Introdução: Avaliar a relação do custo e da efetividade da radiofrequência (RF) em relação ao bloqueio seqüencial na Síndrome Dolorosa Complexa Regional-tipo I (SDCR-I). Métodos: 15 pacientes com dor somática e autonômica cervical foram submetidos a bloqueio torácico simpático, combinado com bloqueio facetário cervical bilateral por 4 semanas. Esta seqüência foi repetida quando a dor atingiu VAS 4 cm, e este período foi definido como tempo de analgesia. Posteriormente, os mesmos pacientes foram submetidos a um bloqueio teste seguido de modulação de RF do gânglio simpático torácico e ablação de ramos facetários medianos cervicais. Os pacientes atuaram como seu próprio controle relacionado à analgesia, atividades rotineiras e padrão de sono. Resultados: 13 pacientes completaram o estudo. O tempo de analgesia após a sequência de 4 bloqueios foi de 4 ± 1 mês e o custo anual R$ 15.000,00. O tempo de analgesia após RF foi de 13 ± 2 meses (p <0,001) e os custos foram reduzidos em 26% no primeiro ano e 34% -38% nos anos seguintes, com extrapolação. A qualidade de vida melhorou para ambos os tratamentos (p> 0,05). Não houve efeitos adversos. Discussão: A RF resultou em analgesia de 13 meses comparada a 4 meses após os bloqueios clássicos e melhora na capacidade física e no padrão de sono. Além disso, a RF foi rentável e reduziu as taxas em 23% durante a avaliação do primeiro ano, seguida de uma redução de custos de 32% a 36% nos anos seguintes, com extrapolação. / Objectives: To evaluate cost-effectiveness of radiofrequency (RF) compared to sequential block in Complex Regional Pain Syndrome-I (CRPS). Methods: 15 patients with cervical somathic and autonomic pain were submitted to a 4- weekly sympathetic thoracic block, combined to bilateral cervical facetary block. This sequence was repeated when pain reached VAS 4-cm, and this period was defined as time of analgesia. Thereafter, same patients were submitted to a test block followed by RF modulation of thoracic sympathetic ganglion and ablation of facetary cervical median branches. Patients acted as their own control related to analgesia, routine activities, sleep pattern and costs. Results: 13 patients completed the study. The analgesia time after the 4-block sequence was 4±1 months and the annual costs USA$5000. Analgesia time after RF was 13±2 months (p<0.001) and costs were reduced by 26% in the first year and 34%-38% in the following years extrapolation. Quality of life improved for both treatments (p> 0.05). There were no adverse effects. Discussion: RF resulted in 13-month compared to 4-month analgesia after the classical 4- weekly blocks, and improved physical capacity and sleep pattern. Besides that, RF was costeffective, and reduced rates by 23% during the first-year evaluation, followed by 32%-36% cost reduction in following years, by extrapolation.

A cirurgia cardíaca é um evento estressante na vida de um paciente, especialmente durante a estadia na unidade de terapia intensiva, no período pós-operatório imediato, podendo ser agravado por fatores como ansiedade, depressão e a capacidade de enfrentamento. Entretanto alguns pacientes conseguem lidar melhor com esse estresse do que outros. Os objetivos deste estudo foram avaliar: as relações entre ansiedade, depressão e senso de coerência de pacientes no préoperatório de cirurgia cardíaca; as relações entre ansiedade, depressão e senso de coerência com as variáveis sexo, idade, escolaridade e tempo de pré-operatório e a relação das medidas de ansiedade, de depressão e de senso de coerência dos pacientes cardíacos, no período pré-operatório, com o estresse percebido no pósoperatório imediato. Os dados foram coletados por entrevistas individuais realizadas pela pesquisadora em dois momentos da internação: no período pré-operatório e no pós-operatório imediato. Para a primeira coleta foi utilizado um instrumento de caracterização sócio-demográfica e clínica; a versão adaptada da Hospital Anxiety and Depression Scale (avaliação da ansiedade e depressão) e a versão adaptada do Questionário de Senso de Coerência de Antonovsky (avaliação da capacidade de enfrentamento). Para a segunda coleta foi utilizada a versão adaptada da Escala de Estressores em Terapia Intensiva. Os dados foram analisados usando o coeficiente de correlação de Spearman, teste de Mann-Whitney e teste de Kruskal-Wallis. O nível de significância adotado foi de 0,05. Participaram da investigação, 91 sujeitos com idade média de 56,9 anos (DP= 13,7), 52,7% eram mulheres; 45 (49,5%) foram submetidos à cirurgia de revascularização do miocárdio. Houve correlações inversas e de moderada magnitude, entre senso de coerência e ansiedade (r= -0,371; p= 0,000) e senso de coerência e depressão (r= -0,516; p= 0,000). As mulheres e os pacientes com menor escolaridade apresentaram maior pontuação para ansiedade (M= 8,1 e M= 7,6, respectivamente) e para depressão (M= 5,8 e M= 5,7, respectivamente). O tempo de internação pré-operatória foi associado à maior ansiedade (p= 0,03) e o nível e escolaridade foi associado à maior depressão (p= 0,01). Pacientes masculinos, acima de 60 anos, com maior grau de escolaridade obtiveram maior senso de coerência. A percepção dos estressores foi maior para os pacientes masculinos, com idade entre 41 e 59 anos, com escolaridade em nível médio ou superior e maior tempo de internação na UTI. Os itens da escala considerados mais estressantes foram ter dor e não conseguir dormir. Concluiuse que houve correlação de moderada magnitude entre as medidas de estressores percebidos e ansiedade (p= 0,01) e depressão (p= 0,003) e correlação fraca entre as medidas de senso de coerência (p= 0,09) e estressores. / Cardiac surgery is a stressful event in a patients life, especially while at the intensive care unit in the immediate postoperative period, and can be aggravated by factors like anxiety, depression and coping capacity. Some patients, however, manage to deal with this stress better than others. This study aimed to assess: the relations between anxiety, depression and sense of coherence of patients in the preoperative period of cardiac surgery; the relations between anxiety, depression and sense of coherence and gender, age, education level and preoperative hospitalization time variables and the relation between preoperative measures of anxiety, depression and sense of coherence in cardiac patients with perceived immediate postoperative stress. Data were collected through individual interviews held by the research at two times during hospitalization: in the preoperative period and in the immediate postoperative period. For the first data collection, an instrument was used to survey sociodemographic and clinical characteristics; the adapted version of the Hospital Anxiety and Depression Scale (assessment of anxiety and depression) and the adapted version of Antonovskys Sense of Coherence Questionnaire (assessment of coping capacity). For the second data collection, the adapted version of the Intensive Care Unit Environmental Stressor Scale was used. Spearmans correlation coefficient, Mann-Whitneys test and Kruskal-Wallis test were used for data analysis. Significance was set at 0.05. Study participants were 91 subjects with a mean age of 56.9 years (SD= 13.7); 52.7% were women; 45 (49.5%) were submitted to coronary artery bypass graft surgery. Inverse and moderate correlations were found between sense of coherence and anxiety (r= -0.371; p= 0.000) and sense of coherence and depression (r= -0.516; p= 0.000). Women and patients with lower education levels presented higher anxiety (M= 8.1 and M= 7.6, respectively) and depression scores (M= 5.8 and M= 5.7, respectively). Preoperative hospitalization time was associated with greater anxiety (p= 0.03) and education level was associated with greater depression (p= 0.01). Male patients older than 60 years with higher education levels obtained a higher sense of coherence. The perception of stressors was greater for male patients between 41 and 59 years old, with secondary or higher education level and longer ICU hospitalization time. The most stressful items on the scale were feeling pain and not being able to sleep. It is concluded that a moderate correlation exists between perceived stress measures and anxiety (p= 0.01) and depression (p= 0.003), and a weak correlation between sense of coherence measures (p= 0.09) and stressors.

Toracoscopia é o método de visibilização da cavidade torácica, tendo sua indicação como exame auxiliar para diagnóstico de afecções como pleuropneumonia, neoplasias, aderências, metástases, pericardites, abscessos pulmomares e hérnias. O aprimoramento da equipe cirúrgica e o avanço tecnológico dos equipamentos endoscópicos fizeram com que esta técnica passasse a ser denominada cirurgia torácica vídeo-assistida, pela sua indicação não somente diagnóstica, mas terapêutica. Este trabalho visou à realização de ressecção da porção dorsocaudal do lobo pulmonar caudal esquerdo com auxílio de sutura mecânica por via toracoscópica. Foram utilizados seis eqüinos clinicamente sadios, machos e fêmeas, de peso, raça e idade variáveis. Estes animais foram avaliados nos períodos pré e pós-operatórios através de exame físico, coleta de material para hemograma e fibrinogênio plasmático, e exame ultra-sonográfico torácico. O local da ressecção pulmonar foi avaliado através de novo procedimento toracoscópico no 30º dia de pós-operatório. Em todos os animais a realização da técnica transcorreu de forma adequada, tendo sido possível o controle do pneumotórax, assim como foi observada evolução clínica satisfatória durante o período pós-operatório. Os resultados obtidos indicam que através de técnica cirúrgica vídeo-assistida pode-se realizar ressecção pulmonar parcial com uso de sutura mecânica em eqüinos, e sua aplicação na rotina hospitalar poderá contribuir para resolução das enfermidades sediadas na cavidade torácica. / Thoracoscopy is a method used to evaluate the thoracic cavity and as such, it is indicated as an auxiliary exam in the diagnosis of diseases as pleuropneumonia, neoplasias, adhesions, metastasis, pericarditis, pulmonary abscesses and herniation. Due to the refinement of the surgical team and the technological advance of endoscopic equipment this technique is currently denominated video-assisted thoracic surgery, which is more adequate, since it is indicated for both diagnostic and therapeutic purposes. In this thoracoscopic study we performed a resection of the dorsocaudal portion of the left caudal lung lobe with the aid of endoscopic stapler. For the purpose of this study we used six healthy horses, females and males, of different weights, breeds and ages. During the pre and postoperative periods, these horses were evaluated by means of physical examination, hemogram and plasmatic fibrinogen dosage, and thoracic ultrasound. The site of lung resection was evaluated by means of a second thoracoscopy on the 30th postoperative day. In all animals the performance of the technique was adequate, it was possible to control the pneumothorax, and furthermore, clinical recovery during the postoperative period was adequate. The results of this study determined that the video-assisted surgical technique provided partial lung resection in horses with the use of endoscopic staplers. Its use in hospital routine may contribute to the resolution of thoracic diseases.

Orientador: Desanka Dragosavac / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-20T23:09:28Z (GMT). No. of bitstreams: 1 Matheus_GabrielaBertolini_M.pdf: 1394514 bytes, checksum: 814cccdf11d81a381fe2058341b4254c (MD5) Previous issue date: 2012 / Resumo: Justificativa e Objetivo: Complicações pulmonares estão entre as maiores causas de morbidade e mortalidade do pós-operatório (PO) de cirurgia cardíaca. As causas são diversas e estão relacionadas à disfunção pulmonar causada pela circulação extracorpórea, esternotomia, uso da artéria mamária interna, drenos torácicos e à dor no período pós-operatório. Ocorre disfunção da musculatura respiratória acompanhada de perda da força muscular e redução das capacidades e volumes pulmonares. Nesse contexto, técnicas fisioterapêuticas têm por objetivo a reexpansão e melhora da capacidade pulmonar além da manutenção ou ganho de força muscular respiratória, e podem contribuir para prevenção e tratamento de tais complicações. O objetivo do presente estudo foi avaliar o efeito do treinamento muscular inspiratório em pacientes submetidos à cirurgia de revascularização do miocárdio, com o uso do Threshold® IMT no período pós-operatório. Método: Quarenta e sete pacientes submetidos à revascularização eletiva do miocárdio através de esternotomia mediana foram randomizados por sorteio prévio à avaliação pré-operatória e divididos em dois grupos: Grupo Estudo (23 pacientes, cinco mulheres e 18 homens) e Grupo Controle (24 pacientes, oito mulheres e 16 homens), com idade média de 61,83±8,61 e 66,33±10,20 respectivamente. Ambos os grupos foram submetidos ao protocolo de rotina para atendimento fisioterápico em pós-operatório de cirurgia cardíaca. Apenas o grupo estudo foi submetido a um protocolo de treinamento inspiratório com o uso do Threshold® IMT com carga de 40% da Pimáx obtida no 1º PO durante três dias. Foram mensuradas e comparadas às pressões respiratórias máximas (Pimáx e Pemáx), VC (Volume Corrente), CV (Capacidade Vital) e Pico de Fluxo Expiratório (Pico de Fluxo Expiratório) no Pré-OP, PO1 e PO3. Resultados: Observou-se redução significativa em todas as variáveis mensuradas no 1º dia de pós-operatório quando comparadas ao pré-operatório, nos dois grupos estudados. Pimáx (p<0,0001), Pemáx (p<0,0001), VC GE (p<0,0004) e GC (p<0,0001), CV GE (p<0,0001) e GC (p<0,0001) e Pico de Fluxo Expiratório (p<0,0001). No PO3, o GE apresentou, em comparação ao GC, maior valor de CV, (GE 1230,4±477,86ml vs GC 919,17±394,47ml, p=0,0222) e VC (GE 608,09±178,24ml vs GC 506,96±168,31ml, p=0,0490). Conclusão: Pacientes submetidos à cirurgia cardíaca sofrem redução da capacidade ventilatória e da força muscular respiratória após a cirurgia. O treinamento muscular realizado foi eficaz em recuperar o volume corrente e a capacidade vital no terceiro dia de pós-operatório, no grupo treinado. Não houve diferença na incidência de complicações respiratórias e o grupo treinado apresentou menor tempo de internação na unidade coronariana / Abstract: Background and Objectives: Pulmonary complications are the major causes of morbidity and mortality of postoperative period (PO) of cardiac surgery. The causes are diverse and are related to pulmonary dysfunction caused by cardiopulmonary bypass, sternotomy, internal mammary artery use, chest drains, and pain in the postoperative period. There may be dysfunction of the respiratory muscles accompanied by loss of muscle strength and reduction of capacity and lung volumes. In this context, physical therapy techniques are designed to re-expansion and improve lung capacity and maintenance or gain of respiratory muscle strength and may contribute to prevention and treatment of such complications. The aim of this study was to evaluate the effect of inspiratory muscle training in patients undergoing coronary artery bypass grafting, using the Threshold® IMT in the postoperative period. Method: Forty-seven patients undergoing elective coronary artery bypass grafting via median sternotomy were randomized by lot prior to the preoperative evaluation, and divided into two groups: Study Group (SG) (23 patients, 5 women and 18 men) and Control group (CG) (24 patients, 8 women and 16 men) and with mean age of 61.83±8.61 and 66.33±10.20 respectively. Both groups were subjected to routine protocol for the physical therapy treatment in post-cardiac surgery. However, only the study group was subjected to inspiratory training protocol using Threshold IMT® with a load of 40% of MIP obtained in first postoperative day for three days. Maximal respiratory pressures (MIP and MEP), VT (Tidal Volume), VC (Vital Capacity) and Peak Flow in the Pre-OP, PO1 and PO3 were measured and compared. Results: There was a significant reduction in all variables measured on PO1 compared to preoperative values in both groups, MIP (p<0.0001), MEP (p<0.0001), VT SG (p<0.0004) and CG (p<0.0001), VC SG (p<0.0001) and CG (p<0.0001) and Peak Flow (p<0.0001). At PO3, SG presented higher value of VT, SG 1230.4±477.86ml vs CG 919.17±394.47ml (p=0.0222) and VC SG 608.09±178.24ml vs CG 506.96±168.31ml (p=0.0490). There were differences between SG and CG for VT (p=0.0490) and VC (p=0.0222) in PO3. Conclusion: Patients undergoing cardiac surgery experience reduced ventilatory capacity and respiratory muscle strength after surgery. Muscle training was performed to retrieve the effective tidal volume and vital capacity in the third postoperative day of the trained group. There was no difference in the incidence of respiratory complications and the trained group had shorter hospitalization in the coronary unit / Mestrado / Fisiopatologia Cirúrgica / Mestre em Ciências

Hintergrund: Das Mammakarzinom stellt weltweit die häufigste maligne Tumorerkrankung der Frau dar und wird immer noch größtenteils als primär systemische Krebsform angesehen. Nach Primärbehandlung werden 5-Jahresüberlebensraten von 80% erreicht. Jedoch überleben Patientinnen, bei denen ein Stadium IV vorliegt, im median nur 20-30 Monate. 5-15% dieser Patientinnen weisen dabei einen isolierten metastatischen Befall der Lunge auf, der als Oligometastasierung im Sinne eines stabilen Zwischenstadiums der Erkrankung angesehen werden kann und somit einer lokalen Therapie zugänglich ist. Etliche Studien weisen darauf hin, dass gerade diese Frauen von einer Resektion ihrer Lungenmetastasen deutlich mehr profitieren können, als von medikamentöser systemischer Therapie allein. Zudem kann das Rezeptorverhalten (Östrogen-, Progesteron-, HER2-Rezeptor) zwischen primärem Mammakarzinom und dessen Metastasen differieren, was in bisher noch nicht geklärtem Umfang Änderungen des Behandlungsschemas zur Folge hat. Frage- und Zielstellung: Ziel der vorliegenden Arbeit ist es, das Outcome von Patientinnen mit pulmonal metastasiertem Mammakarzinom, deren Lungenmetastasen ausschließlich mit einer neuen parenchymsparenden 1318-nm-Lasertechnik reseziert wurden, im Verlauf zu untersuchen und unabhängige prognostische Faktoren zu identifizieren. Weiterhin soll der Nachweis einer Rezeptordiskordanz speziell für pulmonale Fernmetastasen erbracht und aufgezeigt werden, in welchen Größenordnungen mit solchen Rezeptorwechseln zu rechnen ist. Patientinnen und Methoden: Im Rahmen dieser retrospektiven Studie wurde vom 01.01.1996 bis 31.12.2012 bei insgesamt 102 Patientinnen im Alter von 33 bis 78 Jahren und einem Durchschnittsalter von 58 Jahren eine kurative pulmonale Laser-Metastasenresektion mit systematischer Lymphadenektomie vorgenommen. Vorgegebene Einschlusskriterien waren die vollständige Resektion und Kontrolle des Primärtumors sowie das Fehlen von extrapulmonalen/-thorakalen Metastasen bzw. deren präoperative erfolgreiche Therapie. Eine Limitierung bezüglich der Zahl der Lungenmetastasen wurde nicht vorgegeben, allerdings mussten die technische Resektabilität und die funktionelle Operabilität aus der präoperativen Diagnostik ableitbar sein. Mit Hilfe der Kaplan-Meier-Methode wurde das Gesamtüberleben des Patientenkollektivs sowie ausgewählter Subgruppen analysiert. Das Cox-Proportional-Hazard-Modell wurde verwendet, um im uni- und multivariaten Verfahren prognostische Faktoren zu ermitteln. Zum Vergleich des Rezeptorstatus von Primärtumor und Metastasen kam der McNemare-Test zum Einsatz. Eine statistische Signifikanz wurde bei p-Werten von < 0,05 angenommen. Ergebnisse: Insgesamt wurden 936 Lungentumore entfernt, von denen sich nach histopathologischer Sicherung 716 als Metastasen des anamnestisch bekannten Mammakarzinoms erwiesen. Die Anzahl reichte von einer solitären Metastase bis zu 61 zweizeitig entfernten Metastasen (durchschnittlich 7 pro Patientin). Die Lobektomierate betrug 0,98% (n=1). In 7,8% (n=8) der Fälle waren zusätzlich lappensparende Laser-Segmentresektionen möglich. R0-Resektionen konnten bei 73,5% (n=75) der Patientinnen erreicht werden. Das mediane Gesamtüberleben betrug 43 Monate, die 5-Jahresüberlebensrate belief sich auf 46,1%. Als unabhängige prognostische Faktoren konnten der Resektionsstatus (p=0,02), der intrathorakale Lymphknotenbefall (p=0,001) und die Expression des Östrogenrezeptors (p=0,018) nachgewiesen werden. Das Risiko zu versterben war bei tumorbefallenen Lymphknoten und bei fehlender Ausprägung des Östrogenrezeptors 3,2- bzw. 2-fach erhöht. Die Anzahl der resezierten Metastasen, die Art des Lungenbefalls (uni-/bilateral), das krankheitsfreie Überleben nach Primär-Operation (</> 36 Monate) und die Expression des Progesteronrezeptors hatten keinen signifikanten Einfluss auf das Überleben. Angaben zum primären und metastatischen Hormonrezeptor- bzw. HER2-Status waren bei 88,2% (n=90) bzw. 62,7% (n=64) der Patientinnen verfügbar. Es fanden sich Diskordanzraten bzgl. des Östrogen-, Progesteron- und HER2-Rezeptors von 26,7%, 41,1% bzw. 28,1%. Eine Signifikanz der Abweichung zwischen Primärtumor und Metastasen konnte lediglich für den Östrogenrezeptor nachgewiesen werden (p=0,002). In einer Nebenbetrachtung der vorliegenden Arbeit konnten bei 157 Mammakarzinom-Patientinnen mit neu aufgetretenen, radiologisch detektierten Lungenrundherden in 65,6% der Fälle Metastasen des Mammakarzinoms histologisch gesichert werden. Bei den übrigen Befunden handelte es sich um andere therapiebedürftige maligne Tumore und zu etwa 20% um benigne Befunde. Schlussfolgerungen: Die vorliegenden Ergebnisse bekräftigen den positiven Einfluss der Lungenmetastasektomie auf das Überleben ausgewählter Mammakarzinom-Patientinnen mit isolierter pulmonaler Oligometastasierung. Dabei können mit der Anwendung der parenchymsparenden 1318 nm -Lasertechnik, auch bei Vorhandensein von multiplen und beidseitigen Lungenmetastasen, in größerem Umfang als bisher berichtet, vollständige Resektionen ohne wesentlichen Funktionsverlust und somit guter Lebensqualität erreicht werden. Ungeachtet höherer Zahlen resezierter pulmonaler Metastasen werden gegenüber konventionellen Operationstechniken, auch beim pulmonal metastasierten Mammakarzinom, vergleichbare Überlebensraten erreicht. Die Anzahl der präoperativ diagnostizierten Lungenmetastasen sollte daher einen geringen Einfluss auf die Indikationsstellung zur Operation haben, weshalb diesbezüglich eine Erweiterung der Einschlusskriterien sinnvoll erscheint. Eine R0-Resektion konnte erneut als wichtigster prognostischer Parameter bestätigt werden und sollte deshalb stets oberstes Ziel des Operateurs sein. Das wesentlich schlechtere Outcome unvollständig operierter Patientinnen sowie der Vergleich mit der Literatur zur alleinigen systemischen Therapie zeigen, dass das analysierte Patientenkollektiv von einer Resektion der pulmonalen Mammakarzinom-Metastasen deutlich mehr profitieren kann, als von medikamentöser Behandlung allein. Ein intrathorakaler Lymphknotenbefall wurde, nach unserem Wissen, erstmals bei Patientinnen mit isolierten Lungenmetastasen eines Mammakarzinoms, trotz radikaler Ausräumung, als signifikante negative Einflussgröße auf das Überleben nachgewiesen. In Anlehnung an die Therapie des Lungenkarzinoms sollte trotz dessen, zumindest bis zum Vorliegen weiterführender Studien, standardmäßig eine intraoperative systematische Lymphadenektomie durchgeführt werden. Bei positivem Tumornachweis ist eine komplette Lymphknotendissektion zu erwägen, um keine Patientin von einer potenziell kurativen Therapie auszuschließen. Den vorliegenden Ergebnissen zufolge, darf des Weiteren speziell bei Verdacht auf pulmonale Mammakarzinom-Metastasen nicht von einer Konstanz der Expression der Steroidhormon- bzw. HER2-Rezeptoren, insbesondere der des Östrogenrezeptors, ausgegangen werden. Änderungen zum primären Befund treten dabei in relevanten Größenordnungen auf. Die Bestimmung eines aktuellen Rezeptorstatus sollte nach Metastasektomie obligat durchgeführt werden. Bezüglich der Frage des Ursprungs pulmonaler Rundherde bei bekanntem Mammakarzinom kann darüber hinaus durch deren Resektion mit nachfolgender histopathologischer Analyse sicher zwischen Metastasen, Lungenkarzinomen und benignen Tumoren differenziert werden. Insgesamt ermöglicht dies konkrete Therapieentscheidungen zu treffen. Um Patientinnen jedoch in zeitlich limitierter oligometastatischer Tumorausbreitung zu diagnostizieren und einer bestmöglichen Therapie, einschließlich der Resektion, zuzuführen, ist zufolge unserer Daten sowie der neueren Literatur eine konsequente, engmaschige und zudem apparative Nachsorge notwendig. Dieser Problematik wird gegenwärtig in den aktuellen Leitlinien nicht adäquat Rechnung getragen, da sich die Autoren auf ältere, heutzutage kritisch zu hinterfragende Analysen beziehen. Als Limitationen der vorgelegten Arbeit sind das retrospektive Studiendesign und die Form der Kohortenanalyse, die uneinheitliche Bestimmung des primären Rezeptorstatus sowie die Heterogenität der postoperativen Anschlusstherapien anzusehen. Zukünftig sind größere, multizentrische und randomisierte Studien notwendig, um weiterführende Daten zu generieren und die pulmonale Lasermetastasektomie beim Mammakarzinom im Rahmen multimodaler Therapien möglicherweise weiter zu etablieren sowie den Wert einer erweiterten Nachsorge zu evaluieren. / Background: Breast carcinoma is the most common type of cancer in women worldwide and is still regarded as a systemic disease. After primary treatment five-year survival rates around 80% are reported. However, the mean survival time of stadium-IV classified patients is 20-30 months. 5-15% of patients appear with isolated metastases of the lungs which can be considered as an oligometastatic and, therefore, stable intermediate stage in disease process. Several studies point out that especially these women are more likely to benefit from resection of lung metastases than from systemic therapy alone. Furthermore, there is the possibility of a discordant expression of typical receptors (Estrogen-, Progesterone- and HER2-receptor) between primary breast cancer and its paired metastases. As a result a change in treatment regimen might be necessary. Objective: The aim of the present study was to evaluate long-time survival of patients with lung metastases from breast cancer who have been operated exclusively with a new parenchyma-saving and lobe-sparing 1318-nm-lasertechnique. Additionally, the identification of independent prognostic factors was of interest. Furthermore, existence and magnitude of receptor discordance, specifically for distant pulmonary metastases, should be proved. Patients and methods: Within this retrospective study between 1996 and 2012 102 patients (mean age 58; range 33-78 years) underwent curative laser metastasectomy and systematic lymphadenectomy. Inclusion criteria were complete resection of primary breast cancer and absence of extrapulmonary/-thoracal metastases or its previous total treatment. Although there were no limitations regarding the number of metastases, technical resectability and functional operability had to be assumed after the preoperative diagnostics. Kaplan-Meier-analysis was performed to assess overall survival in all patients and selected subgroups. Uni- and multivariate analyses of prognostic factors were performed using the Cox-proportional-hazard model. Comparison of the receptor status of primary breast cancer and paired lung metastases was assessed by the McNemare method. Significant results were assumed if p-values were <0.05. Results: In total 936 intrapulmonary nodules had been resected, including 716 histopathologically confirmed breast cancer metastases. The amount reached from a single metastasis up to 61 two-staged removed pulmonary nodules (mean 7 per patient). The lobectomy rate was 0.98%. In 7.8% of all cases segment-resections, also performed by laser, were possible. Complete resection was achieved in 73.5% (n=75). The median overall survival time was 43 months and the five-year survival rate was 46.1%. As independent prognostic factors resection status (p=0.02), involvement of intrathoracal lymph nodes (p=0.001) and expression of estrogen receptor (p=0.018) were identified. The mortality rate in case of lymph node involvement and negative estrogen receptor status was increased by 3.2- and 2-fold, respectively. The number of resected metastases, type of lung affection (uni-/bilateral), disease free interval after primary breast surgery (</> 36 months), and expression of progesterone receptor had no significant influence on survival. Data concerning the primary and metastatic hormone receptor- and HER2-status were available in 88.2% (n=90) and 62.7% (n=64) of all cases, respectively. Discordant results appeared in 26.7%, 41.1%, and 28.1% regarding the estrogen-, progesterone- and HER2-receptor. Significance of these findings had only been proved for estrogen receptor (p=0.002). A subanalysis of the present study revealed that 65.5% of 157 breast cancer patients who presented with newly occurred radiologically detectable pulmonary nodules had histopathologically confirmed paired metastases. The remaining results showed malignancies other than known breast cancer, and in approximately 20% of all cases there were benign lesions. Conclusions: The results of the present study emphasize the favorable effect of the lung metastasectomy on survival of selected breast cancer patients with isolated pulmonary oligometastatic disease. Via the use of the parenchyma-saving 1318nm-lasertechnique even in case of distinct and bilateral pulmonary metastatic involvement, increased rates of complete resection without substantial loss of lung function can be achieved. Therefore, an adequate quality of life is provided. In comparison with conventional surgery practices, this procedure creates similar survival rates despite higher numbers of resected lung metastases. That is why the number of preoperatively diagnosed metastases should have little influence on decision upon surgery. Thus, an extension of inclusion criteria seems reasonable. Again, complete resection appeared as one of the most important prognostic parameters and should, therefore, be the main objective of the surgeon. The poorer outcome for women with incomplete resections and the results of studies on systemic therapy implicate once more that breast cancer patients are more likely to benefit from the resection of their pulmonary metastases than from medical treatment alone. Furthermore, for the first time according to our knowledge, despite radical excision intrathoracal lymph node involvement has been proved as a significant negative predictive determinant in a collective of patients with isolated pulmonary metastases of breast cancer. Nevertheless, an intraoperative systematic lymph node sampling should be considered, at least until further studies are presented. In reference to the surgical approach of lung carcinoma, as circumstances require, a complete lymph node dissection should be performed to provide potential curative treatment to those affected. Moreover, according to the present findings, in case of the appearance of lung metastases the constancy of metastatic steroid hormone- and HER2 receptor expression, especially of the estrogen receptor, cannot always be assumed. Changes in comparison to the primary carcinoma appear in a relevant number of cases. Thus, the current metastatic receptor status should be evaluated obligatorily after pulmonary metastasectomy. Regarding the origin of pulmonary nodules of patients with history of breast cancer, their surgical resection with subsequent histopathological analysis can reliably differentiate between metastases, lung carcinoma or benign tumors. Altogether this facilitates specific and accurate treatment decisions. However, to identify patients with a limited and stable oligometastatic state of disease and to introduce optimal treatment, including surgical resection, an early, continuous, and also instrument-based follow-up is necessary. This matter is still only slightly taken into account, while the authors of the current guidelines refer to out of date studies, which have to be seen critically. As limitations of the present investigation, the retrospective study design, inconsistent evaluation of the primary receptor status, and also heterogeneity of postoperative medical therapy must be mentioned. In the future larger, multicentric, prospective, randomized trials are necessary to acquire further data, to conceivably continue to establish the pulmonary laser metastasectomy in multimodal therapy settings and also to determine the value of an extended follow-up.

L'existence d'une lésion transfixiante de la coiffe des rotateurs est très fréquente dans la population générale avec une prévalence de près de 20%. Cette prévalence augmente avec l'âge tout comme l'existence de lésions asymptomatiques. Comment explique-t-on l'existence de lésions tendineuses qui ne provoquent pas de symptômes ?Le rôle essentiel de la coiffe des rotateurs est de center la tête humérale en face de la glène pour permettre une action optimale du deltoïde. Cette action de centrage est toujours possible en cas de lésion du supra-spinatus et l'épaule peut conserver une fonction satisfaisante à condition que l'équilibre soit conservé entre la coiffe antérieure (Sub-Scapularis) et la coiffe postérieure (Infra-Spinatus et Teres Minor). Comment expliquer alors que des lésions, même petites du supra-épineux peuvent-être à l'origine d'une impotence fonctionnelle de l'épaule ?Il existe une réelle dissociation anatomo-clinique des ruptures de la coiffe des rotateurs et l'expression clinique des lésions de la coiffe est multifactorielle et inconstante. Elle dépend de la taille de la lésion et de son évolutivité, de l'existence d'une bursite sous-acromiale et de l'existence d'une tendinopathie du long biceps.La comparaison de sujets symptomatiques et de sujets asymptomatiques présentant une rupture de coiffe a permis de pointer du doigt l'importance des muscles péri-scapulaires dans la compréhension du retentissement des lésions de coiffe des rotateurs. En effet, ces muscles péri-scapulaires ont pour fonction d'orienter la scapula et la glène lors des mouvements du bras. Lorsque ceux-ci sont altérés, les anomalies d'orientation de la scapula sont appelés dyskinésies scapulaires.Lors de précédents travaux, nous avons étudié la faisabilité d'étude pseudo-cinématique de la scapula par rapport au thorax lors d'un mouvement d'élévation du bras à l'aide de stéréoradiographies basse-dose EOS®. Cependant cette technique basée sur la localisation de points précis de la scapula sur les différentes vues radiographiques s'est montrée peu reproductible et difficile à utiliser en routine clinique.L'objectif de ce travail de Thèse était tout d'abord d'optimiser cette technique d'analyse prometteuse et peu-irradiante afin d'obtenir une analyse fonctionnelle quantitative fiable et reproductible de la scapula. Ensuite, nous avons souhaité utiliser cette technique in-vivo, sur une cohorte de sujets pour évaluer le comportement de la scapula dans différentes situations pathologiques. / Existence of a full thickness rotator cuff tear is really common in the general population with prevalence near 20%. This prevalence increases with age as the existence of asymptomatic cuff tear. How can we explain that tendinous injuries do not cause symptoms?The essential action of the rotator cuff is to center the humeral head in front of the glenoid cavity in order to enable a maximal action of the deltoid muscle. This centering action is still possible in case of supra-spinatus tendon tear and the shoulder can keep a satisfying function if equilibrium is conserved between the anterior cuff (Sub-scapularis muscle) and the posterior cuff (Infra-spinatus and Teres Minor muscles). How can we explain that supra-spinatus tears, even small, can induce functional impairment of the shoulder?There is a real dissociation between anatomy and clinic for the rotator cuff tears and the clinical expression of cuff tears is multifactorial and variable. It depends of the size of the tear and its evolution, of the existence of a sub-acromial bursitis and of the existence of a long head biceps tendinopathy.Comparison between symptomatic and asymptomatic subjects which present a rotator cuff tear permitted to show the importance of the periscapular muscles for the understanding of the rotator cuff tears. Indeed, the function of the periscapular muscles is to orientate the scapula and the glenoid during arm movements. When periscapular muscles are altered, there are anomalies in the scapular orientation which are called scapular dyskinesis.In previous works, we studied the feasibility of pseudo-kinematic studies of the scapula during arm elevation according to the thorax coordinate system derived from low-dose EOS® stereoradiographs. However, this method which was based on the location of specific scapular bony landmarks on each stereoradiographs, presented a low reproducibility and was difficult to use in clinical conditions.The aim of this Thesis was first to optimize this promising method In order to obtain a functional quantitative analysis of the scapula reliable and reproducible. Then, we would like to use this method in-vivo in order to assess the orientation of the scapula during arm elevation on pathologic subjects.

Abstract Cardiac surgery with cardiopulmonary bypass induces the activation of systemic inflammatory response syndrome (SIRS) and results in at least some degree of global myocardial ischemia. Although these responses are usually short-lived, they may lead to serious complications and organ system failures. The present study evaluated the effects of high-dose glucose-insulin (1IU/kg/h) treatment (GIK) administered with the hyperinsulinemic normoglycemic clamp technique and a leukocyte-depleting filter on markers of systemic inflammatory response and myocardial ischemia-reperfusion injury in certain cardiac surgical risk groups. The study involved four prospective randomized controlled clinical trials and 119 patients. Cardioprotective effects were measured as myocardial enzyme release, recovery of contractile function and incidence of arrhythmias in all studies. The hemodynamic and metabolic effects of high-dose glucose-insulin treatment were evaluated in patients admitted for combined aortic valve (AS) and coronary surgery (40) and for urgent coronary surgery (39), and the latter study also involved proinflammatory cytokine and C-reactive protein analyses. The impacts of leukocyte filter on the expression of neutrophil adhesion molecules along with proinflammatory cytokines were evaluated in patients admitted for combined aortic valve (AS) and coronary surgery (20) and for solitary coronary surgery (20). The high-dose glucose-insulin treatment was associated with better preserved myocardial contractile function and less need for inotropic support after combined aortic valve and coronary surgery (I) and attenuation of postoperative CRP release after urgent coronary surgery (II). No effects on postoperative myocardial enzyme release (I, II) or on proinflammatory cytokine responses (II) were detected. The number of hypoglycemic events was low. The use of a leukocyte filter throughout the cardiopulmonary bypass period increased the neutrophil adhesion molecule CD11b expression in patients with both normal and prolonged CPB times and was associated with an enhanced proinflammatory cytokine response (III, IV). In conclusion, high-dose glucose-insulin treatment is safe, but requires strict control of blood glucose level. It reduces the need for inotropic support in patients with compromised cardiac status. The use of leukocyte filter leads to increased leukocyte activation and proinflammatory reaction.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2018-06-21T18:36:20Z No. of bitstreams: 1 Fernanda Dultra Dias.pdf: 1137972 bytes, checksum: 8be1c4f185164e0cb296225d70598e1b (MD5) / Made available in DSpace on 2018-06-21T18:36:20Z (GMT). No. of bitstreams: 1 Fernanda Dultra Dias.pdf: 1137972 bytes, checksum: 8be1c4f185164e0cb296225d70598e1b (MD5) Previous issue date: 2016-12-18 / Introduction: The VMNI has been showing an adjuvant treatment resource for patients with stable COPD or exacerbation. However little is known about the action that the NIV promotes in thoracic and abdominal and mobility if it is able to promote improvement of asynchrony. Objectives: to evaluate the effects of the NIV in thoracic and abdominal mobility, comparing variables in spontaneous breathing and during the use of NIV in patients with COPD by OEP. Methods: Two groups of individuals (GC with 14 healthy and COPD with 16 patients) were assessed in relation to the thoracic-abdominal asynchrony, respiratory and àcontrubuição variables of each thoracic compartment using a Plethysmograph SPOS System (BTS, Italy) in spontaneous breathing and with two VMNI modes. Results: Patients with COPD evaluated presented ATA in home, we also observed that the COPD asynchrony in all compartments in relation to healthy, which in turn has always maintained its AF next to zero and when it observes only the COPD group, using both methods of VMNI promote decrease of asynchrony in compartment CTS vs. ABD and the key changes found in the COPD group are related to the distribution of aid and action of each compartment toracico. Conclusion: There are ATA in patients with COPD, even at home, the degree of airway obstruction of these patients correlates with the presence of asynchronous Thoracoabdominal, the use of VMNI in the mode continuous positive airway pressure is able to improve thoracic abdominal synchrony in patients with COPD, as well as the use of some blood pressure to A6 led and that the VMNI is able to promote changes in compartmental contribution without promoting significant changes in respiratory variables in patients with COPD compared with age-matched healthy. / Introdução: A VMNI vem se mostrando um recurso adjuvante ao tratamento de pacientes com DPOC estável ou na exacerbação.No entanto pouco se sabe sobre a ação que a VNI promove na mobilidade tóraco abdominal e se é capaz de promover melhora da assincronia respiratória. Objetivos: Avaliar os efeitos da VNI na mobilidade e sincronia tóraco-abdominal, comparando as variáveis em respiração espontânea e durante o uso de VNI em pacientes com DPOC por meio da OEP. Método: Dois grupos de indivíduos (GC com 14 saudáveis e DPOC com 16 pacientes) foram avaliados em relação à assincronia toraco-abdominal, às variáveis respiratórias e àcontrubuição de cada compartimento torácico, utilizando-se um pletismógrafo OEP System (BTS, Italy) em respiração espontânea e com aplicação de dois modos de VMNI. Resultados: Os pacientes com DPOC avaliados apresentaram ATA em repouso, observou-se também que o DPOC apresentou assincronia em todos os compartimentos em relação ao Saudável, que por sua vez sempre manteve seu AF próximo a zero e quando se observa somente o grupo DPOC, o uso de ambas as modalidades de VMNI promovem diminuição da assincronia no compartimento CTS vs ABD e as principais alterações encontradas no grupo DPOC estão relacionadas a distribuição da contribuição e ação de cada compartimento toracico. Conclusão: Há ATA em pacientes com DPOC, mesmo em situação de repouso, o grau de obstrução das vias aéreas desses pacientes não se correlaciona com a presença de assincronia toracoabdominal, o uso de VMNI no modo pressão positiva contínua nas vias aéreas é capaz de melhorar a sincronia tóraco-abdominal em pacientes com DPOC, assim como a utilização de alguns níveis pressóricos de Bilevel e que a VMNI é capaz de promover alterações na contribuição compartimental sem promover alterações significativas nas variáveis respiratórias nos pacientes com DPOC comparando com saudáveis pareados por idade.

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