Randomized Clinical Trials and Observational Tribulations: Providing Clinical Evidence for Personalized Surgical Pain Management Care Models.

Proving clinical superiority of personalized care models in interventional and surgical pain management is challenging. The apparent difficulties may arise from the inability to standardize complex surgical procedures that often involve multiple steps. Ensuring the surgery is performed the same way every time is nearly impossible. Confounding factors, such as the variability of the patient population and selection bias regarding comorbidities and anatomical variations are also difficult to control for. Small sample sizes in study groups comparing iterations of a surgical protocol may amplify bias. It is essentially impossible to conceal the surgical treatment from the surgeon and the operating team. Restrictive inclusion and exclusion criteria may distort the study population to no longer reflect patients seen in daily practice. Hindsight bias is introduced by the inability to effectively blind patient group allocation, which affects clinical result interpretation, particularly if the outcome is already known to the investigators when the outcome analysis is performed (often a long time after the intervention). Randomization is equally problematic, as many patients want to avoid being randomly assigned to a study group, particularly if they perceive their surgeon to be unsure of which treatment will likely render the best clinical outcome for them. Ethical concerns may also exist if the study involves additional and unnecessary risks. Lastly, surgical trials are costly, especially if the tested interventions are complex and require long-term follow-up to assess their benefit. Traditional clinical testing of personalized surgical pain management treatments may be more challenging because individualized solutions tailored to each patient's pain generator can vary extensively. However, high-grade evidence is needed to prompt a protocol change and break with traditional image-based criteria for treatment. In this article, the authors review issues in surgical trials and offer practical solutions.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States.

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Anatomical and developmental aspects of iatrogenic injury to the right recurrent laryngeal nerve in surgical resections of substernal goiter.

Thyroid surgery is the primary treatment for substernal goiters, and iatrogenic injury to the recurrent laryngeal nerve (RNL) is always a risk. The literature suggests that iatrogenic lesions of the RNL post resection of substernal goiter are not equally distributed, being more frequent on the right recurrent laryngeal nerve (R-RLN) in comparison to the left recurrent laryngeal nerve (L-RLN). The relative paucity of basic anatomical and clinical reportages on R-RLN iatrogenic injuries and on the developmental factors that may help explain its higher incidence justifies this study's undertaking. Here we compare incidence of right versus left iatrogenic injuries to the RLN in surgical resections of substernal goiters and discuss the anatomical and embryological factors involved. This report is part of a larger retrospective observational cohort study of 239 patients surgically treated for substernal goiter in the Gaffrée and Guinle University Hospital, Rio de Janeiro, from 2006 to 2018. From 239 patients, 13 presented with iatrogenic RLN injury, one patient presented bilateral lesion, totalling 15 iatrogenic lesions. Our analysis showed that the R-RLN seems to be anatomically more vulnerable to injury due to the embryological underpinnings addressed in this review, R-RLN = 64.29% (n = 9) and L-RLN = 35.71% (n = 5). Pathological factors like malignancy and size of the mass are relevant issues to be considered. The knowledge of anatomical landmarks and embryological development of the thyroid and associated structures can improve our understanding and teaching of surgical anatomy, thus helping prevent and reduce the number of iatrogenic injuries on right RLNs.

Avaliação da mortalidade no pós-operatório de fraturas de fêmur em idosos com comorbidades prévias / Evaluation of postoperative mortality of femoral fractures in elderly with previous comorbidities

Introdução: Queda é o acidente que ocorre com maior frequência no idoso, sendo a principal causa de morte naqueles com mais de 65 anos. As fraturas do quadril ocupam um papel de grande importância, gerando grande problema de ordem clínica envolvendo pacientes e familiares e de ordem econômica para a sociedade. Objetivo: Coletar dados de questionário da admissão e correlacionar a presença de comorbidades prévias a mortalidade em 30 dias do pós-cirurgia. Métodos: Estudo retrospectivo observacional não randomizado com 216 pacientes com fraturas cirúrgicas do quadril com 61 anos ou mais de idade atendidos no setor de emergência do Centro Hospitalar São Lucas na cidade de Niterói, RJ, no período de 30/03/2016 a 20/03/2018. Resultados: A incidência de óbito após a cirurgia do quadril é igual a 6,9% no primeiro mês. O paciente com fratura no quadril tem comorbidades cardiovasculares (75,9%). O óbito está associado à comorbidade hepática em 13,3% e ao baixo peso em 33,3%. O fato de ter duas ou mais comorbidades não está significativamente associado ao óbito. Conclusão: As comorbidades hepáticas, o baixo peso e a presença de disfunções cardiovasculares são importantes preditores prognósticos na mortalidade do paciente com mais de 61 anos após cirurgia de fratura do fêmur no primeiro mês. (AU)

Introduction: Falls are the leading cause of accidents and death in those aged 65 and above. The high incidence of these injuries impact patients, their families and it represents an economic problem for society. Objective: Collect data from the admission survey and correlate previous comorbidities to mortality in 30 days after surgery. Methods: Retrospective observational non-randomized study. 216 patients were included, aged 61 years or older, who were admitted at the emergency department of the Centro Hospitalar São Lucas in Niterói city, Rio de Janeiro. All the participants were candidates of hip fracture surgery between 03/30/2016 and 03/20/2018. Results: The mortality after hip surgery was 6.9% in the first month. Patients who underwent hip surgery had, previously, cardiovascular diseases (75.9%). Death was associated with liver comorbidity in 13.3% and low weight in 33.3%. The fact of having two or more comorbidities was not associated with death. Conclusion: Liver and cardiovascular diseases and low weight are important prognostic predictors in mortality of patients over 61 years of age after femoral fracture surgery in the first month. (AU)

Transaxillary single-port subtotal parathyroidectomy: feasibility study in cadavers.

Objective: to test the minimally invasive technique of single-port transaxillary subtotal parathyroidectomy in non-formalized cadavers to evaluate its viability and reproduction. Method: we performed ten subtotal parathyroidectomies through a transaxillary TriPort access in cadavers. The technique consisted of access through the axillary fossa, creating a subcutaneous tunnel to the anterior cervical region, for handling of the thyroid gland and dissection and resection of the parathyroid glands. Results: all surgeries were successful. The mean time of surgery was 65 minutes (57-79 min), with uncomplicated identification of all anatomical structures. There was no need for complementary incisions in the cervical region. Conclusion: the transaxillary single-port subtotal parathyroidectomy technique was feasible and reproducible, suggesting an alternative for minimally invasive cervical surgery.

Objetivo: testar a técnica minimamente invasiva de paratireoidectomia subtotal transaxilar single-port em cadáveres não formalizados para avaliar sua viabilidade e reprodução. Método: foram realizadas dez paratireoidectomias subtotais por via transaxilar através de acesso por TriPort em cadáveres. A técnica realizada consistiu em acesso pela fossa axilar, criando-se um túnel subcutâneo até a região cervical anterior, para manuseio da glândula tireoide e dissecção e ressecção das paratireoides. Resultados: todas as cirurgias foram realizadas com sucesso. O tempo médio de cirurgia foi 65 minutos (57-79 min), com identificação, sem dificuldades, de todas as estruturas anatômicas. Não houve necessidade de incisões complementares na região cervical. Conclusão: a técnica de paratireoidectomia subtotal transaxilar single-port foi viável e reprodutível, sugerindo uma alternativa para a cirurgia cervical minimamente invasiva.

Transaxillary single-port subtotal parathyroidectomy: feasibility study in cadavers / Paratireoidectomia subtotal transaxilar single-port: estudo de viabilidade em cadáver

ABSTRACT Objective : to test the minimally invasive technique of single-port transaxillary subtotal parathyroidectomy in non-formalized cadavers to evaluate its viability and reproduction. Method : we performed ten subtotal parathyroidectomies through a transaxillary TriPort access in cadavers. The technique consisted of access through the axillary fossa, creating a subcutaneous tunnel to the anterior cervical region, for handling of the thyroid gland and dissection and resection of the parathyroid glands. Results : all surgeries were successful. The mean time of surgery was 65 minutes (57-79 min), with uncomplicated identification of all anatomical structures. There was no need for complementary incisions in the cervical region. Conclusion : the transaxillary single-port subtotal parathyroidectomy technique was feasible and reproducible, suggesting an alternative for minimally invasive cervical surgery.

RESUMO Objetivo: testar a técnica minimamente invasiva de paratireoidectomia subtotal transaxilar single-port em cadáveres não formalizados para avaliar sua viabilidade e reprodução. Método: foram realizadas dez paratireoidectomias subtotais por via transaxilar através de acesso por TriPort em cadáveres. A técnica realizada consistiu em acesso pela fossa axilar, criando-se um túnel subcutâneo até a região cervical anterior, para manuseio da glândula tireoide e dissecção e ressecção das paratireoides. Resultados: todas as cirurgias foram realizadas com sucesso. O tempo médio de cirurgia foi 65 minutos (57-79 min), com identificação, sem dificuldades, de todas as estruturas anatômicas. Não houve necessidade de incisões complementares na região cervical. Conclusão: a técnica de paratireoidectomia subtotal transaxilar single-port foi viável e reprodutível, sugerindo uma alternativa para a cirurgia cervical minimamente invasiva.

Meningite aguda bacteriana na população infantojuvenil: principais agentes e métodos para diagnóstico - uma revisão da literatura / Acute bacterial meningitis in children and young population: main agents and methods for diagnosis - a literature review

A meningite bacteriana é uma afecção de grande significância devido a sua relação com alta mortalidade e morbidade na população neonatal a jovem. Devido a este fato é importante o conhecimento sobre esta doença e os seus principais agentes etiológicos. Com o objetivo de relatar os principais métodos de diagnóstico, assim como os principais agentes etiológicos envolvidos na fisiopatologia da meningite bacteriana em população jovem foi realizada uma busca por artigos publicados nos últimos 5 anos nas bases de dados Pubmed, Scielo, Bireme e Lilacs. A literatura atual aponta como microrganismos predominantes na incidência dessa doença a N. meningitidis S. pneumoniae, sendo as mais recorrentes na população de faixa etária entre 29 dias e 17 anos. Os fatores relacionados ao prognóstico estão intimamente relacionados com a distinção da classificação do agente etiológico em bacteriano ou viral, importante para a determinação da terapia adequada.

Bacterial meningitis is a highly significant disease due to its relationship with high mortality and morbidity in neonatal and young population. Due to this is important to know about this disease and its main etiological agents. In purpose to report the main diagnostic methods, as well as the main etiological agents involved in the pathophysiology of bacterial meningitis was conducted a search for articles published in the last five years in Pubmed, Scielo, Bireme and Lilacs. The current literature indicates N. meningitidis S. pneumoniae the most predominant microorganisms in the incidence of this disease between population aged between 29 days and 17 years. Factors related to prognosis are closely related to the classification distinction of the etiologic agent in bacterial or viral, important to determine the ap- propriate therapy.

Revisiting the Term Neuroprotection in Chronic and Degenerative Diseases.

Thanks to the development of several new researches, the lifetime presented a significant increase, even so, we still have many obstacles to overcome - among them, manage and get responses regarding neurodegenerative diseases. Where we are in the understanding of neuroprotection? Do we really have protective therapies for diseases considered degeneratives such as amyotrophic lateral sclerosis and its variants, Parkinson's disease, Alzheimer's disease and many others? Neuroprotection is defined by many researches as interactions and interventions that can slow down or even inhibit the progression of neuronal degeneration process. We make some considerations on this neuroprotective effect.

Fraqueza muscular adquirida na UTI (ICU-AW): efeitos sistêmicos da eletroestimulação neuromuscular / Muscular weakness acquired in ICU (ICU-AW): effects of systemic neuromuscular electrical stimulation

Com os avanços tecnológicos alcançados atualmente na terapia intensiva e maior sobrevida dos pacientes, outros desafios têm surgido para os profissionais de saúde. Dentre alguns, destaca-se a fraqueza muscular adquirida na UTI (ICU-AW), caracterizada por paresia esquelética e respiratória dos músculos promovendo aumento nas taxas de mortalidade e comprometimento da qualidade de vida. Sua incidência varia de 30% a 60% e tem na síndrome da resposta inflamatória sistêmica (SIRS) e na disfunção de múltiplos órgãos (DMO) sua principal etiologia. Outros fatores de risco como a hiperglicemia, o uso de bloqueadores neuromusculares e sedativos, a imobilidade e a própria ventilação mecânica estão entre os mais comuns. Entre as medidas de combate à ICU-AW, está o conceito de mobilização precoce, bem como despertar diário e controle estreito da glicemia. Nesse contexto, a letroestimulação muscular apresenta-se como recurso de grande valia. Sua principal vantagem está no fato de poder ser empreendida independentemente da cooperação do paciente, e por ser capaz de gerar respostas musculares eficientes, bem como resultados satisfatórios na preservação da massa muscular, condicionamento físico e funcionalidade dos que usam essa ferramenta. Desfechos interessantes têm sido observados em diversos perfis de pacientes, como os de doença pulmonar obstrutiva crônica (DPOC) e traumatismo raquimedular (TRM). No paciente crítico, seu uso tem mostrado redução nos tempos de ventilação mecânica (VM), internação na UTI e maior funcionalidade dos pacientes. A relevância dos efeitos sistêmicos e metabólicos provenientes da eletroestimulação neuromuscular (ENM) tem sido a base para os estudos nos pacientes críticos. Portanto, a ICU-AW é uma realidade no cenário da terapia intensiva e sua prevenção tem dado margem à aparição de novas propostas e ferramentas na prevenção dessas complicações.

With technological advances currently achieved in intensive care and increased patient survival, other challenges have emerged to health professionals. Among some, there is acquired weakness in the ICU (ICU-AW), characterized by skeletal and respiratory muscle paresis promoting an increase in mortality and impaired quality of life. The range of occurrence is 30% to 60% of critically ill patients, and systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction (MOD) are is the main etiology. Other risk factors such as hyperglycemia, the use of neuromuscular blockers and sedatives, immobility and mechanical ventilation are among the most common. Preventing ICU-AW is the concept of early mobilization and daily awakening and tight control of blood glucose. In this context, muscle electrostimulation appears as a great resource. This can be used undertaken regardless of the cooperation of the patient, and be able to generate efficient muscle responses showing satisfactory results in the preservation of muscle mass, physical fitness and functionality of using this tool. Interesting outcomes have been observed in several profiles of patients, such as chronic obstructive pulmonary disease (COPD) and spinal cord injury (SCI). In critically ill patients, its use has shown reduction in mechanical ventilation (MV) days, ICU length and increased functionality of patients. The relevance of the systemic and metabolic effects from the electrostimulation neuromuscular (NMES) has been the basis for studies in critically ill patients. The refore, the ICU-AW is a reality in the setting of intensive care and prevention has given rise to appearance of new proposals and tools in preventing these complications.

Neurofibromatose gigante / Giant neurofibromatosis

Os autores relatam um caso de neurofibromatose gigante, em jovem de 13 anos, com grande deformidade em parede lateral do tronco (regioes costal e flanco esquerdo). Abordam aspectos clínicos o tratamento cirúrgico e a evoluçao.

Linfagioma cístico intra-abdominal: apresentaçåo de dois casos e breve revisåo da literatura / Intra-abdominal cystic lymphangioma: presentation of two cases and a brief review of the literature

O linfangioma cístico intra-abdominal é raro. Såo aqui relatados dois casos, um de localizaçåo mesentérica em criança e outro retroperitoneal em adulto. Discute-se o quadro clínico, o diagnóstico radiológico, os achados operatórios e anatomopatológicos, o tratamento e o prognóstico

Hemiagenesia da tireóide em criança / Hemiagenesis of the thyroid in a child

A case of thyroid hemiagenesis in a ten year-old boy is reported. The patient were euthyroid and presented with a solitary thyroid nodule. The diagnosis of thyroid malformation was established by physical examination, scintiscanning and ultrasonic scanning of the thyroid. The guidelines for diagnosis and treatment of the solitary nodule was based on fine-needle aspiration of the nodule; the pathologic diagnosis of the nodule was follicular adenoma. A brief review of this rare entity is presented

Carcinoma do cisto tireoglosso / Carcinoma of the thyroglossal duct cyst

Carcinoma arising in thyroglossal duct cyst is a rare event that appears in about 1 por cento of all treated cases. Only about 150 cases are reported in the literature. We present two cases of primary papillary carcinoma of thyroglossal duct cyst. Resection by Sistrunk procedure associated with supression therapy was the treatment of choice in our cases

Novo dispositivo atraumático para oclusäo e síntese de feridas cirúrgicas / New method for wound clossure in surgery

Novas metodologias para síntese de feridas vêm sendo empregadas na tentativa de diminuir as complicaçöes referentes ao material de sutura empregado, ou mesmo minimizar as sequelas estéticas provenientes do ato cirúrgico. O uso de suturas mecânicas, curativas adesivos e colas sintéticas säo rotineiros principalmente na área de Cirurgia Plástica. Com o intuito de testar a eficácia de um novo tipo de dispositivo adesivo para síntese de feridas cirúrgicas foi criado um protocolo de estudo utilizando diversos tipos de cirugia e relacionando as complicaçöes com risco cirúrgico, doenças associadas, além de avaliar o resultado estético das cicatrizes após o uso do mesmo. A experiência inicial em 18 casos é analisada, ressaltando que os resultados satisfatórios iniciais devem ser reavaliados futuramente, com uma casuística, mais significativa

Cirurgia de varizes dos membros inferiores no HUGG / The varicose venis surgery of lower limbs

Os autores fazem uma análise retrospectiva de 46 pacientes submetidos a cirurgia de varizes dos membros inferiores (42 unilateral e quatro, bilateral), totalizando 50 membros, no período de junho de 1989 a agosto de 1992. Obtiveram 95,6 por cento de resultados positivos quanto a fatores-funcionais e reintegraçåo social e laborativa

Valor da punçäo aspirativa com agulha fina nas afecçöes malignas da mama / Value of fine needle aspiration cytology in breast cancer

Foi estudado o valor propedêutico da punçäo aspirativa com agulha fina em 50 pacientes portadores de tumoraçöes palpáveis das mamas, provavelmente malignos, no HUGG (UNI-RIO), no período de nov./83 a maio/88. A suspeita de malignidade baseou-se no quadro clínico e/ou nos aspectos mamográficos. A idade variou de 36 a 86 anos, com idade média de 57,7 anos. O diâmetro da tumoraçäo mais freqüente foi entre 4 e 7 cm (28 casos; 56%). Das 50 punçöes estudadas, 34 foram positivas para malignidade (68%), confirmada no exame histopatológico da peça cirúrgica. Em dois casos de punçäo positiva para malignidade a histopatologia revelou papiloma intraductal. Foi procedido em 48 pacientes tratamento cirúrgico, cujos resultados histopatológicos evidenciaram carcinoma ductal (41 casos) e carcinoma lobular (sete casos). Conclui-se pela grande importância do método, näo só no diagnóstico das lesöes mamárias malignas como também no planejamento da cirurgia a ser executada, e pela possibilidade de evitar em muitos casos a biópsia de congelaçäo per-operatória. Säo comparados os resultados com os relatados na literatura médica

Bócios nodulares atóxicos operados: experiência do IEDE em 7 anos 1972-1978 / Atoxic operated nodular goiter from 1972 to 1978 in the Instituto Estadual de Endocrinologia

Säo revistos os dados de 350 pacientes operados no IEDE durante sete anos por serem portadores do bócio nodular atóxico. Säo analisadas a incidência das diversas patologias, a distribuiçäo histológica das malignas, a distribuiçäo das diversas patologias por sexo e idade, o tempo de evoluçäo das enfermedades, os dados cintilográficos, a consistência dos nódulos, a presença de gânglios cervicais, os tipos das cirurgias realizadas, as complicaçöes pós-operatórias e a sobrevida nas diversas patologias malignas. Os resultados encontrados säo concordantes com os assinalados na literatura internacional