Evaluation of the Efficacy of Paracetamol in the Control of Pain After Adenotonsillectomy in the Pediatric Population.

Introduction Adenotonsillectomy is a common surgical procedure in otolaryngology. Over the years, several techniques have been developed and modified in order to reduce mortality and morbidity. Postoperative pain control remains controversial. The aim of this study was to evaluate the efficacy of paracetamol alone in the control of postoperative pain. Methods A prospective study was conducted between May 2018 and February 2019, including 76 pediatric patients (age < 18 years), who underwent adenotonsillectomy. The surgeries were performed by the lead author with the same surgical technique. Patients were evaluated one week and one month after surgery through the application of the visual analog pain scale and the number of days of pain was assessed by the need for medication. Results Seventy-six total adenotonsillectomy were performed, with a total of 152 tonsils removed. The majority of patients were male (n=39, 51.3%), with an average age of 6.9 years (min 5, max 15 years). The most frequent surgical indication was sleep breathing disorders, present in 86.9% of the cases. The average duration of postoperative pain was 3 days, with no significant difference between groups (p>0.05). The average intensity of postoperative pain was 3.36 and was higher in patients with infectious criteria as surgical indications (p<0.05). Postoperative bleeding occurred in 3.9% (n=3) of the children, self-limited, without the need for readmission or surgical revision. Conclusion Pain after adenotonsillectomy was more intense in patients undergoing surgery for infectious criteria. Paracetamol used in monotherapy has shown safety and efficacy in controlling postoperative pain.

STRUCTURING A FECAL MICROBIOTA TRANSPLANTATION CENTER IN A UNIVERSITY HOSPITAL IN BRAZIL.

BACKGROUND: Fecal microbiota transplantation (FMT) is an important therapeutic option for recurrent or refractory Clostridioides difficile infection, being a safe and effective method. Initial results suggest that FMT also plays an important role in other conditions whose pathogenesis involves alteration of the intestinal microbiota. However, its systematized use is not widespread, especially in Brazil. In the last decade, multiple reports and several cases emerged using different protocols for FMT, without standardization of methods and with variable response rates. In Brazil, few isolated cases of FMT have been reported without the implantation of a Fecal Microbiota Transplantation Center (FMTC). OBJECTIVE: The main objective of this study is to describe the process of implanting a FMTC with a stool bank, in a Brazilian university hospital for treatment of recurrent and refractory C. difficile infection. METHODS: The center was structured within the criteria required by international organizations such as the Food and Drug Administration, the European Fecal Microbiota Transplant Group and in line with national epidemiological and regulatory aspects. RESULTS: A whole platform involved in structuring a transplant center with stool bank was established. The criteria for donor selection, processing and storage of samples, handling of recipients before and after the procedure, routes of administration, short and long-term follow-up of transplant patients were determined. Donor selection was conducted in three stages: pre-screening, clinical evaluation and laboratory screening. Most of the candidates were excluded in the first (75.4%) and second stage (72.7%). The main clinical exclusion criteria were: recent acute diarrhea, overweight (body mass index ≥25 kg/m2) and chronic gastrointestinal disorders. Four of the 134 candidates were selected after full screening, with a donor detection rate of 3%. CONCLUSION: The implantation of a transplant center, unprecedented in our country, allows the access of patients with recurrent or refractory C. difficile infection to innovative, safe treatment, with a high success rate and little available in Brazil. Proper selection of qualified donors is vital in the process of implementing a FMTC. The rigorous clinical evaluation of donors allowed the rational use of resources. A transplant center enables treatment on demand, on a larger scale, less personalized, with more security and traceability. This protocol provides subsidies for conducting FMT in emerging countries.

Estruturação de centro de transplante de microbiota fecal em hospital universitário no Brasil / Structuring a fecal microbiota transplantation center in a university hospital in brazil

ABSTRACT BACKGROUND: Fecal microbiota transplantation (FMT) is an important therapeutic option for recurrent or refractory Clostridioides difficile infection, being a safe and effective method. Initial results suggest that FMT also plays an important role in other conditions whose pathogenesis involves alteration of the intestinal microbiota. However, its systematized use is not widespread, especially in Brazil. In the last decade, multiple reports and several cases emerged using different protocols for FMT, without standardization of methods and with variable response rates. In Brazil, few isolated cases of FMT have been reported without the implantation of a Fecal Microbiota Transplantation Center (FMTC). OBJECTIVE: The main objective of this study is to describe the process of implanting a FMTC with a stool bank, in a Brazilian university hospital for treatment of recurrent and refractory C. difficile infection. METHODS: The center was structured within the criteria required by international organizations such as the Food and Drug Administration, the European Fecal Microbiota Transplant Group and in line with national epidemiological and regulatory aspects. RESULTS: A whole platform involved in structuring a transplant center with stool bank was established. The criteria for donor selection, processing and storage of samples, handling of recipients before and after the procedure, routes of administration, short and long-term follow-up of transplant patients were determined. Donor selection was conducted in three stages: pre-screening, clinical evaluation and laboratory screening. Most of the candidates were excluded in the first (75.4%) and second stage (72.7%). The main clinical exclusion criteria were: recent acute diarrhea, overweight (body mass index ≥25 kg/m2) and chronic gastrointestinal disorders. Four of the 134 candidates were selected after full screening, with a donor detection rate of 3%. CONCLUSION: The implantation of a transplant center, unprecedented in our country, allows the access of patients with recurrent or refractory C. difficile infection to innovative, safe treatment, with a high success rate and little available in Brazil. Proper selection of qualified donors is vital in the process of implementing a FMTC. The rigorous clinical evaluation of donors allowed the rational use of resources. A transplant center enables treatment on demand, on a larger scale, less personalized, with more security and traceability. This protocol provides subsidies for conducting FMT in emerging countries.

RESUMO CONTEXTO: O Transplante de microbiota fecal (TMF) é uma importante opção terapêutica para a infecção recorrente ou refratária pelo Clostridioides difficile, sendo método seguro e eficaz. Resultados iniciais sugerem que o TMF também desempenha papel relevante em outras afecções cuja patogênese envolve a alteração da microbiota intestinal. No entanto, seu uso sistematizado é pouco difundido, especialmente no Brasil. Na última década, surgiram múltiplos relatos e séries de casos utilizando diferentes protocolos para o TMF, sem padronização de métodos e com taxas de resposta variáveis. No Brasil, poucos casos isolados de TMF foram relatados sem a implantação de um Centro de Transplante de Microbiota Fecal (CTMF). OBJETIVO: O principal objetivo deste estudo foi descrever o processo de implantação de um CTMF com banco de fezes, em hospital universitário brasileiro, para tratamento de infecção recorrente e refratária pelo C. difficile. MÉTODOS: O CTMF foi estruturado dentro dos critérios exigidos e aprovados por organismos internacionais como o Food and Drug Administration, Grupo Europeu de Transplante de Microbiota Fecal e em consonância com os aspectos epidemiológicos e regulatórios nacionais. RESULTADOS: Foi estabelecida toda uma plataforma envolvida na estruturação de um centro de transplante com fezes congeladas. Determinou-se os critérios para seleção de doadores, processamento e armazenamento de amostras, manejo dos receptores antes e após o procedimento, uniformização de vias de administração do substrato fecal e seguimento a curto e longo prazo dos pacientes transplantados. A seleção dos doadores foi conduzida em três etapas: pré-triagem, avaliação clínica e exames laboratoriais. Boa parte dos candidatos foram excluídos na primeira (75,4%) e segunda etapa (72,7%). Os principais critérios clínicos de exclusão foram: diarreia aguda recente, excesso de peso (IMC ≥25 kg/m2) e distúrbios gastrointestinais crônicos. Quatro dos 134 candidatos foram selecionados após a triagem completa, com taxa de detecção de doadores de 3%. CONCLUSÃO: A implantação de um CTMF, inédito no nosso meio, possibilita o acesso de pacientes com infecção recorrente e refratária pelo C. difficile a tratamento inovador, seguro, com elevada taxa de sucesso e pouco disponível no Brasil. A seleção apropriada de doadores qualificados é vital no processo de implantação de um CTMF. A avaliação clínica rigorosa dos doadores permitiu o uso racional de recursos para realização de exames laboratoriais. Um CTMF possibilita tratamento sob demanda, em maior escala, menos personalizados, com mais segurança e rastreabilidade. Este protocolo fornece subsídios para a realização de TMF em países emergentes.

Fetal programming by high-fat diet promoted the decreased of the prostate in adult Wistar albino rats.

We investigated the effect of a high-fat diet on body metabolism and ventral prostate morphology in 4-months-old offspring. The mother was fed with a control (C) or a high-fat (HF) diet during gestation and lactation. At weaning, the offspring diet remained the same (C/C, n = 8; HF/HF, n = 8) or it was switched (C/HF, n = 8; HF/C, n = 9). Biometry, blood pressure (BP), glucose, lipid metabolism and ventral prostate were evaluated. Triacylglycerol of HF/C increased, and the C/HF group had decreased HDL-c levels (P = 0.0005 and P = 0.0100, respectively). All groups on the HF diet presented hyperglycemia (P = 0.0064). Serum testosterone diminished in the C/HF group (P = 0.0218). The HF diet, regardless of the period, reduced prostatic acinar area (P < 0.0001). The epithelium height was smaller in HF/C and HF/HF groups compared with C/C and C/HF (P < 0.0001), and the volume density of epithelium was lower in HF/C group compared with the C/C and C/HF (P = 0.0024). The volume density of smooth muscle cells diminished in C/HF and HF/C (P = 0.0013), and the volume density of connective tissue was reduced in HF/C and HF/HF (P < 0.0001). High-fat diet intake during prenatal and postnatal life leads to prostatic atrophy, which may impair prostate secretory activity and contractility, and thus disturb reproductive function in adulthood.

Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments.

OBJECTIVE: Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. METHODS: This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. RESULTS: Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. CONCLUSIONS: In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.

Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments / De volta para o futuro: série de casos de reparo minimamente invasivo do pectus excavatum com instrumentos comuns

ABSTRACT Objective: Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. Methods: This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. Results: Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. Conclusions: In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.

RESUMO Objetivo: O minimally invasive repair of pectus excavatum (MIRPE, reparo minimamente invasivo do pectus excavatum) é um tratamento cirúrgico do PE. Durante o procedimento, utiliza-se um introdutor específico a fim de criar um túnel mediastinal para a colocação toracoscópica de uma barra metálica. Já houve casos relatados de perfuração cardíaca durante essa etapa arriscada. O introdutor grande pode ser uma perigosa alavanca em mãos inábeis. Propusemo-nos a determinar a segurança e viabilidade do uso de instrumentos comuns (isto é, sem contar com dispositivos ou ferramentas especiais) para criar o túnel retroesternal durante o MIRPE. Métodos: Estudo preliminar sobre o MIRPE with regular instruments (MIRPERI, MIRPE com instrumentos comuns), envolvendo 28 pacientes com PE. Foram registrados dados demográficos básicos dos pacientes, medições torácicas e detalhes cirúrgicos, bem como complicações intra e pós-operatórias. Resultados: Os pacientes submetidos ao MIRPERI apresentavam índice de Haller entre 2,58 e 5,56. Não ocorreram complicações intraoperatórias. As complicações pós-operatórias incluíram náusea/vômito em 8 pacientes, prurido em 2 e tontura em 2, bem como atelectasia, pneumotórax com drenagem torácica, derrame pleural e dispneia em 1 paciente cada. Conclusões: Neste estudo preliminar, a taxa de complicações associadas ao MIRPERI foi comparável à relatada na literatura para o MIRPE. A abordagem de MIRPERI tem o potencial de melhorar a segurança do reparo do PE, particularmente para cirurgiões que não têm acesso a certos instrumentos especiais ou não foram treinados para utilizá-los.

Evaluation of the effect of mesotherapy in the management of back pain in police working dog.

OBJECTIVE: To evaluate the feasibility and effectiveness of mesotherapy in dogs compared with a positive control group. STUDY DESIGN: Experimental, randomized, blinded study. ANIMALS: Fifteen working police dogs with chronic back pain. METHODS: Animals were divided randomly into control (CG; n = 5) and treatment groups (TG; n = 10). A combination of 140 mg lidocaine, 15 mg dexamethasone and 20 mg thiocolchicoside was administered to group TG along with a 70-day course of a placebo, administered as if it was carprofen. Carprofen was administered to Group CG for 70 days, at a dose adjusted to their weight. On day 0, an intradermal injection of Ringer's lactate was also administered. Both groups were rested for 3 days and resumed normal activity over a 5-day period. Response to treatment, measured by the Canine Brief Pain Inventory (CBPI) and the Hudson Visual Analogue Scale (HVAS), was evaluated before treatment (T0), after 15 days (T1) and 1 (T2), 2 (T3), 3 (T4), 4 (T5) and 5 (T6) months. Results were compared using a Mann-Whitney test or a paired samples t test. RESULTS: When comparing CBPI results, no differences were found between groups TG and CG at T0 through T3 and in T6 and T7. Differences were observed in CBPI sections after the discontinuation of carprofen: at T4 [p = 0.02 for Pain Interference Score (PIS) and p = 0.03 for Pain Severity Score (PSS)] and T5 (p = 0.16 for PIS and p = 0.03 for PSS), with group TG having overall better results. Individual treatment results were considered successful in one dog of group CG (20%), whereas in group TG, success was higher (ranging from 78% at T1 to 22% at T7). No significant differences were registered with the HVAS. CONCLUSIONS AND CLINICAL RELEVANCE: Mesotherapy may be a promising treatment option for canine musculoskeletal-related pain. Further studies are required.

Abnormal Congenital Location of Stapes' Superstructure: Clinical and Embryological Implications.

Congenital middle ear malformations are rare. Most part of them are usually associated with other malformations, such as aural atresia, microtia, and dysmorphic craniofacial features. A clinical case of a 24-year-old male with a right-sided conductive hearing loss since his childhood, without craniofacial malformation, is presented. He was proposed for exploratory tympanotomy under the suspicious diagnosis of otosclerosis. The surgery revealed an abnormal location of stapes' superstructure, which was attached to the promontory and had an isolated and mobile osseous footplate in the oval window. A stapes prosthesis was inserted and resulted in closure of the air-bone gap by 25 dB. A review of the literature was also performed using MEDLINE. Two theories diverge on the embryologic origin of the stapes. Our findings seem to be in favour of the theory that defines two different embryologic origins to the stapes.

Thoracoscopic approach in the treatment of breast cancer relapse in the internal mammary lymph node.

Regional recurrence of breast cancer may involve the surgical site of mastectomy, axillary lymph nodes and the internal mammary lymphatic chain. Treatment of regional recurrent mammary cancer rarely requires thoracic surgery intervention, except in some selected cases of recurrence in the chest wall. Concerning lymphatic recurrence in breast cancer, the therapeutic choice rarely includes surgical lymph node excision. Exclusive videothoracoscopic (VTS) resection of recurrence in internal mammary lymph nodes has not as yet been reported in the literature. Due to the rare surgical exploration of this lymphatic chain, the thoracoscopic approach is described only in three published studies involving humans, furthermore, in these three descriptions, the operation was performed only for mere staging but not for the whole resection of the recurrent lymphatic structure. We present a case of recurrence of breast cancer in lymph nodes of the internal mammary chain that was treated with complete resection by pure VTS surgery.

True incidence and clinical significance of pneumoperitoneum after PEG placement: a prospective study.

BACKGROUND: PEG is a widely used method for providing nutritional support. Although pneumoperitoneum is a known finding after PEG placement, its true incidence is subject to debate. Small retrospective studies have found varied rates of free air after PEG placement. PATIENTS: There were a total of 65 patients. OBJECTIVE: To assess the true incidence of pneumoperitoneum and its clinical significance. DESIGN: Prospective study. SETTING: Long Island Jewish Medical Center. INTERVENTIONS: We obtained upright and anterior-posterior chest radiographs of 65 patients within 3 hours after PEG placement. Type of PEG tube, gauge of the needle used, number of sticks, and indications were recorded. The presence of pneumoperitoneum on the initial chest film was considered to be a positive finding. After a positive result, a repeat chest film was obtained 72 hours later to determine whether there was progression or resolution of the free air. Patients enrolled in the study were also monitored clinically for evidence of peritonitis. MAIN OUTCOME: Of the 65 patients who underwent PEG placement, 13 developed a pneumoperitoneum on the initial chest radiograph; there was complete resolution of pneumoperitoneum at 72 hours in 10 of the 13 patients. In 3 patients, the free air persisted but was of no clinical significance. MEASUREMENTS: The free air was quantified by measuring the height of the air column under the diaphragm and was graded with a scoring system (0, no air; 1, small; 2, moderate; 3, large). RESULTS: Eleven patients who underwent PEG died during the hospitalization; none of the deaths were related to the PEG placement or pneumoperitoneum. The other 54 patients were discharged to a skilled nursing facility. No patients in the study had clinical evidence of peritonitis. There were no adverse events, ie, infection or bleeding, associated with the PEG placement in any of the patients. CONCLUSIONS: Our data suggest that pneumoperitoneum after PEG placement is common and, in the absence of clinical symptoms, is of no clinical significance and does not warrant any further intervention.

Parosteal osteosarcoma with myocardial metastasis 13 years after follow-up

PURPOSE: To report the case of a woman with a diagnosis of grade II (low grade) parosteal osteosarcoma with the occurrence of myocardial metastasis 13 years after resection, and to present a review of the existing literature on the subject. METHODS: Description of the case and review of the literature. CONCLUSION: The review leads to the conclusion that the occurrence of metastasis from parosteal osteosarcoma can occur in up to 38 percent of the cases, in spite of its relatively low aggressiveness. However, myocardial metastasis of a parosteal osteosarcoma is an event that was not found in the literature

Experiência clínica inicial com o uso de sutura mecânica em brônquios / Clinical experience with the use of mechanical suture for closure of the bronchus

No Instituto do Coraçäo, de março de 1989 a agosto de 1990, 19 pacientes foram submetidos a ressecçöes pulmonares com o emprego de sutura mecânica para fechamento do coto brônquico. Todos eram portadores de carcinoma pulmonar, sendo dez adenocarcinoma e nove epidermóide. Quinze pacientes foram submetidos a lobectomia e quatro a pneumectomia. Näo houve intercorrências intra-operatórias. Todos os pacientes apresentaram boa evoluçäo cirúrgica, com seguimento de dois a 14 meses, com média de oito meses. A sutura mecância mostrou-se de fácil realizaçäo, rápida, prática, com bons resultados imediatos