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A esofagectomia é o tratamento curativo do câncer de esôfago não metastático atualmente. Contudo ainda há falta de evidências fiéis que mostrem uma diferença significativa entre as técnicas cirúrgicas e permanece a controvérsia sobre a localização anatômica ideal da anastomose esofagogástrica, intratorácica ou cervical. O objetivo desse estudo foi avaliar a influência do local da anastomose, cervical ou torácica, nas complicações operatórias e mortalidade da esofagogastrectomia com linfadenectomia em dois campos.

Objectives: the surgical approach persists as the main treatment for esophageal cancer. This study compares the patients of the same institution over time at three different times. Methods: this is a retrospective, observational, descriptive study comparing the surgical outcomes obtained by the Division of Surgical Oncology of Erasto Gaertner Hospital. The sample was divided into Period 1 (1987-1997), Period 2 (1998-2003) and Period 3 (2007-2015). Survival rates and disease-free survival were estimated by the Kaplan-Maier method. Survival predictors were identified with Cox regression. ANOVA test was used for comparison between groups. Data were analyzed with SPSS 25.0 and STATA 16, and p

Objectives. Endoscopic gastrostomy occasionally presents limitations such as costs, availability of equipment and special materials, and difficult access to the gastric cavity in the setting of obstructive esophageal tumors. Open jejunostomies present high rates of postoperative complications and limited capacity for abdominal evaluation due to reduced incision size. Thus, to reduce procedure-related complications and overall costs and provide a thorough intraoperative evaluation of the peritoneal cavity, we present the following simplified technique. Methods. Video-assisted jejunostomy in ten steps. Results. The use of this Video-assisted laparoscopic technique proves to be a safe, viable alternative, with cost reduction, decreased use of disposable materials, shortened operative time, and accelerated recovery, in addition to increased technical ease and wide applicability across a variety of hospital settings.

Hepatocellular carcinoma (HCC) is the most frequent primary malignant liver tumor, with more than 800,000 new cases diagnosed each year and with high mortality, ranking fourth in the world in cancer deaths. The worst prognosis is related to the late diagnosis, in which the tumor is at an advanced stage and curative treatments are not efficient in terms of increasing overall survival. Currently, screening and monitoring tests based on current guidelines have limited accuracy, which points to the need for the development of new biomarkers that improve HCC detection as well as its early diagnosis. This review will discuss the five phases of development of a biomarker, from its discovery to its application in clinical practice, and indicate the main biomarkers per development phase. Potential emerging technologies such as "Radiomics", "Proteomics" and "Metabolomics" will also be discussed, which should serve as tools for the elucidation of tumor heterogeneity, as well as provide data for future studies on HCC biomarkers.

Background Hepatic metastasis are frequent and liver resection may be an option for some cases, despite the high complexity of the procedure and the possibility of postoperative complications. Methods This retrospective comparative descriptive study aims to evaluate a series of 86 consecutive liver resections (LRs) performed for the treatment of metastatic liver tumors, comparing the results between patients undergoing major and minor LR. All patients submitted to LR from October 2010 to July 2015 at the Erasto Gaertner Hospital in Curitiba-PR were included. Quantitative numerical variables were analyzed with the Student t-test. The nonparametric Mann–Whitney U test was used for numerical variables of non-normal distribution. Categorical variables were analyzed with the Chi-square test with Fisher's correction. The data were analyzed with the SPSS 23.0 and STATA 15 programs, being p Results Eighty-six LR were performed, 56 cases by colorectal metastasis. The major LR corresponded to 68 cases, with 13.2% of Clavien-Dindo III–V complications and 2.9% of reoperation rate. Eighteen minor LR were performed and one patient had a postoperative complication requiring reoperation. Conclusion Preoperative elevation of transaminases and jaundice negatively influence surgical outcomes in patients undergoing LR. Tumors greater than 3 cm presented worse postoperative survival. Major LR did not significantly increase the surgical morbidity rate. Institutional Review Board registration 1.122.319/2015

Quality is a term used by various specialists, from different perspectives, having as a common point to identify focuses that promote their development in institutional management. Quality processes allow us to improve assistance, reducing complication and death rates and reducing costs. Currently, the positive experience of the patient is highly valued and should be sought by all institutions. The benefits of quality procedures are extensive. There is evidence of lower complication and mortality rates, cost reduction, uniformity of care, improved communication and opportunity for health education. There is a need for financial investment by the institutions, but they can be converted in the future. The idea that these are just bureaucratic steps must be fought because individualistic attitudes are no longer part of safe medicine. The success of a quality process requires interdisciplinarity, integration with quality offices for effective communication. The implementation of feasible attitudes should be sought, with a high adherence rate to seek patient satisfaction and safety. We will address historical aspects, the requirements for the implementation of a quality program, the concepts of indicators and the aspects that influence the quality in surgery, in addition to presenting benefits that such a program can offer to the surgeon and the institution.

Objective: to compare the acquisition and retention of knowledge about surgical cricothyroidostomy by the rapid four-step technique (RFST), when taught by expository lecture, low fidelity and high-fidelity simulation models. Methods: ninety medical students at UFPR in the first years of training were randomized assigned into 3 groups, submitted to different teaching methods: 1) expository lectures, 2) low-fidelity simulator model, developed by the research team or 3) high-fidelity simulator model (commercial). The procedure chosen was surgical cricothyroidostomy using the RFST. Soon after lectures, the groups were submitted to a multiple-choice test with 20 questions (P1). Four months later, they underwent another test (P2) with similar content. Analysis of Variance was used to compare the grades of each group in P1 with their grades in P2, and the grades of the 3 groups 2 by 2 in P1 and P2. A multiple comparisons test (post-hoc) was used to check differences within each factor (test and group). Statistical significance was considered when p0.05). Conclusions: the simulation of low fidelity model was more effective in learning and knowledge retention, being feasible for RFST cricothyroidostomy training in inexperienced students. RESUMO Objetivo: comparar a aquisição e retenção de conhecimento, sobre cricotireoidostomia cirúrgica pela técnica rápida de quatro tempos (TRQT), quando ensinada por aula expositiva, simulação de baixa fidelidade e de alta fidelidade. Métodos: noventa alunos de medicina da UFPR dos primeiros anos foram randomizados em 3 grupos: 1) aula expositiva, 2) simulador de baixa fidelidade, ou 3) simulador de alta fidelidade (comercial). O tema exposto foi a cricotireoidostomia cirúrgica pela técnica rápida de quatro tempos (TRQT). Logo após as aulas, os grupos foram submetidos a uma prova de múltipla escolha com 20 questões (P1). Quatro meses após, realizaram uma outra prova (P2), com conteúdo similar. Análise de Variância foi usada para comparar as notas de cada grupo na P1 com suas notas na P2, e as notas dos 3 grupos de 2 a 2 na P1 e na P2. Utilizou-se um teste de comparações múltiplas (post-hoc) para verificar diferenças dentro de cada fator (prova e grupo). Considerou-se significância estatística quando p0,05). Conclusão: a simulação de baixa fidelidade foi mais eficaz no aprendizado e na retenção de conhecimento, sendo viável para o treinamento de cricotireoidostomia TRQT em alunos inexperientes.

With the expansion of robotic surgical procedures, the acquisition of specific knowledge and skills for surgeons to reach proficiency seems essential before performing surgical procedures on humans. In this sense, the authors present a proposal to establish a certification based on objective and validated criteria for carrying out robotic procedures. A study was carried out by the Committee on Minimally Invasive and Robotic Surgery of the Brazilian College of Surgeons based on a reviewing strategy of the scientific literature. The study serves as a reference for the creation of a standard for the qualification and certification in robotic surgery according to a statement of the Brazilian Medical Association (AMB) announced on December 17, 2019. The standard proposes a minimum curriculum, integrating training and performance evaluation. The initial (pre-clinical) stage aims at knowledge and adaptation to a specific robotic platform and the development of psychomotor skills based on surgical simulation. Afterwards, the surgeon must accompany in person at least five surgeries in the specialty, participate as a bedside assistant in at least 10 cases and perform 10 surgeries under the supervision of a preceptor surgeon. The surgeon who completes all the steps will be considered qualified in robotic surgery in his specialty. The final certification must be issued by the specialty societies affiliated to AMB. The authors conclude that the creation of a norm for habilitation in robotic surgery should encourage Brazilian hospitals to apply objective qualification criteria for this type of procedure to qualify assistance. RESUMO Com a expansão da realização de procedimentos cirúrgicos robóticos, a aquisição de conhecimentos e habilidades específicas para que o cirurgião alcance proficiência antes de realizar procedimentos cirúrgicos em humanos torna-se fundamental. Neste sentido, os autores apresentam uma proposta de estabelecimento de uma certificação baseada em critérios objetivos e validados para a realização de procedimentos robóticos. Um estudo foi executado pela Comissão de Cirurgia Minimamente Invasiva e Robótica do Colégio Brasileiro de Cirurgiões baseado em uma estratégia de revisão da literatura científica. O estudo serve de referência para a criação de uma normativa para a habilitação e certificação em cirurgia robótica de acordo com comunicado da Associação Médica Brasileira anunciado em 17 de dezembro de 2019. A normativa propõe um currículo mínimo, integrando treinamento e avaliação de desempenho. A etapa inicial (pré-clínica) visa o conhecimento e adaptação a uma plataforma robótica específica e o desenvolvimento de habilidades psicomotoras baseada em simulação cirúrgica. Após, o cirurgião deverá acompanhar presencialmente pelo menos cinco cirurgias na especialidade, participar como cirurgião auxiliar em pelo menos 10 casos e realizar 10 cirurgias sob supervisão de um cirurgião preceptor. O cirurgião que concluir todas as etapas será considerado habilitado em cirurgia robótica em sua especialidade. A certificação de habilitação definitiva deverá ser emitida pelas sociedades de especialidades filiadas à AMB. Os autores concluem que a criação de uma normativa para habilitação em cirurgia robótica deve estimular que os hospitais brasileiros apliquem critérios objetivos de habilitação para este tipo de procedimento, no sentido de qualificar a assistência.

Objective: to appraise the general profile of the Brazilian robotic surgeon and the acknowledgment of the new certification process for robotic surgery upon the Associação Médica Brasileira (AMB - Brazilian Medical Association) statement. According to the AMB statement, medical societies and proctors have to achieve leading roles in training and certification of surgeons, acting in partnership with industry. Methods: a national web-based survey was promoted by the Colégio Brasileiro de Cirurgiões (CBC - Brazilian College of Surgeons) among their members. Results: the 294 answers were split into two groups: 133 (45.3%) who had robotic console certification, and 161 (54.8%) who did not have it. The overall median age was 46, but the non-robotic group presented more surgeons with at least 30 years of experience than to the robotic group (32.3% versus 23.3%, p=0.033). Surgeons with robotic certification more frequently work in a city with at least one million inhabitants than surgeons who were not certified (85.7 versus 63.4%, p

The main objectives of emergency department thoracotomy (EDT) are to avoid the cardiovascular collapse from mechanical sources or extreme hypovolemia, in patients in extremis. The indication is to perform in patients presenting pulseless with signs of life, pulseless electrical activity (PEA), sudden cardiac arrest (SCA), or imminence of SCA (profound refractory shock). It must be remembered to avoid in patients with isolated cranial injuries. The best timing of closed-chest CPR plausible to start the thoracotomy is 15 minutes for penetrating traumas and 10 minutes for blunt traumas.

Damage control surgery (DCS) is an abbreviated laparotomy for patients who have life-threating bleeding, injuries, and septic sources. The procedure consists of hemorrhage control, by procedures like hemostasis, packing, clamping, and ligation; limits contamination by simple resections, primary suturation, closed absorbent systems, and external drainage; and leads to temporary abdominal closure as quickly as possible. The non-life-threatening injuries are delayed to a reoperation. The main purpose of the damage control surgery is to prevent complications of the lethal triad: coagulopathy, acidosis, and hypothermia.

The injury severity scores can estimate the prognosis and risk of complications after a trauma. They serve as important adjuncts in triage, patient care, and research. Furthermore, they can be used for evaluation of hospital resource utilization and cost-effectiveness studies in trauma. They consist of complex mathematical equations in which variable qualitative and quantitative data are standardized and transformed into a single value, which represents the clinical conditions and prognosis of the patient shortly after injury.

Objective: to compare intraperitoneal adhesion formation in rats when using polypropylene and polypropylene with poliglecaprone meshes. Methods: we used twenty male, Wistar rats, divided in two groups. In group 1, the rats received the polypropylene mesh on their right side and the polypropylene with poliglecaprone mesh on their left side. In group 2 the position of the meshes was inverted. After 30 days, we analyzed the presence or not of adhesion formation, including only those over the meshes. The findings undergone an analysis through the Mann-Whitney test, at a level of significance of p≤0.05. Results: all meshes presented adhesions. We verified that, for the polypropylene meshes, the percentage of their surface covered by adhesions varied from 10.5 to 100%, with an average of 34.07±24.21%, while for the polypropylene with poliglecaprone mesh, the percentage covered by adhesions varied between 8.5% and 100%, with an average of 44.7±32.85% (p=0.12). Conclusion: both meshes lead to adhesion formation, none being superior to the other. RESUMO Objetivo: comparar a formação de aderências intraperitoneais em ratos, com o uso de tela de polipropileno e tela composta de polipropileno e poliglecaprone. Métodos: vinte ratos Wistar machos, foram alocados em dois grupos. No grupo 1 os ratos receberam tela de polipropileno no lado direito e tela de polipropileno e poliglecaprone no lado esquerdo. No grupo 2 inverteu-se a posição das telas. Analisou-se a presença ou não de aderências após 30 dias, sendo incluídas apenas aderências sobre as telas. Os resultados foram submetidos à análise estatística, adotando-se como nível de significância p≤0,05. Resultados: todas as telas se apresentaram com aderências. Verificou-se que, na tela de polipropileno, a porcentagem de superfície coberta por aderências variou entre 10,5 a 100%, com média 34,07±24,21% enquanto que na tela de polipropileno e poliglecaprone a porcentagem de tela coberta por aderências variou entre 8,5 a 100%, com média 44,7±32,85% (p=0,12) . Conclusão: ambas as telas dão origem às aderências, não havendo vantagem de aplicação no reparo intraperitoneal de uma em relação à outra.

to evaluate the feasibility of abbreviated fasting in oncologic colorectal surgeries, as well as the impact on the surgical outcome of the patients.prospective randomized comparative study with patients undergoing elective colorectal cancer surgeries from May to September 2017. Patients were randomized electronically into two groups according to the preoperative fast to be adopted: conventional or abbreviated.of the 33 patients included, 15 followed the abbreviated fasting protocol and 18 the conventional fasting. Both groups had comparable profiles. No patient underwent mechanical preparation of the colon. In 69.7% of the cases, surgery involved low rectal dissection. The procedures were equivalent in relation to intraoperative variables and severe complications. The time to achieve complete oral intake was shorter for abbreviated fasting (10 versus 16 days, p=0.001), as well as the length of inhospital stay (2 versus 4 days, p=0.009). Hospital costs were lower in the abbreviated fasting (331 versus 682 reais, p0.001). The univariable analysis revealed a correlation between complete oral intake and abbreviated fasting [HR 0.29 (IC95%: 0.12-0.68] and abdominal distension [HR 0.12 (IC95% 0.01-0.94)]. After multivariable analysis, abbreviated fasting presented a lower time for complete oral intake [HR 0.39 (IC95%: 0.16-0.92].the abbreviated preoperative fasting favors the metabolic-nutritional recovery, reducing the time for complete oral intake. The implementation of the abbreviation protocol reduces hospital admission costs.avaliar a viabilidade de abreviação do jejum em cirurgias colorretais oncológicas, bem como, o impacto no desfecho cirúrgico dos pacientes.estudo prospectivo comparativo randomizado com pacientes submetidos à cirurgias eletivas colorretais, por câncer, no período de maio a setembro de 2017. Os pacientes foram randomizados eletronicamente em dois grupos de acordo com o jejum pré-operatório a ser adotado: convencional ou abreviado.dos 33 pacientes incluídos, 15 seguiram o protocolo de jejum abreviado e 18 de jejum convencional. Ambos os grupos apresentaram perfis comparáveis. Nenhum paciente foi submetido a preparo mecânico do cólon. Em 69,7% dos casos, a cirurgia envolveu dissecção baixa do reto. Os procedimentos foram equivalentes em relação às variáveis intraoperatórias e complicações graves. O tempo para atingir realimentação plena foi menor para o jejum abreviado (10 versus 16 dias, p=0,001), assim como, o tempo de internação hospitalar (2 versus 4 dias, p=0,009). Os custos hospitalares foram menores no jejum abreviado (331 versus 682 reais, p0,001). A análise univariável revelou correlação entre a realimentação plena e o jejum abreviado [HR 0,29 (IC95%: 0,12-0,68] e com a distensão abdominal [HR 0,12(IC95%: 0,01-0,94)]. Após análise multivariável, o jejum abreviado apresentou menor tempo para realimentação plena [HR 0,39(IC95%: 0,16-0,92].o jejum pré-operatório abreviado favorece a recuperação metabólico-nutricional, diminuindo o tempo para realimentação plena. A implantação do protocolo de abreviação do jejum reduz custos de internação hospitalar.

to evaluate the perception of surgeons, members of the Brazilian College of Surgeons (CBC), on safety and quality issues in surgery, based on projects of Brazilian Ministry of Health (MS), CBC, World Health Organization (WHO), and American College of Surgeons (ACS).a questionnaire based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members, using Survey Monkey, in March 2018.out of 7,100 members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform general surgery, 88.9% indicated knowing the project called Safe Surgery developed by MS, 73.1%, the CBC manual, and 14.6%, the ACS Strong for Surgery. Among those who indicated knowing the MS project, 73.1% said that they were accustomed to use it as a routine, and, among those who indicated knowing the CBC manual, 46.2% said that they were accustomed to use it. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, being failures related to surgical material (49.7%) and presence of foreign bodies (8.2%) the most common ones. There were distinct opinions on who was responsible for checking over the checklist.the importance of safety and quality in surgery is well known by surgeons, but the practice is varied. Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits.avaliar a percepção dos cirurgiões, membros do Colégio Brasileiro de Cirurgiões (CBC), sobre temas de segurança e qualidade em cirurgia, com base em Projetos do Ministério da Saúde (MS), do CBC, da Organização Mundial de Saúde (OMS) e do Colégio Americano de Cirurgiões (ACS).questionário com base nas iniciativas da OMS, do CBC e do ACS foi enviado pelo Survey Monkey a todos os sócios, ativos e não ativos, do CBC em março de 2018.responderam ao questionário 171 profissionais dentre os 7.100 sócios. Desses, a maioria (63,2%) declarou praticar Cirurgia Geral, 88,9% indicaram conhecer o Projeto Cirurgia Segura do MS, 73,1%, o Manual do CBC e 14,6%, o Strong for Surgery do ACS. Entre os que conhecem o Projeto do MS, 73,1% disseram usá-lo como rotina e, entre os que conhecem o Manual do CBC, 46,2% usam-no. A maior parte dos cirurgiões (81,3%) indicou que já vivenciou falha cirúrgica grave, sendo aquelas relacionadas com material cirúrgico (49,7%) e presença de corpos estranhos (8,2%), isoladamente, as mais comuns. Houve opiniões distintas sobre a responsabilidade de conferência do checklist.a importância da segurança e qualidade em cirurgia é conhecida pelos cirurgiões, mas a prática é variada. Eventos adversos graves foram vivenciados por muitos cirurgiões, principalmente relacionados com material cirúrgico e corpos estranhos. O conceito de interdisciplinaridade parece não ser prática comum. Os dados indicam a necessidade de desenvolver projetos de educação e a obrigatoriedade de auditorias.

RESUMO Objetivo: avaliar a percepção de qualidade de vida entre residentes no primeiro ano de Residência Médica em relação aos residentes de outros anos, dada a importância dessa questão na saúde. Métodos: estudo comparativo, transversal e analítico realizado no período de fevereiro a abril de 2016, realizado em um hospital de trauma terciário de referência do Brasil. Médicos residentes foram submetidos voluntariamente ao questionário validado da Organização Mundial de Saúde (OMS) sobre qualidade de vida, o WHOQOL-BREF, com preenchimento online. Os residentes foram divididos em dois grupos: primeiro ano de residência (R1) e outros anos de residência. Resultados: noventa e sete residentes de diversas especialidades médicas responderam ao questionário. Desses, 59 eram homens e 38, mulheres. A média de idade foi de 27,7 anos. Residentes do primeiro ano representaram 49,5% dos entrevistados. A qualidade de vida de maneira global foi considerada regular em ambos os grupos. Em relação ao domínio psicológico, houve diferença significativa entre o R1 (este, com piores escores neste domínio) e os demais anos de residência (p

RESUMO Objetivo: avaliar a influência do local de ocorrência do trauma nos escores de trauma de pacientes submetidos à laparotomia de emergência. Métodos: estudo retrospectivo observacional analítico. Foram incluídos 212 pacientes submetidos à laparotomias exploratórias no período de janeiro de 2015 e dezembro de 2017. Informações sobre o local do acidente e dados vitais dos pacientes foram obtidas com base na coleta de dados por meio de prontuários eletrônicos e físicos. Foram analisados os índices de trauma de pacientes provenientes de Curitiba e Região Metropolitana e o local em que o paciente foi socorrido (estabelecimento físico ou via pública). Resultados: entre os 212 pacientes estudados, 184 (86,7%) foram trazidos pelo Serviço de Atendimento Pré-Hospitalar provenientes da cidade Curitiba e 28 (13,3%) provenientes de Região Metropolitana de Curitiba. Foram socorridos em estabelecimentos físicos 25 pacientes (17,6%), enquanto 117 (82,4%) foram socorridos em via pública. Observou-se maiores valores de ISS (Injurity Severity Score) dos pacientes procedentes da Região Metropolitana em relação aos procedentes de Curitiba (29,78 vs 22,46, P=0,009), enquanto valores maiores do TRISS (Trauma Trauma and Injury Severity Score) foram observados em pacientes procedentes de Curitiba em relação aos da Região Metropolitana (90,62 vs 81,30; P=0,015). Pacientes socorridos em via pública apresentaram menor valor de RTS (Revised Trauma Score) (6,96 vs 7,65; P=0,024) e TRISS (86,42 vs 97,21; P=0,012). Conclusão: pacientes vítimas de trauma procedentes de locais mais distantes do atendimento no centro de referência apresentaram pior prognóstico à admissão e foi observado pior prognóstico em pacientes socorridos em via pública.

PURPOSE: To compare fibroplasia and the resistance of the abdominal wall when polypropylene meshes and polypropylene/poliglecaprone are used. METHODS: Seventy-seven male Wistar rats were divided into three groups: Control Group (for resistance); Group E (polypropylene mesh); and Group U (polypropylene/poliglecaprone mesh). The animals in Groups E and U had a standard muscular and aponeurotic defect, with integral peritoneum, and correction with the mesh. Measurements were taken 4, 7, 14, 28 and 56 days after surgery. The resistance, and collagen density were studied. RESULTS: Resistance on the 56th day was similar in both meshes. The gain in resistance described an ascending curve for the polypropylene mesh and was irregular in the case of the polypropylene/poliglecaprone. Fibroplasia showed a gain in type I and type III collagen in both groups (p

Objective To evaluate the perception of doctors, residents, and medical students of smartphone use on daily medical practice. Materials and methods Cross-sectional study with data collected online by questionnaire on Google Docs®, with closed multiple-choice questions regarding smartphones use in medical practice and its impact on decision-making and patients' privacy. Results There were 118 questionnaires, mostly from students (61%), followed by medical residents (31%) and medical preceptors (8%). All preceptors confirmed eventual use of smartphones on clinical cases discussions, 77.8% of whom use it in less than half of the time. Among the residents, 94.6% use theirs smartphones, 77% of them in more than half of the time. On the contrary, 12.5% of the students do not use this kind of resource, and among those that do use it, 50% do so more than half of the time. All preceptors, 94.6% residents and 80.6% of the students believe its use does not expose the patients' privacy. Conclusion Preceptors and residents use smartphones more often than medical students. Most agree its use helps on daily decision-making and does not jeopardize the patients' privacy. How to cite this article Abreu-Reis P, Bassani T, Collaco IA, Pereira GD, Faggion HZ, Sawczyn GV, Uchida EP, Nasr A, Tomasich FS, Lopes JA. Telemedicine inside the Pocket: The Impact of Smartphones on Daily Patients' Evaluations. Panam J Trauma Crit Care Emerg Surg 2016;5(2):88-92.

Objective To evaluate the stress level in physicians of different levels of formation and to compare it between different medical specialties and the general population. Methods This was a cross-sectional study, using a questionnaire validated in Brazil in 2010, the Perceived Stress Scale (PSS-10). Results The stress level was higher among surgical doctors in comparison with clinical doctors, regardless of the stage of formation. There was a difference between the sex of the professionals, men showing lower results. None of these was statistically significant. Comparing to the American population or South Brazilian teachers, the medical preceptors presented a significant lower level of stress. Conclusion The medical specialty as well as gender and level of medical formation influence in the professional stress level, being elevated in fields of higher working hours and constant pressure. Descriptors Stress, surgery, residents, medical students. How to cite this article Abreu-Reis P, Nasr A, Tomasich FS, Collaco IA, Bassani T, Clivatti GM, Fontanella AP, Ito JM, Manfrinato MFM, Hammerschmidt I. At the Razor's Edge: Surgeons have Lower Stress Levels than the General Population. Panam J Trauma Crit Care Emerg Surg 2016;5(1):26-30.

to evaluate the influence of the site of trauma occurrence on the trauma scores of patients submitted to emergency laparotomy.this is a retrospective, observational, analytical study. We included 212 patients who underwent exploratory laparotomies in the period of January 2015 and December 2017. We obtained information about the accident site and vital data of the patients based on data collection through electronic and physical records. We analyzed the trauma indices of patients from Curitiba and its Metropolitan Region and the place where the patient was rescued (physical establishment or public road).among the 212 patients studied, 184 (86.7%) were brought by the Prehospital Care Service from the city of Curitiba, and 28 (13.3%), from the Metropolitan Region of Curitiba. Twenty-five patients (17.6%) were rescued in physical establishments, while 117 (82.4%) were rescued on public roads. We observed higher values ​​of Injurity Severity Scores (ISS) in patients coming from the Metropolitan Region than in those coming from Curitiba (29.78 vs 22.46, P=0.009), but higher values ​​of Trauma and Injury Severity Scores (TRISS) in patients from Curitiba than the ones from the Metropolitan Region (90.62 vs 81.30, P=0.015). Patients rescued in public roads presented lower Revised Trauma Scores (RTS) (6.96 vs 7.65, P=0.024) and TRISS (86.42 vs 97.21; P=0.012).trauma victims from sites more distant from the referral center and rescued on public roads presented worse prognosis.avaliar a influência do local de ocorrência do trauma nos escores de trauma de pacientes submetidos à laparotomia de emergência.estudo retrospectivo observacional analítico. Foram incluídos 212 pacientes submetidos à laparotomias exploratórias no período de janeiro de 2015 e dezembro de 2017. Informações sobre o local do acidente e dados vitais dos pacientes foram obtidas com base na coleta de dados por meio de prontuários eletrônicos e físicos. Foram analisados os índices de trauma de pacientes provenientes de Curitiba e Região Metropolitana e o local em que o paciente foi socorrido (estabelecimento físico ou via pública).entre os 212 pacientes estudados, 184 (86,7%) foram trazidos pelo Serviço de Atendimento Pré-Hospitalar provenientes da cidade Curitiba e 28 (13,3%) provenientes de Região Metropolitana de Curitiba. Foram socorridos em estabelecimentos físicos 25 pacientes (17,6%), enquanto 117 (82,4%) foram socorridos em via pública. Observou-se maiores valores de ISS (Injurity Severity Score) dos pacientes procedentes da Região Metropolitana em relação aos procedentes de Curitiba (29,78 vs 22,46, P=0,009), enquanto valores maiores do TRISS (Trauma Trauma and Injury Severity Score) foram observados em pacientes procedentes de Curitiba em relação aos da Região Metropolitana (90,62 vs 81,30; P=0,015). Pacientes socorridos em via pública apresentaram menor valor de RTS (Revised Trauma Score) (6,96 vs 7,65; P=0,024) e TRISS (86,42 vs 97,21; P=0,012).pacientes vítimas de trauma procedentes de locais mais distantes do atendimento no centro de referência apresentaram pior prognóstico à admissão e foi observado pior prognóstico em pacientes socorridos em via pública.

Background It is not always that prehospital trauma life support (PHTLS) principles are applied to daily practice. Lack of training to health care providers and a high amount of patients overwhelming the system capacity may let malpractice behavior to happen. It is the aim of this study to assess injuries misdiagnosed by prehospital trauma care in a capital city in southern Brazil. Study design A prospective observational non-controlled study with 174 random trauma cases that were brought to a level 1 trauma center in the city of Curitiba, between May 28th and June 10th 2006. We analyzed data registered in the prehospital rescue team form. The including criteria were all patients delivered to the trauma center by ambulances. The excluding criteria were patients not transported by ambulances and those without the proper form filled out. Statistical analysis was performed using the Chi-square for discrete, and the students’ t-test for continuous variables. Results Of the 174 patients who met the including criteria, 75% were men with a mean age of 27-year-old. Of the 11 injuries to the neck identified in the Hospital evaluation, eight were missed by the prehospital care (OR 0.26 CI 95% 0.07-0.94). Also, only 7/20 injuries to the back were identified by the PHTLS team (OR 0.32 CI 95% 0.13-0.78). Similarly, only 6/26 injuries to the chest (OR 0.20 CI 95% 0.08-0.50), 4/15 to the abdomen (OR 0.24 CI 95% 0.08-0.76), 4/16 to the pelvis (OR 0.23 CI 95% 0.07-0.70), 13/33 to the upper body (OR 0.34 CI 95% 0.17- 0.68),7/39 to the lower body (OR 0.14 CI 95% 0.06-0.33) and 17/55 (OR 0.23 CI 95% 0.12-0.42) were correctly identified in the prehospital scenario. Conclusion Although it is known PHTLS principles, which save lives when applied in practice, further training and remarks to its importance is needed to fully implement efficient trauma systems. Electronic data collection shall make checklists consistently filled out, so that patient care will be improved. How to cite this article Abreu-Reis P, Nasr A, Tomasich FS, Collaco I. Misdiagnosed Injuries in the Prehospital Trauma Care: Better Training needs to be Implemented. Panam J Trauma Crit Care Emerg Surg 2014;3(3):93-96.

BackgroundTrauma registry remains a great problem to most countries that are implementing trauma systems. Nondigital data assessment and storage may lead to information deterioration along the process. In order to verify the missing registry in prehospital trauma rescuers’ form, we ran this study.Study designA prospective observational noncontrolled study with 288 random trauma cases brought to a Level 1 Trauma Center in Curitiba, between May 28th and June 10th 2006. We analyzed data registered in the prehospital rescue team form. The including criteria were all patients delivered to the trauma center by ambulances. The excluding criteria were patients not transported by ambulances and those without the proper form filled out. Statistical analysis was performed using the Chi-square for discrete, and the student's t-test for continuous variables.ResultsTwo hundred and eighty-eight trauma cases were observed. Twelve patients were excluded. Of the 276 patients who met the including criteria, 75% were men with a mean age of 27-year-old. In only 8.34% of times patients were brought by doctors, while in 91.66% by paramedics. 63.4% of patients were traffic injuries victims, followed by 12.31% falls, 6.52% falls from the high, 5.79% gunshot wounds, 5.34% assaults, 3.62% stab wounds, 2.89% others. Impressively, 16 patients (5.89%) had no records of respiratory rate from the prehospital care assessment, 20 (7.24%) had no data of systolic blood pressure and 13(4.71%)had no pulse registry. Furthermore, 31.25% of the RR not registered were abnormal in the hospital admission evaluation, as well as 15% of the SBPs, and 23% of HR. None of the cases had information regarding time from the scene to the hospital.ConclusionElectronic data collection shall make checklists consistently filled out. It is not well understood the importance of registering data for most of healthcare providers working in the field, especially when they do not follow the in-hospital care of trauma patients.How to cite this articleAbreu-Reis P, Tomasich FS, Nasr A, Collaco I. Prehospital Trauma Care Registry Problems in South Brazil. Panam J Trauma Crit Care Emerg Surg 2014;3(3):97-100.

Objective: Io evaluate the expression of p16INK4a and p53 biomarkers in conization specimens from patients with high grade cervical intraepithelial neoplasia (HG-CIN), correlating them with the ability to predict the recurrence. Methods : we conducted a retrospective study of patients with HG-CIN in cervical biopsy treated with conization between January 1999 and January 2006 who had a minimum follow-up of 18 months. The expression of the p16 and p53 was assessed by tissue microarrays and correlated with disease recurrence. For analysis, we used the test of proportions (chi-square), considering value p0.05). p53 had a positive predictive value (PPV) of 42% and negative predictive value (NPV) of 73%, sensitivity 70%, specificity of 47% and accuracy of 59%. The p16, PPV 42%, NPV 72%, sensitivity 66%, specificity of 49% and accuracy of 56%. Conclusion : immunohistochemistry expression of p53 and p16 showed low sensitivity and low specificity as predictors of HG-CIN recurrence after conization treatment. Objetivo : avaliar a expressão dos biomarcadores p16INK4a e p53, nas peças de conização de pacientes com neoplasia intraepitelial cervical de alto grau (NIC-AG), correlacionando com a capacidade de predizer o risco de recorrência. Métodos : estudo retrospectivo de pacientes com NIC-AG em biópsia de colo uterino, tratadas por conização, entre janeiro de 1999 e janeiro de 2006 e seguimento mínimo de 18 meses. A expressão dos biomarcadores p16 e p53 foi avaliada através de técnica de microarranjos teciduais e correlacionada com a recorrência da doença. Para análise utilizou-se o teste das proporções (qui-quadrado), considerando valor p0,05). O p53 apresentou valor preditivo positivo (VPP) de 42% e valor preditivo negativo (VPN) de 73%, sensibilidade de 70%, especificidade de 47% e acurácia de 59%. O p16, VPP de 42% e VPN de 72%, sensibilidade de 66%, especificidade de 49% e acurácia de 56%. Conclusão : a expressão imunoistoquiímica do p53 e do p16 apresentaram baixa sensibilidade e baixa especificidade como marcadores capazes de predizer a recorrência da NIC-AG tratada por conização.

Background Traffic injuries are among the main causes of death worldwide. Even with the advances in technology, there are still 50% of deaths that cannot be reduced by medical care improvement. These important injuries can though be reduced by prevention of trauma. One of the best ways to address this issue is through incorporating preventive measures to the daily routine of schools. It is the aim of this study to assess children's perception on traumatic events and to introduce a cost-effective peer-education preventive action. Study design A prospective interventional comparative study with children from a basic school in South Brazil. A questionnaire with 9 decision-making questions about traffic scenarios was applied by volunteer medical students from May to June 2012, before and after a peer-educational lecture on prevention of traffic injuries. There were 20 epidemiological questions as well. Data collected was compared between the pre and the posttests of the same students. Statistical analysis was performed using the Chi-square for discrete, and the students’ t-test for continuous variables. Results Among 246 students answered the questionnaires. The mean age was 10.19 years old. 21% reported that always crosses the street alone, while 47% only cross with an adult. Most of the students said they always cross-streets in the zebra-crossing and look to both sides before crossing (60.71 and 84.9% respectively). Impressively, 12.55% said they often/ sometimes drive a car or a motorcycle. Also, 30.76% ride a bike in between the cars. Furthermore, 77.48% of the students use the front seat of the car. Regarding safety issues, only one-third have a horn in their bikes, and less than half use helmet when playing. When comparing their assessments, there was a higher number of correct answers in the decision-making section in the post-test (5.21 vs 3.93, p = 0.000001161). The estimated overall cost was 45 dollars. Conclusion Preventive measures urge to be incorporated to schools curricula. Peer-educational actions are a cost-effective for spreading medical knowledge among children and youth. How to cite this article Abreu-Reis P, Tomasich F, Pinto BES, Manfrinato MFM, Oliveira LB, Nasr A, Slongo H, Cruz JB, Collaço I. Preventive Peer-educational Activities: What can Medical Students do to Potentially Save Lives? Panam J Trauma Critical Care Emerg Surg 2012;1(3):182-185.

OBJETIVO: Avaliar a presença de foco de criptas aberrantes (FCA) em mucosa macroscopicamente normal, localizada na periferia de um câncer colorretal (CCR) e correlacionar a progressão tumoral destes FCA para o CCR, por meio da expressão da β-catenina e o Ki-67. MÉTODOS: Utilizou-se 21 espécimes cirúrgicos contendo adenocarcinoma de junção retossigmóide. Foram coletadas amostras localizadas a 1 e 5 cm proximal e distal ao tumor, quando possível, bem como um fragmento da neoplasia. Os FCA foram selecionados. Subseqüentemente foi realizado estudo imunoistoquímico com os anticorpos β-catenina e o Ki-67. RESULTADOS: A expressão nuclear da β-catenina nos adenocarcinomas, revelou freqüência de 81%. O Ki-67 apresentou a mesma freqüência. Apesar disso o coeficiente Kappa revelou fraca concordância entre estes anticorpos. Foram observados 20 FCA, sendo que 13 destes focos localizavam-se nas proximidades do tumor. Nenhum dos FCA apresentou expressão da β-catenina nuclear, tampouco para o Ki-67. CONCLUSÃO: Nas áreas situadas a 1 cm da neoplasia colorretal, foi observada maior concentração de FCA em relação às áreas situadas a 5 cm do tumor. No entanto, não se observou correlação entre a expressão da β-catenina e ki-67 nos colonócitos das criptas aberrantes das áreas estudadas, com as células neoplásicas do adenocarcinoma.

O leiomiossarcoma da glândula adrenal é uma neoplasia extremamente rara, cuja origem provém da veia central da adrenal ou de suas tributárias. Estes tumores são vistos com incidência aumentada em pacientes infectados pelo vírus da imunodeficiência humana adquirida (HIV) e também pelo vírus Epstein-Barr (EBV). Relata-se o caso de uma paciente de 48 anos diagnosticada, por meio de exames de imagem, massa ocupando loja adrenal esquerda, próxima ao pâncreas. Foi submetida à ressecção cirúrgica com achados histopatológicos e imunohistoquímico compatíveis com leiomiossarcoma primário de adrenal. A paciente foi a óbito após 53 meses da adrenalectomia. Concluiu-se que, não obstante a raridade desta neoplasia, sabe-se que, bem como os demais sarcomas de partes moles, o leiomiossarcoma de adrenal se comporta de maneira agressiva e tem na adrenalectomia o tratamento de escolha, não sendo necessário o emprego de quimio ou radioterapias de rotina, exceto em doença metastática ou irressecável.

OBJETIVO: A bioimpedância é um método utilizado, como medida de massa corporal, volume líquido e volume de gordura corporal. Os autores analisam a utilização e desempenho da impedância em modelo de pesquisa experimental de icterícia obstrutiva. MÉTODO: Utilizaram-se oito ratos da linhagem Wistar, que foram divididos em dois grupos de quatro animais: grupo 1(experimento) e grupo 2 (controle). No grupo 1 foi realizado ligadura do colédoco e no grupo 2 laparotomia. Realizou-se a mensuração da resistência e da reatância capacitiva com aparelho de análise de bioimpedância no pré e pós-operatórios. RESULTADOS: O estudo revelou valores médios de resistência para o grupo controle maiores do que para o experimento, mostrando uma diferença significante. Também os valores de reatância capacitiva apresentaram médias maiores no grupo controle com p

OBJETIVO: Analisar a incidência das complicações pós-operatórias das colecistectomias por via aberta e laparoscópica, em relação ao sexo. Método: Estudo retrospectivo de 1123 pacientes submetidos a colecistectomia eletiva, por via aberta ou laparoscópica, no Departamento de Cirurgia da Santa Casa de Misericórdia de São Paulo, no período de Janeiro/1997 a Janeiro/2001. Foi realizada uma avaliação comparativa das complicações pós-operatórias, relacionando os resultados com a idade, ASA, via de acesso, tempo de cirurgia, acidentes intra-operatórios, necessidade de drenagem, período de permanência hospitalar, resultado anátomo-patológico e mortalidade. RESULTADOS: Houve predominância do sexo feminino na população estudada, com 82,5% dos casos. A média de idade foi de 48,8 anos (14 a 97 ). Das operações realizadas, 693 (61,7%) foram por via laparoscópica, sendo a maior proporção de abordagens abertas no sexo masculino (p=0,0014). A taxa global de conversão foi de 2,31%, sem diferença entre os sexos, assim como a realização de procedimentos associados e a ocorrência de acidentes intra-operatórios. A duração da intervenção, a drenagem, a permanência hospitalar pós-operatória, complicações e mortalidade foram significativamente mais freqüentes entre os homens. Neste grupo, observou-se duração maior do ato operatório e permanência hospitalar pós-operatória, com significância estatística, principalmente quando se realizou o tratamento tradicional. CONCLUSÕES: O sexo masculino mostrou-se como provável fator de risco para complicações nas colecistectomias, resultando em operações prolongadas, maior período de permanência hospitalar, necessidade de drenagem mais freqüente e mortalidade elevada em relação ao sexo feminino.

OBJETIVOS: Avaliar a influência do tratamento neoadjuvante (quimioterápico e/ou radioterápico) nas complicações pós-operatórias e letalidade hospitalar de pacientes com câncer de esôfago submetidos a esofagectomia com linfadenectomia em dois campos. MÉTODOS: Estudo retrospectivo de 132 pacientes com câncer de esôfago admitidos no Departamento de Cirurgia do Hospital Erasto Gaertner de janeiro de 1987 a janeiro de 1998, divididos de acordo com a realização ou não de tratamento neoadjuvante. Analisaram-se as variáveis relativas ao paciente (sexo, idade, estado geral, perda ponderal, co-morbidades, tabagismo, risco pulmonar), ao tumor (tipo histológico, localização, estádio clínico) e ao procedimento cirúrgico (local e tipo da anastomose, tempo cirúrgico, tempo de permanência hospitalar), relacionando-as com as complicações e mortalidade pós-operatórias. RESULTADOS: Noventa e quatro pacientes (71,2%) eram do sexo masculino. O tipo histológico predominante foi o CEC em 94,7% e oito pacientes (66,6%) eram tabagistas, e as principais co-morbidades anotadas foram: DPOC (29,55%) e HAS (15,15%). A principal localização do tumor foi o segmento torácico inferior (56,06%), com extensão tumoral média de 47,72 (8-70) mm. Seis pacientes (4,54%) eram EC I, 44 (33,33%) IIA, 24 (18,18%) IIB, 38 (28,80%) III e 17 (12,90%) IV. Quanto ao tratamento neoadjuvante, 39 pacientes (29,54%) foram submetidos a quimioterapia e 22 (16,67%) a radioterapia. As complicações pós-operatórias foram de 74,35% (p=0,0002) e 72,73% (p=0,0037), respectivamente. A taxa de complicações foi de 39,3% e a letalidade hospitalar 13,70%, representadas mais freqüentemente pelas causas pleuropulmonares. CONCLUSÕES: O tratamento neoadjuvante quimioterápico e radioterápico foi relacionado com maior ocorrência de complicações pós-operatórias, sem influência na letalidade hospitalar.BACKGROUND: To evaluate the influence of neoadjuvant treatment (chemotherapy and/or radiotherapy) on postoperative complications and hospital lethality in patients with esophageal cancer submitted to esophagectomy with two-field lymphadenectomy. METHODS: Retrospective study of 132 patients with esophageal cancer admitted in Department of Surgery in Erasto Gaertner Hospital, from January 1987 to January 1998, divided according to realization of neoadjuvant treatment or not. Variables related to patient (sex, age, general condition, ponderal loss, co-morbidities, tabagism), to tumor (histological type, localization, staging) and to surgical procedure (type and localization of anastomosis, surgical time, hospitalization time) were noted and related to postoperative complications and mortality. RESULTS: Ninety-nine patients (71.2%) were of male sex. The predominant histological type was squamous cell carcinoma in 94.7% of the cases. Eighty-eight patients (66.6%) were smokers, and the main co-morbidities noted were: chronic obstructive pulmonary disease (29.55%) and arterial hypertension (15.15%). The main localization of the tumor was inferior thoracic segment (56.06%), with average tumoral extension of 47,72 (8-70) mm. Six patients (4.54%) were stage I, 44 (33.33%) IIA, 24 (18.18%) IIB, 38 (28.80%) III and 17 (12.90%) IV. Considering the neoadjuvant treatment, 39 patients (29.54%) were submitted to chemotherapy and 22 (16.67%) to radiotherapy. The postoperative complications were 74.35% (p=0.0002) and 72.73% (p=0.0037), respectively. The complication rate was 39.3% and hospital lethality 13.70%, represented more frequently by pleuropulmonar causes. CONCLUSION: Neoadjuvant chemotherapic and radiotherapeutic treatments were related to superior occurrence of postoperative complications, without influence on hospital lethality.

Objetivo: avaliar a correlação entre o nível sérico do CEA e CA 72-4 com a profundidade de invasão e estadiamento das neoplasias gástricas. Material e Métodos: foram avaliados pacientes com adenocarcinoma gástrico admitidos no Serviço de Cirurgia Abdominal do Hospital Erasto Gaertner no período de janeiro de 1996 a janeiro de 2000, incluindo-se neste estudo os pacientes que apresentavam dosagem sérica pré e pós-operatória de pelo menos um dos marcadores (CEA e/ou CA 72-4) e apresentavam estadiamento patológico ou evidências de doença disseminada pelos métodos de imagem. Resultados: dos 144 pacientes elegíveis, 71% eram do sexo masculino. A média de idade foi de 59 anos. O CEA mostrou-se alterado em 66,2% dos casos, e em 70,3% dos casos na análise do CA 72-4. Quanto à profundidade de invasão, o tumor invadia até a camada mucosa em apenas sete (4,8%) pacientes, até a camada submucosa em oito (5,6%) pacientes, muscular em 34 (23,6%), serosa em 45 (31,3%) e órgãos adjacentes em 33 (22,9%) dos casos. Em 17 pacientes a profundidade de invasão não foi avaliável, embora já fosse definida a doença como disseminada por outros meios. Na análise comparativa dos níveis séricos do CEA e do CA 72-4, de acordo com a profundidade de invasão, não observamos significância estatística para positividade dos marcadores nos tumores gástricos. Conclusões: no presente estudo, os marcadores séricos CEA e CA 72-4 não se mostraram como fatores preditivos para profundidade de invasão e estadiamento nos pacientes com câncer gástrico.

Medical students usually do supervised extra-curricular activities in different fields in Brazil. Doing these activities in the resuscitation room (RR) of a Level I Trauma Center is reserved for senior medical students (after 500 hours of extra-curricular activities done at the same hospital). The aim of this study was to assess the number of different procedures a senior medical student can develop in the RR over his extra-curricular activities in this environment.