Results Of Minimally Invasive Vats Thymectomy In Miastenia Gravis Patients Compared With More Invasive Approaches - 10-Year Experience In A Single Center.

INTRODUCTION: Myasthenia gravis (MG) is an autoimmune, neurologic disease that causes a wide range of symptoms. While the transsternal, transcervical and thoracotomy approaches are accepted as effective, there is still debate regarding the VATS approach. MATERIALS AND METHODS: We analyzed our center's surgical experience with thymectomy for myasthenia gravis, comparing the results of patients operated on using VATS and more invasive approaches, over a period of 10 years. A search of the department's surgical database for myasthenia gravis cases between January 2010 and January 2021, revealed a total of 40 cases. Twenty-four patients were included in the final analysis and were distributed into two groups: the VATS procedure group (group A) and the open procedure group (group B). The latter included sternotomy, thoracotomy, transcervical and hemiclamshell approaches. Only radical thymectomies were included. The established outcomes were clinical improvement defined as asymptomatic remission, reduction, or discontinuation of the medication necessary to achieve optimal symptom control. RESULTS: The median follow-up time was 27 months (ranging from 4 to 75 months). Videothoracoscopy radical thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement (reduced symptoms or decreased medication) was observed in 8 cases (66.6%). No change in clinical outcome was noted in 1 patient (8.3%). None of the patients reported worsening symptoms. Open thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement was noted in 6 cases (50%). No change in clinical outcome was observed in 3 patients (25%) whereas 2 of them (16.7%) experienced slightly better symptom control but with a significant increase in medication. One patient (8.3%) described the clinical results as without any significant change. None of the patients reported worsening symptoms. CONCLUSION: The videotoracoscopic approach in the treatment of myasthenia gravis is non-inferior compared to the open approach and effective in a long-term follow-up, offering all the additional benefits of less invasive surgery.

Characteristics and patient-reported outcomes of long-term lung cancer survivors.

Background: Due to advances in screening and treatment of lung cancer, there has been increased interest in long-term lung cancer survivors (LTLCS). The aim of this study was to evaluate the prevalence of LTLCS, their characteristics and patient-reported outcomes (PROs) of LTLCS. Methods: Cross-sectional study that included patients diagnosed with primary lung cancer between Jan 2012 and Dec 2016 whose overall survival (OS) was greater than 5 years. A self-administered questionnaire was applied, including European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30), Patient Health Questionnaire-4 (PHQ-4) and two open questions regarding quality of life (QoL) and suggestions for improvements. Factors potentially related to QoL were analysed. Results: Of 767 lung cancer patients, 158 (20.6%) were LTLCS and LTLCS' proportion increased yearly. Most patients were male (70.9%) with median age of 65 [interquartile range (IQR), 56-71] years. Fifty-seven percent had adenocarcinoma, 66.2% were diagnosed at early stages but 8.9% were at stage IV. During follow-up, 77.1% quitted smoking, 31.8% had disease progression/relapse and 15.2% developed other tumours. Of all living LTLCS, 100 (85%) patients answered the PROs questionnaire. The median Global Health score was 66.67 (IQR, 50-83), social functioning had the best score and emotional functioning the worst. Pain and fatigue were the symptoms with the worst impact on QoL. PHQ-4 identified mental distress in 36% and patients with a lower QoL were more likely to present anxiety (35.3% vs. 9.4%, P=0.007) or depression (27.9% vs. 3%, P=0.006). In the open questions, patients reported pain (17%), lack of familiar/financial support (16%), dyspnoea (14%), depression (8%), concern for the future (8%) and limitations performing daily activities (8%) as the aspects with most impact in QoL. The most suggested measures were improvement of care provided by health institutions (25%) and better social support (16%). Conclusions: Prevalence of LTLCS is increasing and survivors may experience a high prevalence of anxiety and depression as well as a high disease burden affecting QoL. Therefore, it's important to provide multidisciplinary continuous patient-centred care and a careful follow-up for all lung cancer patients, including LTLCS.

Dexmedetomidine compared to low-dose ketamine better protected not only the brain but also the lungs in acute ischemic stroke.

BACKGROUND: Dexmedetomidine (DEX) and low-dose ketamine (KET) present neuroprotective effects in acute ischemic stroke (AIS); however, to date, no studies have evaluated which has better protective effects not only on the brain but also lungs in AIS. METHODS: AIS-induced Wistar rats (390 ± 30 g) were randomized after 24-h, receiving dexmedetomidine (STROKE-DEX, n = 10) or low-dose S(+)-ketamine (STROKE-KET, n = 10). After 1-h protective ventilation, perilesional brain tissue and lungs were removed for histologic and molecular biology analysis. STROKE animals (n = 5), receiving sodium thiopental but not ventilated, had brain and lungs removed for molecular biology analysis. Effects of DEX and KET mean plasma concentrations on alveolar macrophages, neutrophils, and lung endothelial cells, extracted primarily 24-h after AIS, were evaluated. RESULTS: In perilesional brain tissue, apoptosis did not differ between groups. In STROKE-DEX, compared to STROKE-KET, tumor necrosis factor (TNF)-α and vascular cell adhesion molecule-1 (VCAM-1) expressions were reduced, but no changes in nuclear factor erythroid 2-related factor-2 (Nrf2) and super oxide dismutase (SOD)-1 were observed. In lungs, TNF-α and VCAM-1 were reduced, whereas Nrf2 and SOD-1 were increased in STROKE-DEX. In alveolar macrophages, TNF-α and inducible nitric oxide synthase (M1 macrophage phenotype) were lower and arginase and transforming growth factor-ß (M2 macrophage phenotype) higher in STROKE-DEX. In lung neutrophils, CXC chemokine receptors (CXCR2 and CXCR4) were higher in STROKE-DEX. In lung endothelial cells, E-selectin and VCAM-1 were lower in STROKE-DEX. CONCLUSIONS: In the current AIS model, dexmedetomidine compared to low-dose ketamine reduced inflammation and endothelial cell damage in both brain and lung, suggesting greater protection.

Extracellular Vesicles from Different Sources of Mesenchymal Stromal Cells Have Distinct Effects on Lung and Distal Organs in Experimental Sepsis.

The effects of the administration of mesenchymal stromal cells (MSC) may vary according to the source. We hypothesized that MSC-derived extracellular vesicles (EVs) obtained from bone marrow (BM), adipose (AD), or lung (L) tissues may also lead to different effects in sepsis. We profiled the proteome from EVs as a first step toward understanding their mechanisms of action. Polymicrobial sepsis was induced in C57BL/6 mice by cecal ligation and puncture (SEPSIS) and SHAM (control) animals only underwent laparotomy. Twenty-four hours after surgery, animals in the SEPSIS group were randomized to receive saline or 3 × 106 MSC-derived EVs from BM, AD, or L. The diffuse alveolar damage was decreased with EVs from all three sources. In kidneys, BM-, AD-, and L-EVs reduced edema and expression of interleukin-18. Kidney injury molecule-1 expression decreased only in BM- and L-EVs groups. In the liver, only BM-EVs reduced congestion and cell infiltration. The size and number of EVs from different sources were not different, but the proteome of the EVs differed. BM-EVs were enriched for anti-inflammatory proteins compared with AD-EVs and L-EVs. In conclusion, BM-EVs were associated with less organ damage compared with the other sources of EVs, which may be related to differences detected in their proteome.

Incidental giant thymoma-a reminder of the importance of a global look of the imaging scans.

A 49-year-old female patient, without previous medical history, underwent a thoracic CT due to SARS-CoV2 infection. This exam revealed a heterogeneous mass in the anterior mediastinum with 11 × 8.8 cm in close contact with main thoracic vessels and pericardium. Surgical biopsy documented a B2 thymoma. This clinical case reminds the importance of a systematic and global look of the imaging scans. Years before the thymoma diagnosis, the patient underwent a shoulder X-ray due to musculoskeletal pain, where an irregular shape of the aortic arch was visible, probably related to the growing mediastinal mass. An earlier diagnosis would allow a complete mass resection without such extensive surgery and less morbidity.

An Unusual Location for a Lymph Node.

We report a case of a 67-years old non-smoking female diagnosed with hypertension when 24-years-old and complicated with chronic kidney and hypertensive heart diseases. On CT-Chest an incidental discovery of a lesion (16x14x23mm) adjacent to the abdominal aorta was made. Initially suspected to be paraganglioma, a hypothesis which the subsequent MRI did not exclude. Urine analysis showed normal Metanephrine with slightly elevated Chromogranin-A levels. During VATs-procedure "bulging" below the adventitial layer of the descending aorta at the level of the diaphragmatic gutter was identified. By opening the adventitia, a lipomatous lesion with a nodular, consistent center was identified and excised. Final histopathological report confirmed the diagnosis of lymph node not suggestive of neoplasia. Currently, 12 months after the surgery, the patient's condition is good being under surveillance in the Thoracosurgical Outpatient Clinic. Despite not having identified any neuroendocrine component, the patient had clinical signs of clear improvement of arterial hypertension.

Innovative 3d-Printed Prosthesis In A Rare Case Of A Huge Mass Of Anterior Thoracic Wall - Low Grade Fibromyxoid Sarcoma (Lgfms).

The need for complete resection of chest wall tumors creates a huge challenge in terms of reconstructing the complex dynamics of the thorax. We are reporting a case of a low-grade fibromyxoid sarcoma (LGFMS) diagnosed in a young male, where the complete resection of the mass, sternum and parcially the pericardium was performed. Subsequently, a composite porous high-density polyethylene StarPore® prosthesis of the sternum and costal arches was used and the latissimus dorsi muscle free flap with skin graft was implanted over the sternum.

Mild hypothermia combined with dexmedetomidine reduced brain, lung, and kidney damage in experimental acute focal ischemic stroke.

BACKGROUND: Sedatives and mild hypothermia alone may yield neuroprotective effects in acute ischemic stroke (AIS). However, the impact of this combination is still under investigation. We compared the effects of the combination of mild hypothermia or normothermia with propofol or dexmedetomidine on brain, lung, and kidney in experimental AIS. AIS-induced Wistar rats (n = 30) were randomly assigned, after 24 h, to normothermia or mild hypothermia (32-35 °C) with propofol or dexmedetomidine. Histologic injury score and molecular biomarkers were evaluated not only in brain, but also in lung and kidney. Hemodynamics, ventilatory parameters, and carotid Doppler ultrasonography were analyzed for 60 min. RESULTS: In brain: (1) hypothermia compared to normothermia, regardless of sedative, decreased tumor necrosis factor (TNF)-α expression and histologic injury score; (2) normothermia + dexmedetomidine reduced TNF-α and histologic injury score compared to normothermia + propofol; (3) hypothermia + dexmedetomidine increased zonula occludens-1 expression compared to normothermia + dexmedetomidine. In lungs: (1) hypothermia + propofol compared to normothermia + propofol reduced TNF-α and histologic injury score; (2) hypothermia + dexmedetomidine compared to normothermia + dexmedetomidine reduced histologic injury score. In kidneys: (1) hypothermia + dexmedetomidine compared to normothermia + dexmedetomidine decreased syndecan expression and histologic injury score; (2) hypothermia + dexmedetomidine compared to hypothermia + propofol decreased histologic injury score. CONCLUSIONS: In experimental AIS, the combination of mild hypothermia with dexmedetomidine reduced brain, lung, and kidney damage.

Effects of different fluid management on lung and kidney during pressure-controlled and pressure-support ventilation in experimental acute lung injury.

Optimal fluid management is critical during mechanical ventilation to mitigate lung damage. Under normovolemia and protective ventilation, pulmonary tensile stress during pressure-support ventilation (PSV) results in comparable lung protection to compressive stress during pressure-controlled ventilation (PCV) in experimental acute lung injury (ALI). It is not yet known whether tensile stress can lead to comparable protection to compressive stress in ALI under a liberal fluid strategy (LF). A conservative fluid strategy (CF) was compared with LF during PSV and PCV on lungs and kidneys in an established model of ALI. Twenty-eight male Wistar rats received endotoxin intratracheally. After 24 h, they were treated with CF (minimum volume of Ringer's lactate to maintain normovolemia and mean arterial pressure ≥70 mmHg) or LF (~4 times higher than CF) combined with PSV or PCV (VT  = 6 ml/kg, PEEP = 3 cmH2 O) for 1 h. Nonventilated animals (n = 4) were used for molecular biology analyses. CF-PSV compared with LF-PSV: (1) decreased the diffuse alveolar damage score (10 [7.8-12] vs. 25 [23-31.5], p = 0.006), mainly due to edema in axial and alveolar parenchyma; (2) increased birefringence for occludin and claudin-4 in lung tissue and expression of zonula-occludens-1 and metalloproteinase-9 in lung. LF compared with CF reduced neutrophil gelatinase-associated lipocalin and interleukin-6 expression in the kidneys in PSV and PCV. In conclusion, CF compared with LF combined with PSV yielded less lung epithelial cell damage in the current model of ALI. However, LF compared with CF resulted in less kidney injury markers, regardless of the ventilatory strategy.

LUNG RESECTION FOR NON-SMALL-CELL LUNG CANCER - A NEW RISK SCORE TO PREDICT MAJOR PERIOPERATIVE COMPLICATIONS.

OBJECTIVES: Identify risk factors for major perioperative complications (MPC) after anatomical lung resection for NonSmall-Cell Lung Cancer (NSCLC) and establish a scoring system. METHODS: Single center retrospective study of all consecutive patients diagnosed with NSCLC submitted to anatomical lung resection from 2015 to 2019 (N=564). EXCLUSION CRITERIA: previous lung surgery, concomitant non-lung cancer related procedures, urgency surgery. STUDY POPULATION: 520 patients. PRIMARY END-POINT: MPC defined as a composite endpoint including at least one of the in-hospital complications. Univariable and Multivariable analyses were developed to identify predictors of perioperative complications and create a risk score. Discrimination was assessed using the C-statistic. Calibration was evaluated by Hosmer and Lemeshow test and internal validation was obtained by means of bootstrap replication. RESULTS: Mean age of 65 years and 327 (62.9%) were males. Mean hospital stay of 9 days after surgery. Overall MPC rate was 23.3%. Male gender, hypertension, FEV1<75%, thoracotomy, bilobectomy/pneumectomy and additional resection were independent predictors of MPC. A risk score based on the odds ratios was developed - Major Perioperative Complications of Lung Resection (MPCLR) scoring system - and ranged between 0 and 14 points. It was divided in 5 groups: 1-2 points (positive preditive value 15%); 3-4 (PPV 25%); 5-7 (PPV 35%); 8-9 (PPV 60%); >10 points (PPV 88%). The score showed rea- sonable discrimination (C-statistic=0.70), good calibration (P=.643) and it was internally validated (C-statistic=0,70 BCa95% CI,0.65-0.79). CONCLUSIONS: This study proposes a simple and daily-life risk score system that was able to predict the incidence of perioperative complications.

LYMPH NODE UPSTAGING AFTER SURGERY IN PATIENTS WITH NEGATIVE MEDIASTINAL STAGING BY EBUS.

INTRODUCTION: Mediastinal staging is a hot topic in thoracic oncology. According to the guidelines, and besides other criteria, in the presence of a primary lung cancer with increased mediastinal lymph node uptake on PET-CT, a negative result after lymph node sampling by Endobronchial Ultrasound (EBUS) is not enough to rule out mediastinal lymph node involve- ment, demanding a cervical mediastinoscopy to vouch for the results. METHODS AND OBJECTIVES: In order to study the percentage of lymph node surgical upstaging in patients with neg- ative mediastinal node staging by EBUS and evaluate the role of mediastinoscopy in these patients, we conducted a search in our department's database using the key-word EBUS in the period concerned between January 2014 and August 2020. A total of 302 patients were found. After applying defined criteria, we obtained 42 cases. RESULTS: Lymph node surgical upstaging occurred in 11 (26%) patients, of which 8 were upstaged to N2 and 3 to N1. Most of the cases were single station. Only in 5 (12% of the total) of the 11 patients, the upstaging was related to lymph node stations previously sampled by EBUS. Upstaging was more frequent among males and lower lobe tumours. DISCUSSION AND CONCLUSIONS: Regarding the 8 upstage cases for N2, 5 were single station. Of these 8 cases, only 5 would be approachable by cervical mediastinoscopy. Furthermore, 2 of them were single station, eligible for upfront surgery. Then, only in 3 (7%) of the 42 cases cervical mediastinoscopy would be of foremost importance.

Comparative effects of dexmedetomidine and propofol on brain and lung damage in experimental acute ischemic stroke.

Acute ischemic stroke is associated with pulmonary complications, and often dexmedetomidine and propofol are used to decrease cerebral metabolic rate. However, it is unknown the immunomodulatory actions of dexmedetomidine and propofol on brain and lungs during acute ischemic stroke. The effects of dexmedetomidine and propofol were compared on perilesional brain tissue and lung damage after acute ischemic stroke in rats. Further, the mean amount of both sedatives was directly evaluated on alveolar macrophages and lung endothelial cells primarily extracted 24-h after acute ischemic stroke. In twenty-five Wistar rats, ischemic stroke was induced and after 24-h treated with sodium thiopental (STROKE), dexmedetomidine and propofol. Dexmedetomidine, compared to STROKE, reduced diffuse alveolar damage score [median(interquartile range); 12(7.8-15.3) vs. 19.5(18-24), p = 0.007)], bronchoconstriction index [2.28(2.08-2.36) vs. 2.64(2.53-2.77), p = 0.006], and TNF-α expression (p = 0.0003), while propofol increased VCAM-1 expression compared to STROKE (p = 0.0004). In perilesional brain tissue, dexmedetomidine, compared to STROKE, decreased TNF-α (p = 0.010), while propofol increased VCAM-1 compared to STROKE (p = 0.024). In alveolar macrophages and endothelial cells, dexmedetomidine decreased IL-6 and IL-1ß compared to STROKE (p = 0.002, and p = 0.040, respectively), and reduced IL-1ß compared to propofol (p = 0.014). Dexmedetomidine, but not propofol, induced brain and lung protection in experimental acute ischemic stroke.

Effects of propofol and its formulation components on macrophages and neutrophils in obese and lean animals.

We hypothesized whether propofol or active propofol component (2,6-diisopropylphenol [DIPPH] and lipid excipient [LIP-EXC]) separately may alter inflammatory mediators expressed by macrophages and neutrophils in lean and obese rats. Male Wistar rats (n = 10) were randomly assigned to receive a standard (lean) or obesity-inducing diet (obese) for 12 weeks. Animals were euthanized, and alveolar macrophages and neutrophils from lean and obese animals were exposed to propofol (50 µM), active propofol component (50 µM, 2,6-DIPPH), and lipid excipient (soybean oil, purified egg phospholipid, and glycerol) for 1 h. The primary outcome was IL-6 expression after propofol and its components exposure by alveolar macrophages extracted from bronchoalveolar lavage fluid. The secondary outcomes were the production of mediators released by macrophages from adipose tissue, and neutrophils from lung and adipose tissues, and neutrophil migration. IL-6 increased after the exposure to both propofol (median [interquartile range] 4.14[1.95-5.20]; p = .04) and its active component (2,6-DIPPH) (4.09[1.67-5.91]; p = .04) in alveolar macrophages from obese animals. However, only 2,6-DIPPH increased IL-10 expression (7.59[6.28-12.95]; p = .001) in adipose tissue-derived macrophages. Additionally, 2,6-DIPPH increased C-X-C chemokine receptor 2 and 4 (CXCR2 and CXCR4, respectively) in lung (10.08[8.23-29.01]; p = .02; 1.55[1.49-3.43]; p = .02) and adipose tissues (8.78[4.15-11.57]; p = .03; 2.86[2.17-3.71]; p = .01), as well as improved lung-derived neutrophil migration (28.00[-3.42 to 45.07]; p = .001). In obesity, the active component of propofol affected both the M1 and M2 markers as well as neutrophils in both alveolar and adipose tissue cells, suggesting that lipid excipient may hinder the effects of active propofol.

The impact of fluid status and decremental PEEP strategy on cardiac function and lung and kidney damage in mild-moderate experimental acute respiratory distress syndrome.

BACKGROUND: We evaluated the effects of abrupt versus gradual PEEP decrease, combined with standard versus high-volume fluid administration, on cardiac function, as well as lung and kidney damage in an established model of mild-moderate acute respiratory distress syndrome (ARDS). METHODS: Wistar rats received endotoxin intratracheally. After 24 h, they were treated with Ringer's lactate at standard (10 mL/kg/h) or high (30 mL/kg/h) dose. For 30 min, all animals were mechanically ventilated with tidal volume = 6 mL/kg and PEEP = 9 cmH2O (to keep alveoli open), then randomized to undergo abrupt or gradual (0.2 cmH2O/min for 30 min) PEEP decrease from 9 to 3 cmH2O. Animals were then further ventilated for 10 min at PEEP = 3 cmH2O, euthanized, and their lungs and kidneys removed for molecular biology analysis. RESULTS: At the end of the experiment, left and right ventricular end-diastolic areas were greater in animals treated with high compared to standard fluid administration, regardless of PEEP decrease rate. However, pulmonary arterial pressure, indicated by the pulmonary acceleration time (PAT)/pulmonary ejection time (PET) ratio, was higher in abrupt compared to gradual PEEP decrease, independent of fluid status. Animals treated with high fluids and abrupt PEEP decrease exhibited greater diffuse alveolar damage and higher expression of interleukin-6 (a pro-inflammatory marker) and vascular endothelial growth factor (a marker of endothelial cell damage) compared to the other groups. The combination of standard fluid administration and gradual PEEP decrease increased zonula occludens-1 expression, suggesting epithelial cell preservation. Expression of club cell-16 protein, an alveolar epithelial cell damage marker, was higher in abrupt compared to gradual PEEP decrease groups, regardless of fluid status. Acute kidney injury score and gene expression of kidney injury molecule-1 were higher in the high versus standard fluid administration groups, regardless of PEEP decrease rate. CONCLUSION: In the ARDS model used herein, decreasing PEEP abruptly increased pulmonary arterial hypertension, independent of fluid status. The combination of abrupt PEEP decrease and high fluid administration led to greater lung and kidney damage. This information adds to the growing body of evidence that supports gradual transitioning of ventilatory patterns and warrants directing additional investigative effort into vascular and deflation issues that impact lung protection.

PANCOAST TUMOUR WITH SPINE RESECTION - CASE REPORT.

Pancoast tumours are defined as tumours arising from the upper lobe and invading the thoracic inlet,representing less than 5% of all lung cancers. Clinical features depend on the involved structures. For many years invasion of the spine was considered unresectable and fatal. Due to the progress in spine surgery, en bloc resection including the spine is nowadays possible. We report the first case of a successful en bloc vertebral resection of a Pancoast tumour in a 66 year-old male, with a squamous cell carcinoma, treated at our department in a multidisciplinary setting, after induction chemoradiotherapy. An en bloc resection including the left upper lobe, the first three ribs and the vertebral body of D2, was performed through a Paulson incision after posterior cervico-dorsal arthrodesis. A complete R0 resection was confirmed on the pathology specimen. Currently, one year after surgery, although no local recurrence has occurred, the patient is being treated with immunotherapy due to disease progression in the right acetabulum which was irradiated (20Gy) and then submitted to iliac resection and prothesis reconstruction.

POSTOPERATIVE ATRIAL FIBRILLATION - VIDEO-ASSISTED THORACOSCOPIC SURGERY VERSUS OPEN SURGERY.

OBJECTIVES: Compare the incidence of Postoperative atrial fibrillation (PAF) after anatomical lung resection for Non- Small-Cell Lung Cancer (NSCLC) following open surgery versus VATS. METHODS: Single center retrospective study of all consecutive patients diagnosed with NSCLC submitted to anatomical lung resection from 2015 to 2019 (N=564). EXCLUSION CRITERIA: prior atrial fibrillation, previous lung surgery, concomitant procedures, pneumectomy, non-pulmonary resections, urgency surgery. Study population of 439 patients. PRIMARY END-POINT: incidence of PAF. Univariable analysis was used to compare the baseline characteristics of the 2 groups. Inverse probability of treatment weighting (IPTW) multivariable logistic regression was used including 23 clinical variables to analyze the effect of the approach. The balance was assessed by standardized mean differences. RESULTS: Thoracotomy was performed in 280 patients (63.8%) and 159 (36.2%) were submitted to VATS. Patients submitted to VATS were more likely to be females, had a lower prevalence of non-adenocarcinoma cancer, stage TNM IIIIV, Diabetes Mellitus, respiratory disease, and chronic heart failure. They were submitted less often to neoadjuvant therapy, bilobectomy and they presented higher levels of diffusing capacity for carbon monoxide. After IPTW adjustment, all clinical covariates were well balanced. PAF occurred in 8.6% of the patients undergoing thoracotomy and 3,8% of the patients after VATS. After IPTW adjustment, VATS was not associated with a lower incidence of PAF (OR 0.40; CI95%:0.140-1.171; p=0.095). CONCLUSION: In this study, minimally invasive non-rib spreading VATS did not decrease the incidence of PAF when compared with standard thoracotomy regarding anatomical lung resection for NSCLC.

Oxidative Stress-Derived Mitochondrial Dysfunction in Chronic Obstructive Pulmonary Disease: A Concise Review.

Chronic obstructive pulmonary disease (COPD) is a progressive and disabling disorder marked by airflow limitation and extensive destruction of lung parenchyma. Cigarette smoke is the major risk factor for COPD development and has been associated with increased oxidant burden on multiple cell types in the lungs. Elevated levels of reactive oxygen species (ROS) may significantly affect expression of biological molecules, signaling pathways, and function of antioxidant defenses. Although inflammatory cells, such as neutrophils and macrophages, contribute to the release of large quantities of ROS, mitochondrial dysfunction plays a critical role in ROS production due to oxidative phosphorylation. Although mitochondria are dynamic organelles, excess oxidative stress is able to alter mitochondrial function, morphology, and RNA and protein content. Indeed, mitochondria may change their shape by undergoing fusion (regulated by mitofusin 1, mitofusin 2, and optic atrophy 1 proteins) and fission (regulated by dynamin-related protein 1), which are essential processes to maintain a healthy and functional mitochondrial network. Cigarette smoke can induce mitochondrial hyperfusion, thus reducing mitochondrial quality control and cellular stress resistance. Furthermore, diminished levels of enzymes involved in the mitophagy process, such as Parkin (a ubiquitin ligase E3) and the PTEN-induced putative kinase 1 (PINK1), are commonly observed in COPD and correlate directly with faulty removal of dysfunctional mitochondria and consequent cell senescence in this disorder. In this review, we highlight the main mechanisms for the regulation of mitochondrial quality and how they are affected by oxidative stress during COPD development and progression.

Terapia com Levamisole em crianças e adolescentes com Síndrome Nefrótica Córtico dependentes ou recidivantes frequentes: experiência de um centro de referência em Minas Gerais / Levamisole therapy in dependent children and adolescents with Cortic Nephrotic Syndrome or frequent relapses: experience from a reference center in Minas Gerais

Introdução: A terapia poupadora de corticoide é a melhor estratégia para reduzir a exposição a esteroides a longo prazo em pacientes com síndrome nefrótica e o levamisole se mostrou um agente poupador de corticoide de baixo custo, fácil acesso e com baixo índice de eventos adversos. Objetivos: Sintetizar as evidências literárias sobre as estratégias poupadoras de corticoterapia em pacientes pediátricos com síndrome nefrótica. Avaliar a resposta ao uso de levamisole em pacientes pediátricos com síndrome nefrótica córtico dependentes ou recidivantes frequentes. Métodos: Revisão integrativa das evidências disponíveis na literatura em relação ao uso de poupadores de corticoide em pacientes pediátricos com síndrome nefrótica corticossensível recidivantes frequentes ou cortico dependentes. Levantamento de dados de pacientes em uso de levamisole para avaliação da resposta à medicação. Resultados: Não há uma medicação poupadora de corticoide de referência na população pediátrica. Quando necessária, a terapia poupadora de corticoterapia deve ser individualizada e compartilhada com familiares. O uso de corticoide continua sendo o tratamento inicial de escolha. Dos 30 pacientes selecionados para o estudo 86,7% não apresentaram efeitos adversos com uso de levamisole. O poupador de corticoide mais comumente utilizado antes do uso de levamisole foi a ciclofosfamida (26,7%). A biópsia renal foi realizada em 30% dos pacientes e o achado mais comum foi doença por lesões mínimas. Ao longo da avaliação em um ano, não houve piora de nenhum índice hematimétricos (P > 0,05) incluindo neutrófilos. Conclusões: Em nosso estudo o levamisole mostrou eficiência em reduzir o número de recidivas no primeiro ano de uso, além de manter estabilidade da função renal, com baixo índice de evento adverso.

Introduction: Corticosteroid-sparing therapy is the best strategy to reduce long-term steroid exposure in patients with nephrotic syndrome, and levamisole has been shown to be a low-cost, easily accessible, steroid-sparing agent with a low rate of adverse events. Objectives: To synthesize the literature evidence on steroid-sparing strategies in pediatric patients with nephrotic syndrome. To evaluate the response to the use of levamisole in pediatric patients with cortico-resistant nephrotic syndrome or frequent relapses. Methods: An integrative review of the evidence available in the literature regarding the use of steroid-sparing agents in pediatric patients with frequent relapsing or steroid-dependent cortico-sensitive nephrotic syndrome. Data collection of patients using levamisole to assess the response to medication. Results: There is no reference corticosteroid-sparing medication in the pediatric population. When necessary, steroid-sparing therapy should be individualized and shared with family members. Corticosteroid use remains the initial treatment of choice. Of the 30 patients selected for the study, 86.7% had no adverse effects with the use of levamisole. The most used corticosteroid sparing agent before the use of levamisole was cyclophosphamide (26.7%). Renal biopsy was performed in 30% of patients and the most common finding was focal segmental glomerulus sclerosis (FSGS), followed by minimal change disease. Over the course of the one-year evaluation, there was no worsening of any RBC index (P > 0.05) including neutrophils. Conclusions: In our study, levamisole showed efficiency in reducing the number of relapses in the first year of use, in addition to maintaining stability of renal function, with a low rate of adverse events.

Structural Characterisation of the Leaf of Bauhinia monandra Kurz (Fabaceae - Cercidoideae)

Abstract Bauhinia monandra Kurz (Fabaceae) is an ornamental leguminous tree from Africa. Its leaf has been proven to be hypoglycaemic, and are a source of lecithin BmoLL, providing this species with great medicinal potential. Curiously, there are no reports of the anatomical description of the leaf of this species. The present work aimed at describing the leaf anatomy of B. monandra, and make histochemical inferences. To this end, anatomical procedures in light and scanning electron microscopy were performed from different parts of the leaves of plants growing in the state of Bahia, Brazil. The leaf is amphistomatous. It possesses papillate epidermis, nonglandular and navicular trichomes, and the mesophyll is dorsiventral. The central vein is distinct from the others of the first degree. The first, second, and third-degree veins possess thick fibre bundles with associated monocrystals. The other veins are a little fibrous and excessively reduced. The petiole vascularisation consists of circularly arranged collateral bundles, plus two accessory bundles. The pulvinus have a wide parenchymatic cortex with abundant druses and vascularisation restricted to the central region, surrounded by a crystalline sheath and by a starch sheath. The motile cushion has the vascular bundles arranged in series. Associated with the phloem from the pulvinus vascular bundles and the motile apparatus, occur non-lignified septate fibres that confer flexibility to these organs. The absence of lateral projections and the arrangement of vascular bundles in the petiole was the most distinctive anatomical features and of the greatest taxonomic potential observed in the leaf of B. monandra.