilizado um modelo de regressão linear. Os resultados encontrados revelaram diferenças estatisticamente significantes em algumas medidas dos protocolos do Sistema Aerodinâmico Fonatório (SAF). Foi constatada a possibilidade de utilizar o Sistema Aerodinâmico Fonatório (SAF) para auxiliar e aprimorar a produção da voz traqueoesofágica. Todavia, ressalta-se a importância de realizar mais estudos utilizando o aparelho para obter conclusões mais específicas. / Abstract here. The success of surgical treatment in laryngeal cancer can not only pay attention to the survival rate, it is also related to the rapid rehabilitation of voice and speech. To understand how the structures of the digestive tract participate in the production of tracheoesophageal sound, air pressure and the phonatory pressure threshold can be used as a method of analysis in patients with tracheoesophageal voices. The aim of this study was to compare the aerodynamic measurements in total laryngectomized speakers with tracheoesophageal prosthesis with laryngeal individuals. The study included the analysis of two groups, the study group (ES) composed of 28 individuals who underwent total laryngectomy and who opted for the rehabilitation of the alaringeal voice through the tracheoesophageal prosthesis and the other group, called the control group GC), composed of 32 healthy laryngeal individuals. Both groups were submitted to aerodynamic measurements, using the Model 6600 - Spin Aerodynamic System (SAF) (Kaypentax®). The results were presented in a descriptive way and, afterwards, comparisons between the groups (study and control) were carried out with the student t test for independent samples. We presented the estimated differences between the study group and the control group, with their respective p values and confidence intervals (95%). A linear regression model was used to compare the groups and the age groups (40 to 59 years and 60 to 89 years). The results found revealed statistically significant differences for some measures of the Aerodynamic Phonatory System (SAF) protocols. It was verified the possibility of using the Fonody Aerodynamic System (SAF) to aid and improve the production of the tracheoesophageal voice. However, it is important to carry out more studies using the device to obtain more specific conclusions.

Esta pesquisa utilizou a revisão sistemática com o objetivo de identificar os principais tratamentos da fístula faringocutânea após a laringectomia total e elaborar recomendações para as intervenções de enfermagem na assistência ao paciente submetido a laringectomia total, com a complicação fístula faringocutânea. Foram previamente localizados 1007 estudos, dos quais foram selecionados 37 estudos publicados em periódicos científicos indexados no Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE e LILACS, desses 17 (46%) abordavam o tratamento da fístula faringocutânea, após laringectomia total, 10 (27%) discutiam os fatores de risco e os outros 10 (27%) as complicações após a laringectomia total. A análise desses artigos revelou que o delineamento da pesquisa predominante nos estudos foi o retrospectivo com 88,5%, e 11,5% prospectivos. A média de tempo de acompanhamento foi de 8,8 anos e a incidência de fístula faringocutânea, após a laringectomia total variou entre 8,7% e 27,0%, envolvendo um total de 635 pacientes. Os fatores de risco estudados pelos pesquisadores foram: radioterapia pré-operatória, técnica cirúrgica, traqueostomia pré-operatória, estadiamento do tumor, febre, doenças crônicas, vômito, nível de hemoglobina e reinício da alimentação oral, formando subgrupos com um número menor de pacientes e, conseqüentemente obtiveram percentuais individuais maiores de incidência da fístula faringocutânea, quando comparados com o índice geral de fístula proveniente da amostra inicial do estudo. O tratamento conservador e cirúrgico da fístula tem por finalidade preservar e restaurar a região lesada e envolve um processo complexo, dinâmico e sistêmico. Esta complicação aumentou o período de internação e de cicatrização, com médias de 28 e de 36 dias respectivamente. O tratamento predominante é ainda o conservador que implica cuidados higiênicos intensivos e o tratamento da ferida. O planejamento da assistência de enfermagem alicerçado em conhecimentos e habilidades técnico-científicas acerca do tratamento de feridas aliadas à dimensão psicossocial resultarão em intervenções de maior qualidade.A incorporação de conhecimentos oriundos da prática baseada em evidências na prática clínica, trará maior consistência à atuação do enfermeiro no cuidado do laringectomizado total e portador de fístula faringocutânea. / This research carried out a systematic review aimed at identifying the main treatments of pharyngocutaneous fistula after total laryngectomy and at elaborating recommendations for nursing interventions in care delivered to patients submitted to total laryngectomy, including the pharyngocutaneous fistula complication. In advance, 1007 studies were found, out of which we selected 37 studies published in scientific journals indexed in Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE and LILACS. Among these, 17 (46%) dealt with the treatment of pharyngocutaneous fistula after total laryngectomy, 10 (27%) discussed the risk factors and the other 10 (27%) were about complications after total laryngectomy. The analysis of these articles revealed that the predominant research orientation was retrospective (88.5%) and 11.5% corresponded to prospective studies. Average follow-up time was 8.8 years and the occurrence of pharyngocutaneous fistula after total laryngectomy varied from 8.7% to 27.0%, involving 635 patients in total. Analyzed risk factors were: pre-operative radiotherapy, surgical technique, pre-operative tracheostomy, tumor stage, fever, chronic disease, vomiting, hemoglobin level and restarting oral feeding. These constitute subgroups with a lower number of patients which, consequently, obtained higher individual percentage values for the occurrence of pharyngocutaneous fistula in comparison with the general fistula rate from the initial study sample. The conservative and surgical treatment of fistula aims to preserve and restore the injured region and involves a complex, dynamic and systemic process. This complication increased the internment and healing periods, with an average duration of 28 and 36 days respectively. The conservative treatment still predominates and implies intensive hygienic care and wound treatment. The planning of nursing care, based on technical-scientific knowledge and abilities related to wound treatment, in association with the psychosocial dimension, will result in higher-quality interventions. Incorporating evidence-based knowledge into clinical practice will offer greater consistency to nursing actions in caring for patients after total laryngectomy who suffer from pharyngocutaneous fistula.

Introdução: A correção cirúrgica primária do palato é de fundamental importância na reabilitação do indivíduo com fissura labiopalatina e visa tanto a restauração anatômica local, com o fechamento da comunicação existente entre a cavidade nasal e oral, como a restauração funcional do anel velofaríngeo por meio do reposicionamento dos músculos palatinos. Ao longo dos anos, as técnicas de fechamento de palato foram evoluindo progressivamente utilizando, cada vez mais, o procedimento de reposicionamento da musculatura responsável pelo fechamento do esfíncter velofaríngeo, denominado veloplastia intravelar. Tal procedimento favorece o funcionamento sinérgico da musculatura velar e faríngea evitando, assim, os sintomas decorrentes da insuficiência velofaríngea. No entanto, apesar de todos os esforços no sentido de conseguir o funcionamento velofaríngeo adequado, intercorrências intra-operatórias e complicações pós-operatórias imediatas e/ou tardias podem contribuir para o insucesso da palatoplastia primária e, consequentemente, levar ao aparecimento de hipernasalidade. Objetivos: Investigar o efeito da palatoplastia primária realizada com veloplastia intravelar sobre a ressonância da fala e o índice de intercorrências intra-operatórias e complicações pós-operatórias da cirurgia e, ainda, correlacionar as intercorrências e complicações pós-operatórias com os resultados de ressonância. Material e Métodos: Foram avaliados, prospectivamente, 60 pacientes com fissura labiopalatina, de ambos os sexos, submetidos à correção primária do palato aos 13 meses de idade, em média, por um único cirurgião plástico. Todos os pacientes foram submetidos à palatoplastia primária com veloplastia intravelar, utilizando amplo descolamento muscular da mucosa nasal e mínimo descolamento da mucosa oral e reposicionamento posterior do grupo muscular. Intercorrências intra-operatórias, tais como, sangramento excessivo, lasceração da mucosa, extubação e as complicações pós-operatórias imediatas e tardias, tais como febre, tosse, choro, vômito, infecção cirúrgica, infecção não cirúrgica e trauma local foram investigadas, por meio de anotações feitas no prontuário e pelo relato dos pais. A presença e localização de fístula ou deiscência do palato foi feita por meio de avaliação clínica realizada pelo mesmo cirurgião plástico, 14,8 meses, em média, após a cirurgia. Os pacientes foram submetidos, também, à gravação em áudio de amostra de fala, as quais foram analisadas por três fonoaudiólogas, que classificaram a hipernasalidade da fala em presente ou ausente. O escore final da hipernasalidade foi obtido pelo consenso entre as três avaliadoras. As intercorrências intra-operatórias e as complicações pós-operatórias foram analisadas de forma descritiva. A associação entre as intercorrências intra-operatórias e complicações imediatas e tardias com a formação de fístulas, bem como a associação entre a ocorrência de fístulas e deiscências com a presença e ausência de hipernasalidade foram analisadas por meio de Teste Exato de Fisher. Resultados: Verificou-se 5% de intercorrências intra-operatórias (sangramento excessivo e lasceração de mucosa), 20% de complicações imediatas (tosse, febre, choro, sangramento e vômito) e 13,3% de complicações tardias (tosse, sangramento e infecção não cirúrgica). O índice de ocorrência de fístulas foi de 16,67% e de deiscências foi de 5%. A proporção de hipernasalidade foi de 18,6%. Conclusão: A palatoplastia com veloplastia intravelar utilizada no presente estudo demonstrou ser uma técnica segura, de fácil execução, eficiente para a fala e com baixos índices de complicações. / Introduction: Primary surgical palate repair is fundamental for the rehabilitation of individuals with cleft lip and palate. This procedure aims at local anatomic restoration, closing the communication between nasal and oral cavities, but also at functional restoration of the velopharynx by repositioning of the palatal muscles. Along the years, the techniques for palate repair have been progressively improved, increasingly using the procedure for repositioning of velopharyngeal sphincter muscles, called intravelar veloplasty. This procedure favors the synergic functioning of the velar and pharyngeal musculature, thus avoiding the symptoms of velopharyngeal insufficiency. However, despite all efforts to achieve an adequate velopharyngeal closure, intraoperative events and immediate and/or late postoperative complications may contribute to the failure of primary palatoplasty, consequently leading to the occurrence of hypernasality. Objectives: To investigate the effect of primary palatoplasty with intravelar veloplasty on the speech resonance, the rate of intraoperative events and postoperative complications of surgery, as well as to correlate the events and postoperative complications with resonance outcomes. Material and Methods: A total of 60 individuals with cleft lip and palate were prospectively evaluated, of both genders, underwent primary palate repair at 13 months of age in the average, by a single plastic surgeon. All individuals were submitted to primary palatoplasty with intravelar veloplasty, with wide muscular dissection of the nasal mucosa, minimum dissection of the oral mucosa and posterior muscle repositioning. Intraoperative events, such as excessive bleeding, mucosal laceration and extubation; and immediate and late postoperative complications, including fever, cough, crying, vomiting, surgical infection, non-surgical infection and local trauma were assessed from the patients records and parents reports. The presence and location of palatal fistula or dehiscence were clinically analyzed by the same plastic surgeon, at 14.8 months after surgery in the average. The individuals were also submitted to audio recording of speech samples, which were analyzed by three speech-language pathologists who scored the speech hypernasality as present or absent. The final score of hypernasality was obtained by consensus among the three examiners. The intraoperative events and postoperative complications were descriptively analyzed. The Fishers exact test was applied to investigate the association between intraoperative events, immediate and late complications and the occurrence of fistulas, as well as between the occurrence of fistulas and dehiscences and the presence or absence of hypernasality. Results: The findings revealed 5% of intraoperative events (excessive bleeding and mucosal laceration), 20% of immediate complications (cough, fever, crying, bleeding and vomiting) and 13.3% of late complications (cough, bleeding and non-surgical infection). The occurrence of fistulas was 16.67%, and dehiscences were observed in 5%. The proportion of hypernasality was 18.6%. Conclusion: Palatoplasty with intravelar veloplasty used in the present study presented to be a safe technique, with easy accomplishment, effective for speech and with low rates of complications.