Safety and systemic consequences of pleurodesis with three different doses of silver nitrate in patients with malignant pleural effusion.

BACKGROUND: Silver nitrate (SN) is an alternative to talc pleurodesis in patients with malignant pleural effusion (MPE). Nevertheless, SN complications have not been thoroughly investigated so far. OBJECTIVE: To evaluate frequent adverse events (AE) of SN treatment at three different doses for pleurodesis in patients with MPE. The secondary objective was to evaluate systemic inflammation, efficacy and quality of life in these patients. METHODS: A double-blind, randomized, clinical trial was conducted in patients with recurrent MPE at a tertiary university hospital. The study patients underwent pleural catheter insertion and were randomly assigned to one of the three pleurodesis groups treated with 30 ml 0.3%, 30 ml 0.5% or 60 ml 0.3% SN. Patients were discharged 3 days after the procedure, and returned to follow-up visits on days 10 and 30. During follow-up, AE, inflammatory markers, quality of life and CT scans were systematically assessed and documented. RESULTS: Sixty patients (11 males and 49 females, median age 62.13 years) were included. Overall, 199 AE were observed, including 23 serious AE. Grade 1/2 metabolic AE, such as increases in creatinine and liver enzymes, were the most frequent. Grade 3/4 hypoxia was observed in 13 patients. Four patients died, 3 due to disease progression and in 1 patient death was possibly related to pleurodesis. C-reactive protein levels increased in a dose-dependent manner and peaked 48 h after pleurodesis. No significant difference was observed among groups regarding quality of life or clinical/radiological recurrence. CONCLUSION: Hypoxia was the most significant AE following SN pleurodesis; mild metabolic events were very common. SN instillation causes substantial dose-dependent systemic inflammatory responses.

VALIDITY AND RELIABILITY OF THE MANCHESTER SCALE USED IN THE ORTHOPEDIC EMERGENCY DEPARTMENT.

OBJECTIVES: To describe the clinical utility of the Manchester triage scale adapted for orthopedic emergency departments and to evaluate its validity in identifying patients with the need for hospital care and its reliability when reproduced by different professionals. METHODS: Five triage flowcharts were developed based on the Manchester scale for the following orthopedic disorders: traumatic injuries, joint pain, vertebral pain, postoperative disorders, and musculoskeletal infections. A series of patients triaged by two orthopedists was analyzed to assess the concordance between the evaluators (reliability) and the validity of the Manchester scale as predictive of severity. RESULTS: The reliability analysis included 231 patients, with an inter-observer agreement of 84% (Kappa = 0.77, p <0.001). The validity analysis included 138 patients. The risk category had a strong association with the need for hospital care in patients with trauma (OR = 6.57, p = 0.001) and was not significant for non-traumatic disorders (OR = 2.42; p = 0.208). The overall sensitivity and specificity were 64% and 76%, respectively. CONCLUSION: The evaluated system presented high reliability. Its validity was adequate, with good sensitivity for identifying patients requiring hospital care among those with traumatic lesions. However, the sensitivity was low for patients with non-traumatic lesions. Level of Evidence III, Retrospective Study.

OBJETIVOS: Descrever a utilização clínica da escala de triagem de Manchester adaptada ao pronto-socorro ortopédico e avaliar sua validade para detectar pacientes com necessidade de cuidados hospitalares e sua confiabilidade quando reproduzida por diferentes profissionais. MÉTODOS: Cinco fluxogramas de triagem foram desenvolvidos com base na escala de Manchester: lesões traumáticas, dor articular, dor vertebral, transtorno pós-operatório e infecção musculoesquelética. Uma série de pacientes triados por dois ortopedistas foi analisada para avaliação da concordância entre os avaliadores (confiabilidade) e sua validade como preditivo de gravidade. RESULTADOS: A avaliação da confiabilidade incluiu 231 pacientes, com concordância inter-observadores de 84% (Kappa = 0,77; p <0,001). A análise da validade incluiu 138 pacientes. A classificação de risco apresentou forte associação com a necessidade de cuidados hospitalares em pacientes com trauma (OR = 6,57; p = 0,001), não sendo significativa nos transtornos não-traumáticos (OR = 2,42; p = 0,208). A sensibilidade geral foi de 64% e a especificidade de 76%. CONCLUSÃO: O sistema avaliado apresentou alta confiabilidade. Sua validade foi adequada, com boa sensibilidade para detectar pacientes com necessidade de procedimentos hospitalares em lesões traumáticas, enquanto a sensibilidade foi baixa em pacientes com lesões não-traumáticas. Nível de Evidência III, Estudo Retrospectivo.

Late failure of posterior fixation without bone fusion for vertebral metastases.

OBJECTIVE: : To verify the frequency of late radiological com-plications in spinal fixation surgeries performed without fu-sion in oncological patients. METHODS: : This is a retrospective analysis analysing failure in cases of non-fused vertebral fixation in an oncology reference hospital between 2009 and 2014. Failure was defined as implant loosening or bre-akage, as well as new angular or translation deformities. RESULTS: : One hundred and five cases were analyzed. The most common site of primary tumor was the breast and the most common place of metastasis was the thoracic spine. The average follow-up was 22.7 months. Nine cases (8%) of failure were reported, with an average time until failure of 9.5 months. The most common failure was implant loosening. No case required further surgery. CONCLUSION: : The occurrence of failure was not different than that reported for fused cases. The time interval until failure was higher than the median of survival of the majority (88%) of cases. Level of Evidence IV, Therapeutic Study.

Validity and reliability of the manchester scale used in the orthopedic emergency department / Validade e confiabilidade da escala de manchester aplicada no pronto-socorro ortopédico

ABSTRACT Objectives: To describe the clinical utility of the Manchester triage scale adapted for orthopedic emergency departments and to evaluate its validity in identifying patients with the need for hospital care and its reliability when reproduced by different professionals. Methods: Five triage flowcharts were developed based on the Manchester scale for the following orthopedic disorders: traumatic injuries, joint pain, vertebral pain, postoperative disorders, and musculoskeletal infections. A series of patients triaged by two orthopedists was analyzed to assess the concordance between the evaluators (reliability) and the validity of the Manchester scale as predictive of severity. Results: The reliability analysis included 231 patients, with an inter-observer agreement of 84% (Kappa = 0.77, p <0.001). The validity analysis included 138 patients. The risk category had a strong association with the need for hospital care in patients with trauma (OR = 6.57, p = 0.001) and was not significant for non-traumatic disorders (OR = 2.42; p = 0.208). The overall sensitivity and specificity were 64% and 76%, respectively. Conclusion: The evaluated system presented high reliability. Its validity was adequate, with good sensitivity for identifying patients requiring hospital care among those with traumatic lesions. However, the sensitivity was low for patients with non-traumatic lesions. Level of Evidence III, Retrospective Study.

RESUMO Objetivos: Descrever a utilização clínica da escala de triagem de Manchester adaptada ao pronto-socorro ortopédico e avaliar sua validade para detectar pacientes com necessidade de cuidados hospitalares e sua confiabilidade quando reproduzida por diferentes profissionais. Métodos: Cinco fluxogramas de triagem foram desenvolvidos com base na escala de Manchester: lesões traumáticas, dor articular, dor vertebral, transtorno pós-operatório e infecção musculoesquelética. Uma série de pacientes triados por dois ortopedistas foi analisada para avaliação da concordância entre os avaliadores (confiabilidade) e sua validade como preditivo de gravidade. Resultados: A avaliação da confiabilidade incluiu 231 pacientes, com concordância inter-observadores de 84% (Kappa = 0,77; p <0,001). A análise da validade incluiu 138 pacientes. A classificação de risco apresentou forte associação com a necessidade de cuidados hospitalares em pacientes com trauma (OR = 6,57; p = 0,001), não sendo significativa nos transtornos não-traumáticos (OR = 2,42; p = 0,208). A sensibilidade geral foi de 64% e a especificidade de 76%. Conclusão: O sistema avaliado apresentou alta confiabilidade. Sua validade foi adequada, com boa sensibilidade para detectar pacientes com necessidade de procedimentos hospitalares em lesões traumáticas, enquanto a sensibilidade foi baixa em pacientes com lesões não-traumáticas. Nível de Evidência III, Estudo Retrospectivo.

Late failure of posterior fixation without bone fusion for vertebral metastases

ABSTRACTOBJECTIVE: To verify the frequency of late radiological com-plications in spinal fixation surgeries performed without fu-sion in oncological patientsMETHODS: This is a retrospective analysis analysing failure in cases of non-fused vertebral fixation in an oncology reference hospital between 2009 and 2014. Failure was defined as implant loosening or bre-akage, as well as new angular or translation deformitiesRESULTS: One hundred and five cases were analyzed. The most common site of primary tumor was the breast and the most common place of metastasis was the thoracic spine. The average follow-up was 22.7 months. Nine cases (8%) of failure were reported, with an average time until failure of 9.5 months. The most common failure was implant loosening. No case required further surgeryCONCLUSION: The occurrence of failure was not different than that reported for fused cases. The time interval until failure was higher than the median of survival of the majority (88%) of cases. Level of Evidence IV, Therapeutic Study.

Conduta cirúrgica do derrame pleural parapneumônico em adultos / Surgical treatment for parapneumonic pleural effusion in adults

Cerca de 40% dos pacientes portadores de pneumoniadesenvolverão derrame pleural parapneumônico (DPP), o que está associado a considerável morbimortalidade. O DPP possui três fases: exsudativa, fibrino-purelenta e de organização, que representam o progresso da doença. Apesar das várias opções de tratamento existentes, a conduta terapêutica não está bemestabelecida, visto que para cada fase a eficácia de cada método é variável. Procurou-se, nesta revisão de literatura, analisar as diversas opções disponíveis e os critérios que determinam suaindicação. De modo geral, o uso da toracocentese terapêutica deve ser restrito a casos de DPP simples pequenos, que ocupam até metade do hemitórax. Já a toracostomia com drenagem fechada apresenta indicação mais ampla: DPP simples volumosos ouDPP complicados e empiema livres na cavidade. Para tais casos com múltiplas loculações, a decorticação vídeo-assistida (VATS) constitui o tratamento ideal. Por fim, a decorticação por toracotomia está indicada em casos mais crônicos com encarceramentopulmonar, embora existam evidências de que a VATS também pode ser empregada nesses casos e, em caso de necessidade, convertida no intra-operatório para toracotomia. Em relação aos agentes fibrinolíticos, os dados existentes sobre sua eficácia sãocontraditórios, de modo que seu uso ainda é restrito...

At least, 40% of all patients with pneumonia will have a parapneumonic pleural effusion (PPE), which is associated to considerable morbidity and mortality. The PPE has three phases: exsudative, fibrinopurulent and organizing, which represent the development of the disease. Despite the great number of therapeutic methods, the PPE management is not well established, because for each phase the success rate of each technique is variable. The objective of this review of literature was to analyzeeach method available and its indications. Briefly, the use oftherapeutic thoracocentesis is restricted to small simple PPE, which are limited to half of the hemithorax. On the other hand, tube thoracostomy has a wider indication: large simple effusions and free-flowing complicated PPE or empyema. For multiloculated cases, the Video-assisted Thoracoscopic Surgery (VATS) is recommendable. Finally, the decortication through thoracotomy isindicated for chronic cases with lung entrapment, although there areevidences that VATS can be used too and, if needed, converted tothoracotomy in the operation room. Regarding thrombolytics, the data available about its efficacy is controversial, thereby its use isstill very restricted...