Desempenho funcional do membro superior após cirurgia para câncer de mama de mulheres no menacme / Functional performance of upper limb after breast cancer surgery in women at menacme

Após a cirurgia para câncer de mama, algumas complicações podem levar a restrições da amplitude de movimento (ADM), dor e impacto negativo na realização das tarefas de vida diária. Neste contexto, a fisioterapia é importante na recuperação da funcionalidade. Objetivo: Avaliar o efeito da fisioterapia na amplitude de movimento, na intensidade de dor e no desempenho funcional do membro superior após a cirurgia para câncer de mama de mulheres no menacme. Métodos: Ensaio clínico não controlado, considerando mulheres que realizaram cirurgia para câncer de mama associada a linfonodectomia axilar. Foram avaliados a ADM pela fleximetria, intensidade de dor pela escala visual analógica (EVA) e o desempenho funcional pelo questionário "deficiência do ombro braço e mão" (DASH). Resultados: Após as 10 sessões de fisioterapia, foi observado aumento significativo da ADM de todos os movimentos, diminuição da intensidade de dor de 4,09 ± 2,51) para 2,54 ± 2,18, (p = 0,04), e dos escores do DASH de 35,31 ± 17,23 para 17,75 ± 13,09, (p = 0,001), indicando significativa melhora do desempenho funcional. Conclusão: A abordagem fisioterapêutica foi satisfatória em melhorar a ADM, intensidade de dor e o desempenho funcional em mulheres na pré-menopausa. Contudo, acompanhamento por mais longo prazo e incrementar os exercícios podem trazer melhora adicional. (AU)

Cinesioterapia para melhora da qualidade de vida após cirurgia para câncer de mama / Kinesiotherapy to improve quality of life after breast cancer surgery

Introdução: O tratamento cirúrgico para o câncer de mama pode trazer limitações físico-funcionais e prejuízos na qualidade de vida (QV). Assim, a cinesioterapia representa uma possibilidade terapêutica para prevenir ou tratar estas disfunções. Objetivo: Comparar a QV antes e após 10 sessões de cinesioterapia. Métodos: Ensaio clínico não aleatorizado, envolvendo mulheres que realizaram 10 sessões de fisioterapia após cirurgia para câncer de mama. O protocolo incluiu alongamentos, exercícios ativos-livres e exercícios resistidos. A QV foi avaliada pelo questionário genérico European Organization for Research and Treatment of Cancer (EORTC): o Quality of Life Questionnaire C-30 (QLQ-C30) e o específico, Breast Cancer Module (BR-23). Resultados: Foram incluídas 35 mulheres, sendo a mastectomia à esquerda o procedimento mais realizado. No QLQ-C30, foi observada melhora significativa da escala de função física (p = 0,01), desempenho funcional (p = 0,02), fadiga (p = 0,03), dor (p = 0,01), insônia (p = 0,02) e piora apenas de diarreia (p = 0,02). No BR-23, observou-se melhora significativa nos sintomas da mama (p = 0,01) e do braço (p = 0,01). Outros escores, como função cognitiva, social, dispneia, constipação, dificuldade financeira, imagem corporal e perspectiva futura, melhoraram sem diferença significativa. Conclusão: Após a cinesioterapia, observou-se melhora de diversos aspectos da QV. Maior tempo de seguimento e outros instrumentos de avaliação poderão mostrar ganhos adicionais. (AU)

Introduction: Breast cancer is the most common health problem among the female population and its surgical treatment may cause physical limitations and impair quality of life (QOL). Kinesiotherapy becomes a possibility of treatment to reduce the complications of surgery. Objective: To compare QOL before and after 10 kinesiotherapy. Methods: Non-randomized clinical trial, involving women who underwent 10 physical therapy training after surgery to treat breast cancer. The kinesiotherapy protocol included stretching, active-free exercises, and resistance exercises. To assess QOL, the European Organization for Cancer Research and Treatment (EORTC) generic instrument, the C-30 Quality of Life Questionnaire (QLQ-C30) and the Breast Cancer Module (BR-23) were applied. Results: 35 women were included, with the mastectomy on the left being the most performed procedure. In the generic questionnaire of the EORTC, QLQ-C30, an improvement was observed in the scores of the scale of physical function (p = 0.01), functional performance (p = 0.02), fatigue (p = 0.03), pain (p = 0.01) and insomnia (p = 0.02) and worsens only in diarrhea symptoms (p = 0.02). In BR-23, significant improvements were observed in the symptoms of the breast (p = 0.01) and the arm (p = 0.01). Conclusion: Kinesiotherapy has beneficial effects on QOL. After kinesiotherapy there was an improvement of several aspects of QOL. Longer follow-up and other assessment tools may show additional gains. (AU)

Antiplatelet Drugs and Risk of Bleeding After Bedside Pleural Procedures: A National Multicenter Cohort Study.

BACKGROUND: The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking. RESEARCH QUESTION: Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures? STUDY DESIGN AND METHODS: We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death. RESULTS: A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding. INTERPRETATION: Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety.

Experts' guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF) : In collaboration with the pediatric Association of French-speaking Anaesthetists and Intensivists (ADARPEF), French-speaking Group of Intensive Care and Paediatric emergencies (GFRUP) and Intensive Care physiotherapy society (SKR).

BACKGROUND: Intubation and extubation of ventilated patients are not risk-free procedures in the intensive care unit (ICU) and can be associated with morbidity and mortality. Intubation in the ICU is frequently required in emergency situations for patients with an unstable cardiovascular or respiratory system. Under these circumstances, it is a high-risk procedure with life-threatening complications (20-50%). Moreover, technical problems can also give rise to complications and several new techniques, such as videolaryngoscopy, have been developed recently. Another risk period is extubation, which fails in approximately 10% of cases and is associated with a poor prognosis. A better understanding of the cause of failure is essential to improve success procedure. RESULTS AND CONCLUSION: In constructing these guidelines, the SFAR/SRLF experts have made use of new data on intubation and extubation in the ICU from the last decade to update existing procedures, incorporate more recent advances and propose algorithms.

Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care.

RATIONALE: Encephalitis caused by anti-N-methyl-d-aspartate receptor (NMDAR) antibodies is the leading cause of immune-mediated encephalitis. There are limited data on intensive care unit (ICU) management of these patients. OBJECTIVES: To identify prognostic factors of good neurologic outcome in patients admitted to an ICU with anti-NMDAR encephalitis. METHODS: This was an observational multicenter study of all consecutive adult patients diagnosed with anti-NMDAR encephalitis at the French National Reference Centre, admitted to an ICU between 2008 and 2014. The primary outcome was a good neurologic outcome at 6 months after ICU admission, defined by a modified Rankin Scale score of 0-2. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients were included from 52 ICUs. First-line immunotherapy consisted of steroids (n = 61/74; 82%), intravenous immunoglobulins (n = 71/74; 96%), and plasmapheresis (n = 17/74; 23%). Forty-five (61%) patients received second-line immunotherapy (cyclophosphamide, rituximab, or both). At 6 months, 57% of patients had a good neurologic outcome. Independent factors of good neurologic outcome were early (≤8 d after ICU admission) immunotherapy (odds ratio, 16.16; 95% confidence interval, 3.32-78.64; for combined first-line immunotherapy with steroids and intravenous immunoglobulins vs. late immunotherapy), and a low white blood cell count on the first cerebrospinal examination (odds ratio, 9.83 for <5 vs. >50 cells/mm3; 95% confidence interval, 1.07-90.65). Presence of nonneurologic organ failures at ICU admission and occurrence of status epilepticus during ICU stay were not associated with neurologic outcome. CONCLUSIONS: The prognosis of adult patients with anti-NMDAR encephalitis requiring intensive care is good, especially when immunotherapy is initiated early, advocating for prompt diagnosis and early aggressive treatment.

Extended-spectrum beta-lactamase--producing enterobacteriaceae in the intensive care unit: acquisition does not mean cross-transmission.

BACKGROUND: In intensive care unit (ICU), infection and colonization by resistant Gram-negative bacteria increase costs, length of stay and mortality. Extended-spectrum beta-lactamase--producing Enterobacteriaceae (ESBL-E) is a group of pathogens increasingly encountered in ICU setting. Conditions that promote ESBL-E acquisition are not completely understood. The increasing incidence of infections related to ESBL-E and the unsolved issues related to ESBL-E cross-transmission, prompted us to assess the rates of referred and acquired cases of ESBL-E in ICU and to assess patient-to-patient cross-transmission of ESBL-E using a multimodal microbiological analysis. METHODS: During a 5-month period, all patients admitted to a medical ICU were tested for ESBL-E carriage. A rectal swab was performed at admission and then twice a week until discharge or death. ESBL-E strains were analyzed according to antibiotic susceptibility pattern, rep-PCR (repetitive-element Polymerase chain reaction) chromosomal analysis, and plasmid PCR (Polymerase chain reaction) analysis of ESBL genes. Patient-to-patient transmission was deemed likely when 2 identical strains were found in 2 patients hospitalized simultaneously in the ICU. RESULTS: Among the 309 patients assessed for ESBL-E carriage on admission, 25 were found to carry ESBL-E (importation rate: 8%). During follow-up, acquisition was observed among 19 of them (acquisition rate: 6.5%). Using the multimodal microbiological approach, we found only one case of likely patient-to-patient ESBL-E transmission. CONCLUSIONS: In unselected ICU patients, we found rather low rates of ESBL-E referred and acquired cases. Only 5% of acquisitions appeared to be related to patient-to-patient transmission. These data highlight the importance of jointly analyzing phenotypic profile and molecular data to discriminate strains of ESBL-E.

Differential Perceptions of Noninvasive Ventilation in Intensive Care among Medical Caregivers, Patients, and Their Relatives: A Multicenter Prospective Study-The PARVENIR Study.

BACKGROUND: Noninvasive ventilation (NIV) requires a close "partnership" between a conscious patient and the patient's caregivers. Specific perceptions of NIV stakeholders and their impact have been poorly described to date. The objectives of this study were to compare the perceptions of NIV by intensive care unit (ICU) physicians, nurses, patients, and their relatives and to explore factors associated with caregivers' willingness to administer NIV and patients' and relatives' anxiety in relation to NIV. METHODS: This is a prospective, multicenter questionnaire-based study. RESULTS: Three hundred and eleven ICU physicians, 752 nurses, 396 patients, and 145 relatives from 32 ICUs answered the questionnaire. Nurses generally reported more negative feelings and more frequent regrets about providing NIV (median score, 3; interquartile range, [1 to 5] vs. 1 [1 to 5]; P < 0.0001) compared to ICU physicians. Sixty-four percent of ICU physicians and only 32% of nurses reported a high level of willingness to administer NIV, which was independently associated with NIV case-volume and workload. A high NIV session-related level of anxiety was observed in 37% of patients and 45% of relatives. "Dyspnea during NIV," "long NIV session," and "the need to have someone at the bedside" were identified as independent risk factors of high anxiety in patients. CONCLUSIONS: Lack of willingness of caregivers to administer NIV and a high level of anxiety of patients and relatives in relation to NIV are frequent in the ICU. Most factors associated with low willingness to administer NIV by nurses or anxiety in patients and relatives may be amenable to change. Interventional studies are now warranted to evaluate how to reduce these risk factors and therefore contribute to better management of a potentially traumatic experience. (Anesthesiology 2016; 124:1347-59).

Alteration of skin perfusion in mottling area during septic shock.

BACKGROUND: Mottling score has been reported to be a strong predictive factor during septic shock. However, the pathophysiology of mottling remains unclear. METHODS: In patients admitted in ICU for septic shock, we measured on the same area the mean skin perfusion by laser Doppler, the mottling score, and variations of both indices between T1 (6 hours after vasopressors were started) and T2 (24 hours later). RESULTS: Fourteen patients were included, SAPS II was 56 [37-71] and SOFA score at T1 was 10 [7-12]. The mean skin surface area analyzed was 4108 ± 740 mm2; 1184 ± 141 measurements were performed over each defined skin surface area. Skin perfusion was significantly different according to mottling score and decreased from 37 [31-42] perfusion units (PUs) for a mottling score of [0-1] to 22 [20-32] PUs for a mottling score of [2-3] and 23 [16-28] for a score of [4-5] (Kruskal-Wallis test, P = 0.05). We analyzed skin perfusion changes during resuscitation in each patient and together with mottling score variations between T1 and T2 using a Wilcoxon signed-rank test. Among the 14 patients included, mottling score increased (worsened) in 5 patients, decreased (improved) in 5 patients, and remained stable in 4 patients. Baseline skin perfusion at T1 was arbitrarily scored 100%. Mean skin perfusion significantly decreased in all the patients whose mottling score worsened from 100% baseline to 63.2 ± 10.7% (P = 0.001), mean skin perfusion significantly increased in all patients whose mottling score improved from 100% baseline to 172.6 ± 46.8% (P = 0.001), and remained stable in patients whose mottling score did not change (100.5 ± 6.8%, P = 0.95). CONCLUSIONS: We have shown that mottling score variations and skin perfusion changes during septic shock resuscitation were correlated, providing additional evidence that mottling reflects skin hypoperfusion.

Prediction of evolution toward brain death upon admission to ICU in comatose patients with spontaneous intracerebral hemorrhage using simple signs.

The aim of the study was to identify the predictors of brain death (BD) upon admission to the intensive care unit (ICU) of comatose patients with spontaneous intracerebral hemorrhage (ICH). Patients admitted in our ICU from 2002 to 2010 for spontaneous ICH and placed under mechanical ventilation were retrospectively analyzed. Of the 72 patients, 49% evolved to BD, 39% died after withdrawal of life support, and 12% were discharged alive. The most discriminating characteristics to predict BD were included in two models; Model 1 contained ≥3 abolished brainstem responses [adjusted odds ratios (OR) = 8.4 (2.4, 29.1)] and the swirl sign on the baseline CT-scan [adjusted OR = 5.0 (1.6, 15.9)] and Model 2 addressed the abolition of corneal reflexes [unilateral/bilateral: adjusted OR = 4.2 (0.9, 20.1)/8.8 (2.4, 32.3)] and the swirl sign on the baseline CT-scan [adjusted OR = 6.2 (1.9, 20.0)]. Two scores predicting BD were created (sensitivity: 0.89 and 0.88, specificity: 0.68 and 0.65). Risk of evolution toward BD was classified as low (corneal reflexes present and no swirl sign), high (≥1 corneal reflexes abolished and swirl sign), and intermediate. Simple signs at ICU admission can predict BD in comatose patients with ICH and could increase the potential for organ donation.