Cough impairment and risk of postoperative pulmonary complications after open upper abdominal surgery.

BACKGROUND: Cough impairment is often described as part of the pathophysiological basis of postoperative pulmonary complications (PPCs). However, there have been few studies examining cough effectiveness and its relationship with PPCs following open upper abdominal surgery. The goal of this study was to estimate (1) changes in cough efficacy after upper abdominal surgery through the assessment of peak cough flow and (2) the extent to which cough impairment is associated with postoperative pain, FVC, and risk of PPCs. METHODS: This prospective cohort study assessed 101 subjects (45% male, 56 ± 16 y old) admitted for elective upper abdominal surgery. Measurements of peak cough flow and FVC were performed on the day before surgery and repeated on postoperative days 1, 3, and 5. PPCs were assessed daily by a pulmonologist blinded to the cough measurement results. RESULTS: Peak cough flow dropped to 54% of the preoperative value on postoperative day 1 and gradually increased on postoperative days 3 (65%) and 5 (72%) (P < .05). On all postoperative days, peak cough flow was strongly correlated with FVC (P < .001) and weakly correlated with pain (P = .006). Six subjects (6%) developed PPCs. The association between peak cough flow and risk of PPCs was not statistically significant (unadjusted odds ratio of 0.80, 95% CI 0.45-1.40, P = .44; adjusted odds ratio of 0.66, 95% CI 0.32-1.38, P = .41). CONCLUSIONS: Cough effectiveness is impaired after upper abdominal surgery. Postoperative restrictive lung dysfunction seems to be associated with this impairment. There is no significant association between peak cough flow and PPCs; however, cough impairment might result in clinically important consequences in a high-risk population.

Evaluation of intraorbital injection of rituximab for treatment of primary ocular adnexal lymphoma: a pilot study.

An interventional pilot study to assess the tolerability and activity of the intralesional injection of rituximab, a chimeric mAb that targets the CD20 antigen, in patients with orbital B-cell lymphoma. Five patients received four intralesional injections (one injection a week) of rituximab together with ropivicaine 2%. Side-effects and tumor response were assessed after each injection and during the follow-up (20 months). Two patients obtained complete remission of the intraorbital lesion. Two patients showed incomplete response after induction therapy and received planned escalating rituximab doses, obtaining regression of subjective symptoms. One patient did not achieve tumor regression after the first injection and underwent systemic treatment. This small exploratory study suggests that intralesional rituximab is a well-tolerated treatment for patients with primary ocular adnexal lymphoma. These preliminary findings suggest that intralesional rituximab is a well-tolerated strategy in anterior intraorbital lesion localization of lymphoma.

Utilization of positive-pressure devices for breathing exercises in the hospital setting: a regional survey in São Paulo, Brazil.

BACKGROUND: The use of breathing exercises with positive-pressure devices during hospitalization aims to prevent the development of nosocomial pulmonary complications or to facilitate recovery from pulmonary conditions already present. Although this type of intervention has potential benefits and theoretical advantages over more conventional respiratory physiotherapy techniques, the literature on the effects of breathing exercises with positive-pressure is controversial and inconsistent. OBJECTIVE: To evaluate the extension of the use of breathing exercises with positive-pressure devices by physiotherapists in São Paulo, Brazil. METHODS: A list of hospitals located in the city of São Paulo was obtained through the Municipal Secretary of Health. Physiotherapists at 43 hospitals were surveyed about their use of exercises with positive-pressure devices in: patients after abdominal, thoracic, and cardiac surgery; patients with chronic obstructive pulmonary disease; patients with pneumonia; and patients with neuromuscular disease. RESULTS: 120 physiotherapists responded to the questionnaire. All the respondents used breathing exercises with positive-pressure devices in their clinical practice, with all types of patients addressed in the questionnaire. The devices most frequently used were continuous positive airway pressure (78%) and intermittent positive-pressure breathing (73%). The most frequently cited indications for positive-pressure breathing exercises were atelectasis and oxygenation impairment. CONCLUSIONS: Despite a lack of evidence of benefit from breathing exercises with positive-pressure in the hospital setting, this type of intervention is used extensively in clinical practice for a wide variety of patients and conditions.

Mydriasis induced by sub-Tenon's ropivacaine injection in patients undergoing strabismus surgery.

PURPOSE: To investigate the effects of sub-Tenon's capsule ropivacaine injection on pupillary diameter in strabismus surgery. METHODS: A total of 16 patients were randomly assigned to 2 groups. The ropivacaine group (R) received sub-Tenon's ropivacaine 1% (2.5-3 mL) injections. In the control group (C), general anesthesia was induced and a saline solution (2.5-3 mL) was injected in the sub-Tenon's capsule. Pupillary diameter was measured at baseline and 2 and 5 minutes from the injections. The effects of the injections were expressed as a ratio of final (5 minutes) versus basal diameter. RESULTS: A significant mydriasis occurred in the ropivacaine group when compared with the control group (Group R vs Group C ratio = 2.32, p < 0.0001) or with unoperated fellow eye (R vs unoperated eye ratio = 2.29, p < 0.0001). CONCLUSIONS: Ropivacaine in the sub-Tenon's capsule induces a mydriasis probably related to a pharmacological ciliary ganglion block.

Atypical presentation of a case of solitary fibrous tumor of the orbit.

PURPOSE: To describe a rare case of solitary fibrous tumor of the orbit in a child, clinically misdiagnosed as arterious hemangioma. METHODS: A nine-year-old child presented a hard-elastic palpable mass located in the right inferotemporal orbit. Computed tomography, orbital pulsed-wave Doppler and internal carotid artery angiography consented diagnosis of high-vascularization mass probably related to arterious hemangioma with feeder vessel arising from a branch of ophthalmic artery. The orbital mass was surgically removed. RESULTS: The histological examination showed mesenchimal tumor, CD34 positive, related to solitary fibrous tumor of the orbit. CONCLUSIONS: Solitary fibrous tumor of the orbit should be considered in the differential diagnosis of arterious hemangioma.

Association of a single-nucleotide polymorphism in the pregnane X receptor (PXR 63396C-->T) with reduced concentrations of unboosted atazanavir.

This study investigated pregnane X receptor polymorphisms in relation to unboosted atazanavir plasma concentrations in 2 cohorts of patients. The polymorphism 63396T-->C predicted concentrations below the minimum effective concentration (150 ng/mL) with odds ratios of 18 (P = .008) and 5.13 (P = .02). Prospective studies determining potential clinical usefulness are now warranted.

Surgical treatment of obstruction of the nasolacrimal ducts in patients with anatomical endonasal variants.

The presence of anatomical endonasal variants (concha bullosa, nasal septal deviation, or hypertrophic turbinates) may cause more complications in patients with epiphora who have external dacryocystorhinostomy (DCR). The purpose of this study was to assess the results of surgical placement of a stent in 28 patients. They were randomised into two groups and had either DCR or placement of a Song's polyurethane stent. They were followed up for 18 months. Twenty-six patients had a good result. The success rate was 13/14 for those who had DCR and 13/14 for those who had a stent. Operating time was significantly less for placing a stent (mean (SD) 15 (2) minutes) compared with 40 (3) minutes for DCR (p <0.01). Placement of a polyurethane stent is an effective and short procedure for nasolacrimal obstruction, which is suitable for patients with unusual intranasal conditions.

Acute onset concomitant esotropia: sensorial evaluation, prism adaptation test, and surgery planning.

BACKGROUND AND OBJECTIVE: Acute acquired concomitant esotropia is a rare form of strabismus that usually presents during infancy or early childhood with diplopia and minimal refractive error. The aim of this study was to evaluate the response to the prism adaptation test in a group of normosensorial patients with acute acquired concomitant esotropia and to determine its predictive value for surgical outcome. PATIENTS AND METHODS: Six patients (median age, 11 .5 years) with acute acquired concomitant esotropia underwent the prism adaptation test by applications of Fresnel press-on and prismatic lenses. The sensorial condition of each patient had been evaluated with theTNO stereopsis test, the Irvine test, Bagolini striated glasses, and the Worth four-dot test during the prism adaptation test, when maximum compensation angle was achieved, and after surgery. In all patients, surgery was performed based on the angle of the squint after the prism adaptation test. Patients were observed 1 day, 3 months, 6 months, and 1 year after surgery. RESULTS: An increase in the angle of the squint occurred in all patients during prism adaptation. The maximum value was obtained in the same amount of time whether with prisms of increasing power or by direct application of the final value of the prisms. The final prismatic value (target angle) was always the same. CONCLUSIONS: The accuracy of the patients' selection confirmed the existence of highly reproducible compensational movements to the prismatic correction in not only patients with anomalous retinal correspondence but also normosensorial patients. Prism adaptation test results were useful in these patients because of their high predictive value for the surgical treatment.