Small intestinal neuroendocrine tumor (SI-NET) is the most common small bowel tumor in Europe and USA, with an annual incidence of around 0.3-1.3/100000 persons. SI-NETs are the most common type of gastroenteropancreatic NETs (GEP-NETs), and they are known for their ability to produce hormones such as tachykinins and serotonin, as well as for their favorable long-term prognosis in comparison to gastrointestinal adenocarcinoma. The overall aim of the thesis was to investigate unknown or unclear aspects of SI-NET disease, in connection with prognosis, treatment and follow-up. Paper I confirmed several known negative prognostic factors and also showed, for the first time, that para-aortal lymph node metastases and peritoneal carcinomatosis were associated with worse survival by multivariable analyses. Locoregional surgery was associated with a low post-operative mortality, and a prolonged long-term survival by multivariable analysis. In Paper II we continued to investigate peritoneal carcinomatosis and found it be a risk factor not only for death, but also for emergency re-surgery. Furthermore, genetic analyses of samples from primary tumors in patients with and without peritoneal carcinomatosis showed a difference in the DNA between these two groups. In Paper III the outcome after liver surgery and/or radiofrequency ablation of liver metastases was investigated. To summarize, no difference in survival was seen in patients treated with surgery/radiofrequency ablation in comparison with matched controls. However, a superior radiological response of liver metasases and lower U-5-HIAA values were seen in patients subjected to liver surgery and/or radiofrequency ablation compared to matched controls. Paper IV compared ultrasonography, computed tomography and 11C-5HTP-PET in the follow-up after radiofrequency ablation of NET liver metastases. The study concluded that 11C-5HTP-PET depicted all residual tumors after RFA and that it, if used, should be combined with computed tomography for easier interpretation, as RFA areas are not clearly distinguishable with 11C-5HTP-PET alone. Paper V studied gallstone complications after somatostatin analog treatment in SI-NET patients, and concluded that there was a rather high risk to be subjected to a cholecystectomy due to biliary colic, cholecystitis, cholangitis or pancreatitis after primary surgery in somatostatin analog treated patients.

Introduction: Forty years ago the life saving and life prolonging therapy of dialysis was rationed. It was extremely unlikely that people aged over 50 years would be offered treatment. Today, those aged over 65 years are becoming the fastest growing group of patients on dialysis. Changing population demographics and referral patterns, the opening up of eligibility for dialysis to high risk individuals, refinement and developments in dialysis technology and its ‘success’ in keeping more patients alive for longer periods, along with rising public expectation, are just some of the reasons behind this change in the age profile of those being currently treated for kidney failure. Older people are likely to have multiple co-morbidities and decreased functional status that may complicate their decision-making about dialysis and limit their treatment options. / Enhancing choice and involvement in treatment decision-making to the patient’s satisfaction is a central theme of health care ethics. Current national and international ethical guidelines about the initiation of dialysis recommend shared or joint decision-making and discuss patient ‘benefit’ and patient ‘need’. This project sought to determine how these recommendations, and other ethical issues related to informed consent, possible withdrawal of treatment and quality of life, were embodied in the personal experiences of a group of older people facing dialysis decisions. / Aim: The general aim of this research was to follow the dialysis decision-making process over time amongst a group of people aged 65 years and older. More specifically, this research sought to explore with the participants the following issues: what factors impacted on their dialysis decision-making; how they understood both what was happening to them and the goals of treatment; their preferences for information seeking; how they perceived any future decision-making; how or whether the commencement and experience of dialysis influenced their decision-making; and once treatment had been initiated, how they felt about their initial decisions. / Method: A predominantly longitudinal qualitative study was undertaken. Meetings were conducted prior to the potential initiation of dialysis with 21 participants. These meetings involved a semi-structured interview and the administration of three questionnaires focusing on preferences for decision-making, information seeking and quality of life. Data was also collected from the participants’ health records. For those participants who commenced dialysis a further two meetings were undertaken one month and then six months after treatment was instigated. The qualitative data was analysed thematically using concepts that had either been pre-determined and explored within the interviews or, had emerged from the participants’ stories. / Findings: Findings from this study include: participants not feeling that they had a choice about dialysis; a mismatch between theoretical expectations of informed consent and shared decision-making and the ‘actor centred experiential’ model of decision-making adopted by participants; a need to re-evaluate the balance and relationships between physiological measures of effectiveness emphasised by health professionals, and psychosocial and functional markers valued by participants; and treatment goals not being individually negotiated. / Conclusion: An interest in remaining alive was the driving force behind why participants chose to have dialysis. Other factors impacting on decisions about dialysis were multi-faceted and were based on priorities other than what health professionals consider important. Shared decision-making, as described in the literature, is not unproblematic. However, health professionals need to accept the underlying premises on which shared decision-making is based so that they can find out what expectations patients have of treatment, beyond that of saving life. Such expectations need to be discussed with patients and the various treatment options need to be negotiated in an attempt to achieve patients’ goals. Patients should be encouraged however to be involved in decision-making to the extent to which they desire.

Thesis (Masters) -- The College of Saint Elizabeth, 2009. / Typescript. Available at The College of Saint Elizabeth - Office of Graduate Programs. "December 2009"

O câncer colorretal é a terceira neoplasia mais freqüente no mundo ocidental. No reto encontram-se 30 a 57% dos casos, sendo 80% destes passíveis de alcançar pelo exame digital do reto. Apesar de inúmeros avanços diagnósticos e terapêuticos, ainda são detectados tardiamente. A sobrevida em 5 anos mantém-se em torno de 50%, e os aspectos clínicopatológicos são os critérios prognósticos disponíveis. O presente estudo objetiva avaliar a sobrevida e os fatores clínico-patológicos relacionados aos tumores de reto em nosso meio. Os prontuários de 112 pacientes com adenocarcinoma primário e único de reto submetidos a cirurgia eletiva, num período de 7 anos (1988 a 1995), foram revisados retrospectivamente quanto a: idade, sexo, CEA pré-operatório, tipo e curabilidade da cirurgia, recidiva, seguimento, sobrevida e histopatologia do tumor. Para análise da sobrevida utilizou-se o método de Kaplan-Meyer. Nas análises bivariada e estratificada, um valor de P <0,05 foi considerado significativo. O coeficiente de correlação de Kendall foi utilizado para comparação dos sistemas de estadiamento. No modelo multivariado, utilizou-se um IC de 90%. A média de idade foi de 62,03±14,37 anos, com 52% dos casos do sexo feminino.Sessenta e dois por cento dos tumores encontravam-se no reto distal. Foram submetidos a amputação do reto 56,3% dos casos, e os demais, a retossigmoidectomia, sendo 25 procedimentos não-curativos. Sessenta e quatro pacientes (57%) apresentaram recidiva tumoral (14,3% locorregional, 32,1% à distância, e 10,7% ambas). Quarenta e cinco pacientes (40%) faleceram da neoplasia. O tempo mediano de seguimento foi de 35,27 meses (14,5 – 57,63). A sobrevida em 5 anos foi de 51%, tendo reduzido proporcionalmente ao avanço dos estágios histopatológicos da doença (P<0,001). O sistema de estadiamento de Dukes/Astler- Coller se correlacionou significativamente com o sistema TNM (τ=0,91). O adenocarcinoma 6 moderadamente diferenciado foi o mais freqüente (73,2%). A maioria dos tumores (68,2%) estendia-se até os tecidos perirretais; apenas 3,8% eram restritos à mucosa. Sessenta e sete pacientes tinham linfonodos positivos (29,4%, N1; e 30,3%, N2). Na classificação de Dukes/Astler-Coller, 14 eram estágio D; 55, C1 e C2; 15, B2; e 28, B1 e A. A localização do tumor no reto médio ou distal não influenciou a ocorrência dos óbitos, as recidivas, nem a curabilidade da cirurgia. Os tumores menos diferenciados (P=0,009), com maior penetração na parede (P=0,013), com envolvimento linfonodal (N2>N1, P<0,001), com cirurgia nãocurativa (P=0,002) e os que apresentaram recidiva (P<0,001) influenciaram significativamente a mortalidade. A classificação de Dukes/Astler-Coller e a diferenciação tumoral (P=0,089) foram fatores prognósticos independentes, bem como a penetração do tumor na parede retal (P=0,091) e o comprometimento linfonodal (P<0,001), quando excluída a classificação histopatológica. Os achados deste estudo estão de acordo com a literatura. Além da diferenciação tumoral, os fatores prognósticos identificados correspondem aos níveis de classificação dos sistemas de estadiamento vigentes, concordando com a observação de que estes ainda são os critérios prognósticos disponíveis. Este relato corrobora a predominância dos tumores em estágios avançados ao diagnóstico e a ausência de valor prognóstico da localização do tumor no reto. / Colorectal cancer is the third most common neoplasia in the Western world. About 30 to 57% of cases occur in the rectum, and, among these, 80% can be reached by digital rectal examination. However, most of them are diagnosed in advanced stages. Five-year survival rate is maintained at about 50% and clinicopathological features are still the prognostic criteria available. To evaluate survival and clinicopathological factors, the records of 112 patients submitted to elective resection of adenocarcinoma of the rectum from 1988 to 1995 were reviewed. Data were analysed as for: age, gender, preoperative serum level of CEA, type and curability of surgery, recurrence, follow-up, survival and tumor histopathology. Kaplan- Meyer method was used to analyse survival. Statistical significance on bivariate and stratified analysis was considered for a P value less than 0,05. Kendall correlation coefficient was used to compare histopathologic classifications. In the multivariate model, a 90% confidence interval was considered significant. Mean (SD) age was 62 (14) years and 52% of patients were female. Sixty-two percent of rectal tumors were distally located. Abdominoperineal resection was performed in 56% of cases and the remaining patients underwent low anterior resection. Twenty-five (22%) of these were non-curative procedures.Overall, recurrence was observed in 64 (57%) patients: local in 14%, distant in 32% and both in 10%. Forty-five patients (40%) died from disease. Median (range) follow-up was 35 (14 - 57) months. Fiveyear survival rate was 51% and reduced significantly by tumor progression (histopathologic stages; P<0,001). Both stage systems were well correlated (τ=0,91). Moderately differentiated adenocarcinoma was the most frequent tumor grade (73%). Most tumors (68%) extended to perirectal tissues, only 4% were confined to the mucosa. Positive lymph nodes were observed in 67 patients (30% each, N1 and N2). Fourteen patients were Dukes/Astler-Coller D stage; 55 were C1 or C2; 15 were B2; and 28 were B1 or A. Tumor location had no influence on deaths, recurrences or curability. On bivariate analysis, tumor grade (P=0,009), depth (P=0,013) or recurrence (P<0,001), lymph node involvement (N2>N1, P<0,001), noncurative procedure (P=0,002) related with poorer outcome. On multivariate analyses, Dukes/Astler-Coller stages and tumor grade (P=0,089) were found to be independent prognostic factors, as well as depth of invasion and lymph node involvement, when excluding Dukes staging (P=0,091 and <0,001, respectively). These findings are similar to those reported in the literature. Besides tumor grade, prognostic factors identified meet classification levels on current staging systems. Accordingly, these criteria are still the prognostic factors available. The present report corroborates the predominance of advanced stage tumours at diagnosis and the lack of prognostic value of tumor location in the rectum.

A carcinomatose peritoneal (CP), secundária ao avanço neoplásico maligno na cavidade abdominal, causa grande morbidade e tem como recomendação terapêutica atual um tratamento multimodal, que consiste na combinação de cirurgia citorredutora (CCR) agressiva e quimioterapia hipertérmica intraperitoneal (HIPEC). O objetivo do presente estudo é caracterizar a função respiratória desse grupo de pacientes, potencialmente candidatos à abordagem de tratamento multimodal e a relação da função respiratória com a capacidade de exercício e qualidade de vida relacionada à saúde (QVRS). Nesse estudo transversal, 25 pacientes com CP candidatos à abordagem de tratamento multimodal, foram avaliados em um centro terciário de saúde, entre maio de 2013 e abril de 2014. Foram avaliados o performance status (PS), espirometria, pressões respiratórias máximas, capacidade de exercício pelo teste de caminhada de seis minutos (TC6m) e um questionário de QVRS (QQVRS) específico para portadores de câncer. Os valores médios da avaliação de força muscular respiratória e da espirometria estavam dentro dos limites de normalidade. Todavia, foram encontrados valores reduzidos na pressão inspiratória máxima (PImax), na pressão expiratória máxima (PEmax) e na distância percorrida no TC6m em 6/25 (24%), 4/25 (16%), e 9/20 (45%), respectivamente. A PImax se associou com o PS, enquanto que a PEmax se associou com a capacidade de exercício, escala funcional do QQVRS e PS. Em conclusão, uma significativa proporção de pacientes apresentava fraqueza muscular respiratória e redução da capacidade de exercício. A força muscular respiratória mostrou associação significativa com PS, enquanto que a PEmax se relacionou com a capacidade de exercício e escala funcional do questionário de QVRS. / Peritoneal carcinomatosis (PC), secondary to advanced abdominal malignancies, causes great morbidity and is currently treated using multimodal approaches combining aggressive cytoreductive surgery (CRS) and intraperitoneal hyperthermic chemotherapy (HIPEC). The aim of the present study is to characterize the respiratory functional status of patients with PC potentially candidates to multimodal treatment approaches and the relationship of respiratory function with exercise capacity and health related quality of life (HRQL). In a cross-sectional study, 25 patients with PC referred for CRS plus HIPEC treatment approach at a tertiary care center between May 2013 and April 2014 were evaluated. Performance status, spirometry, maximal respiratory pressure measures,6-minute walk test (6MWT) and cancer specific HRQL questionnaire were assessed. Mean values of spirometry and respiratory muscle strength were above normal limits. However, reduced maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and 6MWT distance was found in 6/25 (24%), 4/25 (16%), and 9/20 (45%), respectively. MIP was associated with performance status while MEP was associated with exercise capacity, functional scale of HRQL questionnaire and performance status. A significant proportion of patients presented respiratory muscle weakness and impaired exercise capacity. MEP and MIP were related with performance status while MEP was additionally associated with exercise capacity and functional scale of HRQL.

O câncer colorretal é a terceira neoplasia mais freqüente no mundo ocidental. No reto encontram-se 30 a 57% dos casos, sendo 80% destes passíveis de alcançar pelo exame digital do reto. Apesar de inúmeros avanços diagnósticos e terapêuticos, ainda são detectados tardiamente. A sobrevida em 5 anos mantém-se em torno de 50%, e os aspectos clínicopatológicos são os critérios prognósticos disponíveis. O presente estudo objetiva avaliar a sobrevida e os fatores clínico-patológicos relacionados aos tumores de reto em nosso meio. Os prontuários de 112 pacientes com adenocarcinoma primário e único de reto submetidos a cirurgia eletiva, num período de 7 anos (1988 a 1995), foram revisados retrospectivamente quanto a: idade, sexo, CEA pré-operatório, tipo e curabilidade da cirurgia, recidiva, seguimento, sobrevida e histopatologia do tumor. Para análise da sobrevida utilizou-se o método de Kaplan-Meyer. Nas análises bivariada e estratificada, um valor de P <0,05 foi considerado significativo. O coeficiente de correlação de Kendall foi utilizado para comparação dos sistemas de estadiamento. No modelo multivariado, utilizou-se um IC de 90%. A média de idade foi de 62,03±14,37 anos, com 52% dos casos do sexo feminino.Sessenta e dois por cento dos tumores encontravam-se no reto distal. Foram submetidos a amputação do reto 56,3% dos casos, e os demais, a retossigmoidectomia, sendo 25 procedimentos não-curativos. Sessenta e quatro pacientes (57%) apresentaram recidiva tumoral (14,3% locorregional, 32,1% à distância, e 10,7% ambas). Quarenta e cinco pacientes (40%) faleceram da neoplasia. O tempo mediano de seguimento foi de 35,27 meses (14,5 – 57,63). A sobrevida em 5 anos foi de 51%, tendo reduzido proporcionalmente ao avanço dos estágios histopatológicos da doença (P<0,001). O sistema de estadiamento de Dukes/Astler- Coller se correlacionou significativamente com o sistema TNM (τ=0,91). O adenocarcinoma 6 moderadamente diferenciado foi o mais freqüente (73,2%). A maioria dos tumores (68,2%) estendia-se até os tecidos perirretais; apenas 3,8% eram restritos à mucosa. Sessenta e sete pacientes tinham linfonodos positivos (29,4%, N1; e 30,3%, N2). Na classificação de Dukes/Astler-Coller, 14 eram estágio D; 55, C1 e C2; 15, B2; e 28, B1 e A. A localização do tumor no reto médio ou distal não influenciou a ocorrência dos óbitos, as recidivas, nem a curabilidade da cirurgia. Os tumores menos diferenciados (P=0,009), com maior penetração na parede (P=0,013), com envolvimento linfonodal (N2>N1, P<0,001), com cirurgia nãocurativa (P=0,002) e os que apresentaram recidiva (P<0,001) influenciaram significativamente a mortalidade. A classificação de Dukes/Astler-Coller e a diferenciação tumoral (P=0,089) foram fatores prognósticos independentes, bem como a penetração do tumor na parede retal (P=0,091) e o comprometimento linfonodal (P<0,001), quando excluída a classificação histopatológica. Os achados deste estudo estão de acordo com a literatura. Além da diferenciação tumoral, os fatores prognósticos identificados correspondem aos níveis de classificação dos sistemas de estadiamento vigentes, concordando com a observação de que estes ainda são os critérios prognósticos disponíveis. Este relato corrobora a predominância dos tumores em estágios avançados ao diagnóstico e a ausência de valor prognóstico da localização do tumor no reto. / Colorectal cancer is the third most common neoplasia in the Western world. About 30 to 57% of cases occur in the rectum, and, among these, 80% can be reached by digital rectal examination. However, most of them are diagnosed in advanced stages. Five-year survival rate is maintained at about 50% and clinicopathological features are still the prognostic criteria available. To evaluate survival and clinicopathological factors, the records of 112 patients submitted to elective resection of adenocarcinoma of the rectum from 1988 to 1995 were reviewed. Data were analysed as for: age, gender, preoperative serum level of CEA, type and curability of surgery, recurrence, follow-up, survival and tumor histopathology. Kaplan- Meyer method was used to analyse survival. Statistical significance on bivariate and stratified analysis was considered for a P value less than 0,05. Kendall correlation coefficient was used to compare histopathologic classifications. In the multivariate model, a 90% confidence interval was considered significant. Mean (SD) age was 62 (14) years and 52% of patients were female. Sixty-two percent of rectal tumors were distally located. Abdominoperineal resection was performed in 56% of cases and the remaining patients underwent low anterior resection. Twenty-five (22%) of these were non-curative procedures.Overall, recurrence was observed in 64 (57%) patients: local in 14%, distant in 32% and both in 10%. Forty-five patients (40%) died from disease. Median (range) follow-up was 35 (14 - 57) months. Fiveyear survival rate was 51% and reduced significantly by tumor progression (histopathologic stages; P<0,001). Both stage systems were well correlated (τ=0,91). Moderately differentiated adenocarcinoma was the most frequent tumor grade (73%). Most tumors (68%) extended to perirectal tissues, only 4% were confined to the mucosa. Positive lymph nodes were observed in 67 patients (30% each, N1 and N2). Fourteen patients were Dukes/Astler-Coller D stage; 55 were C1 or C2; 15 were B2; and 28 were B1 or A. Tumor location had no influence on deaths, recurrences or curability. On bivariate analysis, tumor grade (P=0,009), depth (P=0,013) or recurrence (P<0,001), lymph node involvement (N2>N1, P<0,001), noncurative procedure (P=0,002) related with poorer outcome. On multivariate analyses, Dukes/Astler-Coller stages and tumor grade (P=0,089) were found to be independent prognostic factors, as well as depth of invasion and lymph node involvement, when excluding Dukes staging (P=0,091 and <0,001, respectively). These findings are similar to those reported in the literature. Besides tumor grade, prognostic factors identified meet classification levels on current staging systems. Accordingly, these criteria are still the prognostic factors available. The present report corroborates the predominance of advanced stage tumours at diagnosis and the lack of prognostic value of tumor location in the rectum.

A carcinomatose peritoneal (CP), secundária ao avanço neoplásico maligno na cavidade abdominal, causa grande morbidade e tem como recomendação terapêutica atual um tratamento multimodal, que consiste na combinação de cirurgia citorredutora (CCR) agressiva e quimioterapia hipertérmica intraperitoneal (HIPEC). O objetivo do presente estudo é caracterizar a função respiratória desse grupo de pacientes, potencialmente candidatos à abordagem de tratamento multimodal e a relação da função respiratória com a capacidade de exercício e qualidade de vida relacionada à saúde (QVRS). Nesse estudo transversal, 25 pacientes com CP candidatos à abordagem de tratamento multimodal, foram avaliados em um centro terciário de saúde, entre maio de 2013 e abril de 2014. Foram avaliados o performance status (PS), espirometria, pressões respiratórias máximas, capacidade de exercício pelo teste de caminhada de seis minutos (TC6m) e um questionário de QVRS (QQVRS) específico para portadores de câncer. Os valores médios da avaliação de força muscular respiratória e da espirometria estavam dentro dos limites de normalidade. Todavia, foram encontrados valores reduzidos na pressão inspiratória máxima (PImax), na pressão expiratória máxima (PEmax) e na distância percorrida no TC6m em 6/25 (24%), 4/25 (16%), e 9/20 (45%), respectivamente. A PImax se associou com o PS, enquanto que a PEmax se associou com a capacidade de exercício, escala funcional do QQVRS e PS. Em conclusão, uma significativa proporção de pacientes apresentava fraqueza muscular respiratória e redução da capacidade de exercício. A força muscular respiratória mostrou associação significativa com PS, enquanto que a PEmax se relacionou com a capacidade de exercício e escala funcional do questionário de QVRS. / Peritoneal carcinomatosis (PC), secondary to advanced abdominal malignancies, causes great morbidity and is currently treated using multimodal approaches combining aggressive cytoreductive surgery (CRS) and intraperitoneal hyperthermic chemotherapy (HIPEC). The aim of the present study is to characterize the respiratory functional status of patients with PC potentially candidates to multimodal treatment approaches and the relationship of respiratory function with exercise capacity and health related quality of life (HRQL). In a cross-sectional study, 25 patients with PC referred for CRS plus HIPEC treatment approach at a tertiary care center between May 2013 and April 2014 were evaluated. Performance status, spirometry, maximal respiratory pressure measures,6-minute walk test (6MWT) and cancer specific HRQL questionnaire were assessed. Mean values of spirometry and respiratory muscle strength were above normal limits. However, reduced maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and 6MWT distance was found in 6/25 (24%), 4/25 (16%), and 9/20 (45%), respectively. MIP was associated with performance status while MEP was associated with exercise capacity, functional scale of HRQL questionnaire and performance status. A significant proportion of patients presented respiratory muscle weakness and impaired exercise capacity. MEP and MIP were related with performance status while MEP was additionally associated with exercise capacity and functional scale of HRQL.

A carcinomatose peritoneal (CP), secundária ao avanço neoplásico maligno na cavidade abdominal, causa grande morbidade e tem como recomendação terapêutica atual um tratamento multimodal, que consiste na combinação de cirurgia citorredutora (CCR) agressiva e quimioterapia hipertérmica intraperitoneal (HIPEC). O objetivo do presente estudo é caracterizar a função respiratória desse grupo de pacientes, potencialmente candidatos à abordagem de tratamento multimodal e a relação da função respiratória com a capacidade de exercício e qualidade de vida relacionada à saúde (QVRS). Nesse estudo transversal, 25 pacientes com CP candidatos à abordagem de tratamento multimodal, foram avaliados em um centro terciário de saúde, entre maio de 2013 e abril de 2014. Foram avaliados o performance status (PS), espirometria, pressões respiratórias máximas, capacidade de exercício pelo teste de caminhada de seis minutos (TC6m) e um questionário de QVRS (QQVRS) específico para portadores de câncer. Os valores médios da avaliação de força muscular respiratória e da espirometria estavam dentro dos limites de normalidade. Todavia, foram encontrados valores reduzidos na pressão inspiratória máxima (PImax), na pressão expiratória máxima (PEmax) e na distância percorrida no TC6m em 6/25 (24%), 4/25 (16%), e 9/20 (45%), respectivamente. A PImax se associou com o PS, enquanto que a PEmax se associou com a capacidade de exercício, escala funcional do QQVRS e PS. Em conclusão, uma significativa proporção de pacientes apresentava fraqueza muscular respiratória e redução da capacidade de exercício. A força muscular respiratória mostrou associação significativa com PS, enquanto que a PEmax se relacionou com a capacidade de exercício e escala funcional do questionário de QVRS. / Peritoneal carcinomatosis (PC), secondary to advanced abdominal malignancies, causes great morbidity and is currently treated using multimodal approaches combining aggressive cytoreductive surgery (CRS) and intraperitoneal hyperthermic chemotherapy (HIPEC). The aim of the present study is to characterize the respiratory functional status of patients with PC potentially candidates to multimodal treatment approaches and the relationship of respiratory function with exercise capacity and health related quality of life (HRQL). In a cross-sectional study, 25 patients with PC referred for CRS plus HIPEC treatment approach at a tertiary care center between May 2013 and April 2014 were evaluated. Performance status, spirometry, maximal respiratory pressure measures,6-minute walk test (6MWT) and cancer specific HRQL questionnaire were assessed. Mean values of spirometry and respiratory muscle strength were above normal limits. However, reduced maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and 6MWT distance was found in 6/25 (24%), 4/25 (16%), and 9/20 (45%), respectively. MIP was associated with performance status while MEP was associated with exercise capacity, functional scale of HRQL questionnaire and performance status. A significant proportion of patients presented respiratory muscle weakness and impaired exercise capacity. MEP and MIP were related with performance status while MEP was additionally associated with exercise capacity and functional scale of HRQL.

O câncer colorretal é a terceira neoplasia mais freqüente no mundo ocidental. No reto encontram-se 30 a 57% dos casos, sendo 80% destes passíveis de alcançar pelo exame digital do reto. Apesar de inúmeros avanços diagnósticos e terapêuticos, ainda são detectados tardiamente. A sobrevida em 5 anos mantém-se em torno de 50%, e os aspectos clínicopatológicos são os critérios prognósticos disponíveis. O presente estudo objetiva avaliar a sobrevida e os fatores clínico-patológicos relacionados aos tumores de reto em nosso meio. Os prontuários de 112 pacientes com adenocarcinoma primário e único de reto submetidos a cirurgia eletiva, num período de 7 anos (1988 a 1995), foram revisados retrospectivamente quanto a: idade, sexo, CEA pré-operatório, tipo e curabilidade da cirurgia, recidiva, seguimento, sobrevida e histopatologia do tumor. Para análise da sobrevida utilizou-se o método de Kaplan-Meyer. Nas análises bivariada e estratificada, um valor de P <0,05 foi considerado significativo. O coeficiente de correlação de Kendall foi utilizado para comparação dos sistemas de estadiamento. No modelo multivariado, utilizou-se um IC de 90%. A média de idade foi de 62,03±14,37 anos, com 52% dos casos do sexo feminino.Sessenta e dois por cento dos tumores encontravam-se no reto distal. Foram submetidos a amputação do reto 56,3% dos casos, e os demais, a retossigmoidectomia, sendo 25 procedimentos não-curativos. Sessenta e quatro pacientes (57%) apresentaram recidiva tumoral (14,3% locorregional, 32,1% à distância, e 10,7% ambas). Quarenta e cinco pacientes (40%) faleceram da neoplasia. O tempo mediano de seguimento foi de 35,27 meses (14,5 – 57,63). A sobrevida em 5 anos foi de 51%, tendo reduzido proporcionalmente ao avanço dos estágios histopatológicos da doença (P<0,001). O sistema de estadiamento de Dukes/Astler- Coller se correlacionou significativamente com o sistema TNM (τ=0,91). O adenocarcinoma 6 moderadamente diferenciado foi o mais freqüente (73,2%). A maioria dos tumores (68,2%) estendia-se até os tecidos perirretais; apenas 3,8% eram restritos à mucosa. Sessenta e sete pacientes tinham linfonodos positivos (29,4%, N1; e 30,3%, N2). Na classificação de Dukes/Astler-Coller, 14 eram estágio D; 55, C1 e C2; 15, B2; e 28, B1 e A. A localização do tumor no reto médio ou distal não influenciou a ocorrência dos óbitos, as recidivas, nem a curabilidade da cirurgia. Os tumores menos diferenciados (P=0,009), com maior penetração na parede (P=0,013), com envolvimento linfonodal (N2>N1, P<0,001), com cirurgia nãocurativa (P=0,002) e os que apresentaram recidiva (P<0,001) influenciaram significativamente a mortalidade. A classificação de Dukes/Astler-Coller e a diferenciação tumoral (P=0,089) foram fatores prognósticos independentes, bem como a penetração do tumor na parede retal (P=0,091) e o comprometimento linfonodal (P<0,001), quando excluída a classificação histopatológica. Os achados deste estudo estão de acordo com a literatura. Além da diferenciação tumoral, os fatores prognósticos identificados correspondem aos níveis de classificação dos sistemas de estadiamento vigentes, concordando com a observação de que estes ainda são os critérios prognósticos disponíveis. Este relato corrobora a predominância dos tumores em estágios avançados ao diagnóstico e a ausência de valor prognóstico da localização do tumor no reto. / Colorectal cancer is the third most common neoplasia in the Western world. About 30 to 57% of cases occur in the rectum, and, among these, 80% can be reached by digital rectal examination. However, most of them are diagnosed in advanced stages. Five-year survival rate is maintained at about 50% and clinicopathological features are still the prognostic criteria available. To evaluate survival and clinicopathological factors, the records of 112 patients submitted to elective resection of adenocarcinoma of the rectum from 1988 to 1995 were reviewed. Data were analysed as for: age, gender, preoperative serum level of CEA, type and curability of surgery, recurrence, follow-up, survival and tumor histopathology. Kaplan- Meyer method was used to analyse survival. Statistical significance on bivariate and stratified analysis was considered for a P value less than 0,05. Kendall correlation coefficient was used to compare histopathologic classifications. In the multivariate model, a 90% confidence interval was considered significant. Mean (SD) age was 62 (14) years and 52% of patients were female. Sixty-two percent of rectal tumors were distally located. Abdominoperineal resection was performed in 56% of cases and the remaining patients underwent low anterior resection. Twenty-five (22%) of these were non-curative procedures.Overall, recurrence was observed in 64 (57%) patients: local in 14%, distant in 32% and both in 10%. Forty-five patients (40%) died from disease. Median (range) follow-up was 35 (14 - 57) months. Fiveyear survival rate was 51% and reduced significantly by tumor progression (histopathologic stages; P<0,001). Both stage systems were well correlated (τ=0,91). Moderately differentiated adenocarcinoma was the most frequent tumor grade (73%). Most tumors (68%) extended to perirectal tissues, only 4% were confined to the mucosa. Positive lymph nodes were observed in 67 patients (30% each, N1 and N2). Fourteen patients were Dukes/Astler-Coller D stage; 55 were C1 or C2; 15 were B2; and 28 were B1 or A. Tumor location had no influence on deaths, recurrences or curability. On bivariate analysis, tumor grade (P=0,009), depth (P=0,013) or recurrence (P<0,001), lymph node involvement (N2>N1, P<0,001), noncurative procedure (P=0,002) related with poorer outcome. On multivariate analyses, Dukes/Astler-Coller stages and tumor grade (P=0,089) were found to be independent prognostic factors, as well as depth of invasion and lymph node involvement, when excluding Dukes staging (P=0,091 and <0,001, respectively). These findings are similar to those reported in the literature. Besides tumor grade, prognostic factors identified meet classification levels on current staging systems. Accordingly, these criteria are still the prognostic factors available. The present report corroborates the predominance of advanced stage tumours at diagnosis and the lack of prognostic value of tumor location in the rectum.

A hidrocefalia é uma doença ocasionada pelo distúrbio na formação, circulação ou absorção do líquido cefalorraquidiano (líquor) que acarreta na elevação da pressão intracraniana. O tratamento mais usual para a disfunção é a derivação ventrículo-peritoneal (DVP) responsável pela drenagem do líquor do ventrículo até o abdômen do paciente, através do implante de um cateter ventricular, uma válvula neurológica e um cateter peritoneal. Desse modo, o presente estudo apresenta o conceito de uma nova válvula neurológica com um mecanismo inovador para alteração da pressão de funcionamento, com um menor custo produtivo e de possível aceitação pelo Sistema Único de Saúde (SUS). A norma ISO 7197 forneceu as diretrizes atendidas no desenvolvimento da válvula neurológica ajustável e as informações para a construção das bancadas de testes, utilizadas para a realização dos ensaios hidrodinâmicos no protótipo do dispositivo valvular. Foram pesquisados os biomateriais empregados na fabricação de válvulas neurológicas comerciais, para a proposição dos materiais necessários para a construção da válvula ajustável por acionamento mecânico proposta. O aparato utilizado nos testes hidrodinâmicos apresentou incertezas experimentais, que não comprometem os resultados e a avaliação do desempenho in vitro do dispositivo testado. O protótipo da válvula resistiu aos testes de vazamento e de refluxo de fluido. As pressões de abertura e de fechamento apresentaram-se adequadas para o início e a interrupção do escoamento na DVP. Também foi obtido o comportamento do diferencial de pressão, em função da vazão, para as quatro classes de funcionamento disponíveis no protótipo testado. A avaliação hidrodinâmica do protótipo da válvula ajustável por acionamento mecânico apresenta resultados satisfatórios no controle da drenagem de líquor, frente a todos os ensaios hidrodinâmicos realizados. / Hydrocephalus is a disease caused by disturbance in formation, circulation or absorption of cerebrospinal fluid (CSF) which causes high intracranial pressure. The most common treatment for the dysfunction is the ventricle-peritoneal shunt responsible for drainage of cerebrospinal fluid from the patient\'s ventricle to the abdomen, through the implant of a ventricular catheter, a neurological valve and a peritoneal catheter. Thus, the present study introduces the concept of a new valve with an innovative mechanism to change the working pressure, with a lower cost of production and possible acceptance by the Brazilian Health System. ISO 7197 provided the guidelines met in the development of adjustable neurological valve and the information for the construction of testing rigs, used for hydrodynamic testing on the valve device prototype. Biomaterials used in manufacturing commercial neurological valves have been researched for proposition of materials needed for the proposed adjustable neurological valve by mechanical drive. The apparatus used in hydrodynamic tests presented experimental uncertainties, which do not compromise the results and evaluation of in vitro performance of the device tested. The prototype of the valve withstood the leak and the fluid backflow testing. The opening and closing pressures were suitable for the beginning and the interruption of the flow in the ventricle-peritoneal shunt. It was also obtained the behavior of the pressure differential, due to the flow, for the four classes of operation available in the prototype tested. Hydrodynamic evaluation of the prototype of the adjustable valve by mechanical drive shows satisfactory results in the control of CSF drain, dealing with all hydrodynamic tests carried out.