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The number of patients requiring admission in intensive care units and prolonged invasive mechanical ventilation (MV) has increased significantly during the coronavirus disease 2019 (COVID-19) pandemic. Tracheoesophageal fistula (TEF) following prolonged invasive MV is a rare condition. Numerous COVID-19 pathophysiological mechanisms and treatment-related effects might support the increase of tracheal complications in this subgroup of patients. We report a case of TEF in a COVID-19 patient submitted to prolonged invasive MV and discuss its diagnosis and management.

The temozolomide protocol established in 2005 increased overall survival rates in patients with glioblastoma. It defined a treatment period of 6 months, but most neuro-oncological centers prescribe more than this, reaching up to 3 years of continuous therapy. The objective of this paper was to compare duration of treatment in groups of patients and analyze the overall survival in each group. Retrospectively, 54 patients were evaluated with glioblastoma operated on from 2004 to 2009. All data were statistically analyzed using Kaplan-Meier curves, ANOVA test, multivariate logistic regression models and Pearson´s correlation. Analyses consisted on age, gender, Karnofsky Performance Scale (KPS) at diagnosis, side and localization of tumor, grade of surgical removal, period of use of temozolomide until recurrence, progression-free survival, KPS after recurrence and overall survival. According to uni and multi-varied analysis there was no statistic significant correlation between survival and age < 45, gender, KPS at diagnosis, and grade of resection. The overall survival in 6, 12, 18 and 24 months were 96.3%, 72.6%, 58.1% and 43.5% respectively. The length of treatment with temozolomide before recurrence showed strong positive correlation (r=0.66) with survival up to 15 months. Also, a correlation (r=0.64) between length of use of temozolomide and progression free-survival was found. Patients receiving treatment with temozolomide presented longer survival when compared with those not treated with it. Longer survival (p=0.04) was observed in those treated more than 12 months. This series could clearly show longer survival in patients treated with 15-cicles over patients treated with 6 or 12-cicles.

Trigeminal neuralgia in general is a disease of the elderly. Rarely, the disease presents during childhood. Therefore we sought to explore the role of vascular compression in pediatric patients with medically refractory trigeminal neuralgia. A case of venous compression related to trigeminal neuralgia is presented in a 17-year-old girl. Upper petrous vein was found to be related to aneurovascular conflict with unusual response to neurovascular decompression with complete resolution of symptoms in postoperativeperiod.

Background: Chondromas are benign tumors with slow growth pattern that may develop along the body. Intracranial chondromas are rare, 0.1 to 0.3% of all intracranial tumors, usually in parasellar region. Few papers reported cavernous sinus chordomas. Case Description: We reported two cases of cavernous sinus chondromas. Two patients presented diplopia, one facial hypoesthesia and one presented extension to the petroclival region. Surgical approaches were frontotemporal combining presigmoid/middle fossa. Literature was reviewed concerning incidence, clinical symptoms, treatment and outcome. Both cases achieved complete tumor resection without postoperative complication. Preoperative deficits improved. Literature review confirms their rarity, clinical symptoms are related to deficits of cranial nerves passing through the cavernous sinus and cure can be achieved through radical surgical removal. Conclusion: Cavernous sinus chondromas are rare benign lesions with insidious growth. Adequate knowledge of cavernous sinus anatomy, microsurgical experience, intraoperative monitoring of cranial nerves and neuronavigation allows radical tumor removal with no additional neurological deficits.

Objectives: To present a technique of internal auditory canal (IAC) reconstruction using a pediculated dural flap, after removal of vestibular schwannomas through the retrosigmoid craniotomy. Methods: From a series of 213 patients with vestibular schwannomas operated between January 2008 and March 2016 through the retrosigmoid-transmeatal approach, 183 underwent reconstruction of the internal auditory canal with a pediculated dural flap. The IAC was drilled towards the fundus preserving the labyrinthine structures. The dura mater over the IAC was dissected from the bone, remaining pediculated at the entrance of the jugular foramen. This dural flap was used to cover the cranial nerves inside the IAC after tumor removal. Opened mastoid cells and the IAC were closed with muscle or fat grafts and fibrin glue. Results: Reconstruction of the IAC using the described technique was possible in in 183 cases. Fifteen patients (6.8%) developed postoperative cerebrospinal fluid (CSF) leakage and seven patients required reoperation (3.2%) to close the fistulae. Postoperative magnetic resonance imaging (MRI) examinations showed the presence of CSF within the IAC around the preserved cranial nerves. Conclusions: This technique of IAC reconstruction after surgical resection of vestibular schwannomas may avoid scar and adhesion of muscle or fat tissue with preserved cranial nerves, allowing CSF enter inside the IAC. It may help to identify tumor remnants and/or recurrences in postoperative MRI examinations. Comparative studies are needed to evaluate if this technique improves postoperative hearing and facial nerve outcomes.

Introduction: Resection of gliomas in eloquent areas such as motor and supplementary motor areas has always been a main challenge for the surgeon due to the risk of severe neurological sequelae. An important tool used during the procedure to avoid postoperative deficits is the intraoperative cortical stimulation of eloquent areas as a safe option of functional area mapping. Methods: In this study, authors examined 50 patients with gliomas located in the motor and supplementary motor area that have undergone surgery with cortical stimulation, using clinical assessment of muscle strength in the pre- and immediate postoperative assessments and three months after surgery as parameters. Results: There was significant difference (p

Levels of carbohydrate antigen 19-9 (CA19-9) in metastatic pancreatic cancer are used in daily practice as a marker of response to chemotherapy. The association between CA19-9 levels and mortality remains uncertain. This study sought to determine the most accurate level of CA19-9 associated with early mortality, both at diagnosis and during the course of metastatic disease. This research is a retrospective analysis of 64 patients with metastatic adenocarcinoma of the pancreas evaluated from January 2010 to December 2015. A receiver-operating characteristic (ROC) curve analysis was performed to evaluate the CA19-9 value and the association with early death (death within 2 months after diagnosis of advanced disease). The survival analysis was estimated by the Kaplan-Meier method, and variables of interest were assessed by proportional hazards regression Cox models. The mortality rate was 92.2%, and the estimated median survival was 11.0 months. For the ROC curve analysis of initial CA19-9, an area under the curve of 0.868 (95% confidence interval 0.782 to 0.954) was obtained; the cutoff of 2504 U/ml had a sensitivity of 100% and specificity of 82.8% for early death. The effect of initial CA19-9 and chemotherapy contributed independently to the survival time, and every increase of 1000 CA19-9 units increased the risk of death by 9% (p = 0.0003). CA19-9 levels in advanced pancreatic adenocarcinoma are associated independently with worse prognosis and early death. CA19-9 levels could be considered as a stratification factor for future clinical trials.

Summary According to our research, this is the first case described in the literature of spontaneous intracranial epidural hematoma secondary to the use of Xareltor. Spontaneous intracranial epidural hematomas are rarely described in the literature. They are associated with infectious diseases of the skull, coagulation disorders, vascular malformations of the dura mater and metastasis to the skull. Long-term post-marketing monitoring and independent reports will probably detect the full spectrum of hemorrhagic complications of the use of rivaroxaban.

Introduction: Vascular access (VA) in hemodialysis (HD) is essential to end-stage renal disease (ESRD) patients survival. Unfortunately, after some years in HD program, a significant number of patients may develop VA failure for many reasons. In this situation, arterial venous fistula (AVF) confection or catheters placement in traditional vascular sites (jugular, femoral or subclavian) are not feasible. In this scenario, translumbar tunneled dialysis catheter (TLDC) may be a salvage option. Objectives: To describe placement technic, complications, and patency of 12 TLDC. Methods: A retrospective study was performed to analyze 12 TLDC placement in an angiography suite using fluoroscopic guidance at the University Hospital of the Rio Grande do Norte Federal University from January 2016 to October 2017. The data collected of the total procedures performed consisted of demographic characteristics, success rates, observed complications, patient survival, and catheter patency. Results: All 12 TLDC were placed with success; there were only 2 significant periprocedure complications (major bleeding and extubation failure); 41.6% of patients presented a catheter-related first infection after 98 ± 72.1 (6-201) days, but catheter withdrawal was not necessary, mean total access patency was 315.5 (range 65 - 631) catheter-days, and catheter patency at 3, 6 and 12 months was 91 %, 75%, and 45%. Conclusion: TLDC is an option for patients with VA failure, improving survival and acting as a bridge for renal transplantation. Resumo Introdução: O acesso vascular (AV) para hemodiálise (HD) é crucial para os pacientes portadores de doença renal crônica (DRC) estágio V. Infelizmente, com o passar dos anos, um percentual não desprezível desses enfermos evolui para falência de AV por diversos motivos, o que impossibilita a confecção de novas fístulas arteriovenosas (FAV) ou o implante de cateteres venosos centrais nos sítios de punções tradicionais. Nesse cenário, o implante de cateteres translombares para hemodiálise (CTLHD) em veia cava inferior ganha destaque como medida salvadora. Objetivos: Relatar uma série de 12 casos de implante de CTLHD, sua técnica de implante, patência e complicações. Métodos: Estudo retrospectivo que analisou 12 implantes de CTLHD por radiologista intervencionista no setor de hemodinâmica do Hospital Universitário da Universidade Federal do Rio Grande do Norte (UFRN), no período de janeiro/2016 a outubro/2017. Os dados coletados consistiram em: características demográficas da população estudada, taxa de sucesso, complicações observadas, sobrevida dos pacientes, patência do cateter e desfechos clínicos. Resultados: Todos os 12 CTLHD foram implantados e utilizados com sucesso; ocorreram apenas 2 complicações associadas ao procedimento (sangramento e falha na extubação); 41,6% dos pacientes apresentaram infecção relacionada ao cateter após 98 ± 72,1 dias (6-201 dias), mas não houve necessidade de remoção; e a patência foi de 315,5 cateteres-dia (65-631 dias). Conclusão: O CTLHD é uma opção para pacientes com falência de acesso vascular, prolongando a sobrevida dos pacientes e atuando como ponte para o transplante renal.

Vestibular schwannomas (VS) are the most common lesions of cerebellopontine angle (CPA) corresponding to 76-91 % of the cases. Usually, these lesions present typical CT and MRI findings. Non-schwannomatous tumors restricted to the internal auditory meatus (IAM) are rare and their preoperative radiological diagnosis may be difficult. This article describes nine surgically treated intrameatal non-schwannomatous lesions (NSL) and reviews the literature. In the last 16 years, a total of 471 patients with diagnosis of VS were operated on in our department. Preoperatively, 42 patients had diagnosis of intrameatal schwannomas, but surgery revealed in nine cases NSL (3 meningiomas, 3 arachnoiditis/neuritis, 1 cavernoma, 1 vascular loop, and 1 arachnoid cyst). Most frequent symptoms presented by patients with NSL were hearing loss 89 % (8/9) of patients, tinnitus 78 % (7/9), and vertigo 33 % (3/9). Almost all lesions (8/9) presented MRI findings of isointense signal in T1W with contrast enhancement. The only exception was the arachnoid cyst with intracystic bleeding, which was hyperintense in T1W that is not enhanced with contrast. This series shows an occurrence of 21.4 % of non-schwannomatous tumors in 42 cases of lesions restricted to the IAM. Whenever a solely intrameatal enhanced tumor is detected, it is necessary to think about other diagnostic possibilities rather than VS. Therapeutic management may be changed, specially if radiosurgical treatment is considered.

PURPOSE: This paper proposes a practical model of microneurosurgical training using a nonliving swine head. METHODS: Fresh porcine heads were obtained from butchery and dissected at our Laboratory of Microsurgery. Brain and skull base surgery were trained under microscopic magnification. RESULTS: Several neurosurgical procedures could be simulated in the nonliving pig model, including transcallosal approach to the lateral ventricle, lateral sulcus and middle fossa dissection, and posterior fossa surgery. CONCLUSION: The swine model perfectly simulates standard microneurosurgical procedures, and is a useful tool for developing and refining surgical skills.

Objective: Evaluate clinical outcome of dorsal root ganglia (DRG) pulsed radiofrequency (PRF) treatment in neuropathic pain of patients with radiculopathy regarding improvement of pain and degree of patients’ satisfaction. Method: Forty-five procedures in cervical and lumbossacral spine. Data collected by phone call interviews (independent researcher). Evaluation done after one month and at minimum three months follow-up. Analyzed data included objective and subjective improvement, and degree of satisfaction. Results: Outcome much better in 31%, 36% better, 24% unchanged, 9% worse. At initial evaluation, relief was rated: 24% excellent, 16% good, 27% moderate, 33% poor. At late evaluation, 27% excellent, 18% good, 7% moderate, 49% poor. Degree of satisfaction was high (82% of patients reported they certainly or probably would repeat the procedure). Conclusion: PRF was effective and safe in selected patients. Most patients were satisfied and would repeat/recommend the procedure.

OBJETIVO: Avaliar a resposta da embolização arterial tireoidiana como terapêutica para o hipertireoidismo primário. MATERIAIS E MÉTODOS: Cinco mulheres com falha ao tratamento farmacológico com tionamida foram submetidas a vaso-oclusão em três artérias dominantes tireoidianas (avaliadas por ultrassonografia Doppler e arteriografia) e acompanhadas até 8 semanas após o procedimento (três acompanhadas até 16 semanas) com ultrassonografia Doppler, calcemia, função tireoidiana e controle clínico. RESULTADOS: Nenhuma alcançou remissão permanente de doença após 8 semanas. Houve recidiva de hipertireoidismo em 24 semanas, mesmo com redução do volume tireoidiano de 49,5 ± 15,2% em 16 semanas. Não encontramos complicações, mas radioiodo foi necessário após 24 semanas em três das pacientes acompanhadas. CONCLUSÃO: Nas pacientes que concluíram o protocolo, a vaso-oclusão arterial com polivinil álcool nas três artérias dominantes permitiu redução volumétrica do bócio, entretanto, foi ineficiente em controlar o hipertireoidismo. OBJECTIVE: To evaluate the therapeutic response to thyroid arterial embolization for primary hyperthyroidism. MATERIALS AND METHODS: Five women whose pharmacological treatment with thionamides failed to control Graves' disease were submitted to embolization of three dominant thyroid arteries (following assessment with ultrasound Doppler and arteriography) and followed-up at the 1st, 8th and 16th weeks after the procedure, with ultrasound Doppler, calcium blood test, thyroid function test and clinical examination. Three of the patients completed 16-week follow-up. RESULTS: None of the patients achieved permanent remission after 8 weeks. Disease recurrence was observed at the 24th week, despite the decrease in thyroid volume (49.5 ± 15.2%) observed at the 16th week. Complications were not observed, but radioiodine therapy was required for three of the patients followed-up. CONCLUSION: Embolization of three dominant thyroid arteries with polyvinyl alcohol allowed reduction in goiter volume in the three patients who completed the protocol, but was not effective to control hyperthyroidism.

The suboccipital lateral or retrosigmoid approach is the main neurosurgical approach to the cerebellopontine angle (CPA). It is mainly used in the treatment of CPA tumors and vascular decompression of cranial nerves. A prospective study using navigation registered with anatomical landmarks in order to identify the transverse and sigmoid sinuses junction (TSSJ) was carried out in a series of 30 retrosigmoid craniotomies. The goal of this study was to determine the accuracy of this navigation technique and to establish the relationship between the location of the asterion and the TSSJ. From March through November 2008, 30 patients underwent a retrosigmoid craniotomy for removal of CPA tumors or for surgical treatment of neurovascular syndromes. Magnetic resonance imaging (MRI) T1 sequences with gadolinium (FSPGR with FatSst, 1.5 T GE® Signa) and frameless navigation (Vector vision®, Brainlab®) were used for surgical planning. Registration was performed using six anatomical landmarks. The position of the TSSJ indicated by navigation was the landmark to guide the craniotomy. The location of the asterion was compared with the position of the TSSJ. After craniotomy, the real TSSJ position was compared with the virtual position, as demonstrated by navigation. There were 19 cases of vestibular schwannomas, 5 petroclival meningiomas, 3 trigeminal neuralgias, 1 angioblastoma, 1 epidermoid cyst and 1 hemifacial spasm. In all cases, navigation enabled the location of the TSSJ and the emissary vein, with an accuracy flaw below 2 mm. The asterion was located directly over the TSSJ in only seven cases. One patient had a laceration of the sigmoid sinus during the craniotomy. Navigation using anatomical landmarks for registration is a reliable method in the localization of the TSSJ for retrosigmoid craniotomies and thereby avoiding unnecessary sinus exposure. In addition, the method proved to be fast and accurate. The asterion was found to be a less accurate landmark for the localization of the TSSJ using navigation.

The study of the Resource-Based View as a source of competitive advantage in information technology organizations participating in Local Production Software is a little explored in theoretical and empirical studies theme. Competitive advantage in an unstable organizational environment as IT is addressed in research on dynamic capabilities that assist in the construction of this process. The aim of this study is to characterize the sources of sustainable competitive advantages and temporal, classified under their tangibility and dynamism of the features and capabilities of the organization and influence of APL has this construction. The result of the analysis of this case study is that there is evidence that the resources and capabilities that generate potential sustainable competitiveness: Learning, influenced by APL and reputation, partly influenced by APL. Potential temporal competitiveness: Training, influenced by participation in APL. The search strategy used was a qualitative case study and three organizations were chosen cases of Technology Information APL participants IGUASSU IT. Full Paper PDF: http://www.contecsi.fea.usp.br/envio/11contecsi-files/papers/1014/submission/director/1014-2584-1-DR.pdf

According to its location, the surgical treatment of intracranial meningioma can be of considerable challenge for the neurosurgeon. The aplication of neuronavigation for meningioma surgery is commonly related to tumor localization. However, this concept is applied only to convexity located lesions. Its usage can range from a simple craniotomy flap localization to a deep brain tumor resection respecting tract fibers, eloquent areas and neurovascular structures. In some cases, neuronavigation may not be necessary, but, ifavaliable, it should promotes a safer surgery, as it has yet to become an integral part of intracranial procedures. The aim of this article is show how to enhance the neuronavigation usage for meningioma surgery.

The objective of this study was to the evaluate physiological, hematological and biochemical parameters of eventing horses fed diets containing soybean oil and submitted to physical effort tests. Twelve horses were used in a completely randomized design with two diets and six replications. The diets used were: diet without soybean oil inclusion (control) and diet with inclusion of 10% soybean oil. The experiment lasted 82 days, with three exercise tests: at the beginning, 60th and 82th day of the experiment. There were five data collections for each test: before the test with the horses at rest, immediately after the test, and at 10, 20 and 120 minutes after each test. Body temperature and rate heart were taken and blood samples were collected to evaluate hematological and biochemical variables.The mean values of the physiological, metalogical and biochemical parameters were submitted to non-parametric analysis.The inclusion of soybean oil only altered the γ-glutamyltransferase (GGT) and creatinine concentration in function time of intake of the diet. There was effect of trainings time on the horses conditioning that improved with reduction in the lactate concentration while the glucose concentration increased at the last exercise test. Objetivou-se avaliar os parâmetros fisiológicos, hematológicos e bioquímicos de equinos de concurso completo de equitação consumindo dieta contendo óleo de soja e submetidos a testes de esforço físico. Foram utilizados 12 equinos em delineamento experimental inteiramente casualizado, com duas dietas e seis repetições. As dietas utilizadas foram: dieta sem inclusão de óleo de soja (controle); dieta com inclusão de 10% de óleo de soja. O ensaio teve duração de 82 dias e incluiu três testes de esforço físico: ao início, no 60º e no 82º dia. Em cada teste, foram realizadas cinco coletas de dados: antes do teste com os animais em repouso; imediatamente após o teste; e 10, 20 e 120 minutos após os testes. Foram avaliadas a temperatura corporal e a frequência cardíaca e realizadas coletas de amostras de sangue para análises hematológicas e bioquímicas. Os valores médios dos parâmetros fisiológicos, hematológicos e bioquímicos foram submetidos à análise não-paramétrica. Somente ao longo do tempo de consumo das dietas, a inclusão do óleo de soja somente alterou a concentração de γ-glutamil transferase (GGT) e creatinina. O tempo de treinamento físico tem efeito no condicionamento dos equinos, que melhora com a redução da concentração de lactato, e na concentração de glicose, que aumentou no teste de esforço físico.

The fuzzy clustering proportional membership (FCPM) proposes a model of how data are generated from a cluster structure to be identified. Cluster prototypes and membership functions are meaningful in the context of the model. In particular, the membership of an entity to a cluster expresses the proportion of the cluster's prototype reflected in the entity (proportional membership). We explore the notion of proportional membership and compare it against the fuzzy c-means (FCM) distance membership. The ability of FCPM to reveal the underlying clustering model of data has been studied and a comparison with FCM had also been performed.

The goal of this paper is to further investigate the extreme behaviour of the fuzzy clustering proportional membership model (FCPM) in contrast to the central tendency of fuzzy c-means (FCM). A data set from the field of psychiatry has been used for the experimental study, where the cluster prototypes are indeed extreme, expressing the concept of 'ideal type'. While augmenting the original data set with patients bearing less severe syndromes, it is shown that the prototypes found by FCM are changed towards the more moderate characteristics of the data, in contrast with the almost unchanged prototypes found by FCPM, highlighting its suitability to model the concept of 'ideal type'.

Several information theory based measures have been used in machine learning. Using the definition of the Kullback-Leibler entropy, this paper presents a new measure for clustering objects — the attribute redundancy measure. First, an introduction to clustering is made, with its interpretation from the machine learning point of view and a classification of clustering techniques pointed out. Then, a description of the use of information theory based measures in machine learning, both in supervised and in unsupervised learning is made, including the application of the mutual information. Next, the new measure is presented, highlighting its ability to capture relations between attributes and outlining its closeness to other concepts of information theory. Finally, and a genetic algorithm as the search procedure to find the best clustering, a comparison between the attribute redundancy measure and the mutual information is made.

The general building contractor is presented with an information model as an approach for deriving a high-level work plan of construction activities applied to road building. Road construction activities are represented in a Road Plan Model (RPM), which is modeled in the ISO standard STEP/EXPRESS and adopts various concepts from the GARM notation. The integration with the preceding road design stage and the succeeding phase of resource scheduling is discussed within the framework of a Road Construction Model. Construction knowledge is applied to the road design and the terrain model of the surrounding road infrastructure for the instantiation of the RPM. Issues regarding the implementation of a road planner application supporting the RPM are discussed.

Due to the complexity of underwater transients and background interference, model based approaches to transient detection/classification are often not practical. This has motivated an interest for data-driven, model-free methods. One such method was presented by Jones and Sayeed (see Proceedings of the 1995 IEEE International Conference on Acoustics, Speech and Signal Processing CASSP 95, Detroit, MI, p.1033-1036) and modified by Oliveira and Barroso (see Proc. of MTS/IEEE Oceans 2000, August 2000), where it was applied to the detection of underwater transients. We extend that approach, to allow its use in the more demanding environment of a brown water environment, where background noise is constituted by a multitude of different interferences, non-white, and highly non-stationary. Also, the assumption of linear separability amongst the transients and the background noise in the time-frequency or related domains will be discarded, leading to the use of an additional classifier stage. A technique to minimize the number of prototypes on this classifier is presented. The developed methods are used to detect and classify real underwater transients, recorded off the Portuguese coast. Estimation of the overall error rate of the method is obtained using cross-validation with the available data set, showing that these methods can effectively be used in real environment situations.