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Introdução O Ministério da Saúde, MS, vem adquirindo inovações promissoras e controvertidas e as testando mediante estudos controlados em polos de referência da Rede SUS. Apresenta-se o exemplo da aquisição de um robô cirúrgico visando avaliar segurança, efetividade e sua relação de custo-efetividade em um UNACON. Métodos Estudo controlado randomizado por blocos conforme os tipos de cirurgia de câncer contratualizados pelo MS nas especialidades de gastroenterologia, ginecologia, cirurgias de cabeça e pescoço, urologia e pneumologia. Casuística: portadores de neoplasias com indicação cirúrgica e elegíveis para as três técnicas cirúrgicas em estudo, i.e., cirurgia aberta, videolaparoscopia e videolaparoscopia robótica, informados e concordaram com o protocolo assinando o TCLE, foram randomizados. O protocolo delineado (NCT02292914/ ClinicalTrials.gov) foi executado segundo as Diretrizes Metodológicas/Avaliação Econômica do MS, com micro-custeio operacional. Os custos de treinamento, de aquisição de capital, de manutenção etc. e custos indiretos, foram excluídos. Instrumentos validados foram usados para comparar benefícios funcionais e qualidade de vida por 36 a 60 meses. Resultados Oito cirurgias de câncer foram avaliadas em 783 pacientes randomizados, (4 de gastroenterologia, 1 ginecologia, 1 de cabeça e pescoço, 1 urologia, e 1 pneumologia) nos 3 Grupos: Robô (n = 421), Videolaparoscopia (n = 173) e Convencional-Aberta (n = 189), Idade Média±DP de 62±9 anos e IMC 27,6±5,4 kg/m2, no ICESP/HCFMUSP entre 2014 e 2021, com impacto da pandemia COVID no seguimento. A distribuição absoluta dos custos dos controles (laparoscópicos, exceto prostatectomias vs. cirurgia aberta) e das diferenças médias incrementais pela robótica e desvios de dias de internação no período pós-operatório e de custos totais foi de Esofagectomias (R*n=21) -3,6 dias de internação e incremento de R$ 15.691,08± R$ 4.252,56 comparado aos 22/lap internados por 20,3±7,4 dias e custo de R$ 50.998,44± R$ 14.601,45; Gastrectomias (*n=20) -0,2 dias e incremento de R$ 14.644,03± R$ 1.758,44 vs. 24/ lap com 11,5±4,1 dias e custaram R$ 22.303,28± R$ 5.526,34; Reto (*n=24) -1,1 dias e mais R$ 7.642,08± R$ 1.959,34 vs. 24/lap com 10,0±2,5 e custo R$ 24.997,87± R$ 5.296,93; Pancreatectomias (*n=29) com 7,8±1,2 dias de internação e custaram R$ 23.901,79± R$ 3.785,65 sem controles; Histerectomias (R*n=43) com +0,1 dia adicionou R$ 9.141,37± R$ 744,27 vs. 42/lap com 3,3±1,3 dias e custo de R$ 22.025,58± R$ 10.054,45; Cabeça & Pescoço (*n=36) -2,5 e incrementou R$ 1.631,66± R$ 1.530,95 vs. 55/videolap com 7,3±5,4 dias e custo R$ 18.463,00± R$ 8.872,60; Prostatectomias (*n=169) -0,7 dias e mais R$ 9.660,99± R$ 3.305,69 que as 167/abertas com 3,7±0,9 dias e custo de R$ 8.989,73± R$ 1.909,38; e, Lobectomias pulmonares (R*n=43) -0,3 dia economizaram -R$ 420,60± R$ 2.602,66 vs. 40/lap que permaneceram 6,0±3,1 dias e custaram R$ 34.103,60± R$ 2.112,03, respectivamente. Não houve complicações maiores ou mortalidade relacionadas às cirurgias nos braços estudados. A qualidade de vida e escores funcionais tenderam a ser melhores até 12 meses e foram similares no seguimento extendido. Discussão e conclusões Embora com ganhos estruturais, trabalhistas, ensino e pesquisa, este estudo corroborou a controvérsia internacional sobre os modestos benefícios da robótica no local para os pacientes. Atualmente, o custo de materiais descartáveis e monopólio da empresa o tornam pouco sustentáveis no SUS.

Introduction: Stage III NSCLC is a heterogeneous disease, representing approximately one-third of newly diagnosed lung cancers. Brazil lacks detailed information regarding stage distribution, treatment patterns, survival, and prognostic variables in locally advanced NSCLC. Methods: RELANCE/LACOG 0118 is an observational, retrospective cohort study assessing sociodemographic and clinical data of patients diagnosed with having stage III NSCLC from January 2015 to June 2019, regardless of treatment received. The study was conducted across 13 cancer centers in Brazil. Disease status and survival data were collected up to June 2021. Descriptive statistics, survival analyses, and a multivariable Cox regression model were performed. p values less than 0.05 were considered significant. Results: We recruited 403 patients with stage III NSCLC. Most were male (64.0%), White (31.5%), and smokers or former smokers (86.1%). Most patients had public health insurance (67.5%), had stage IIIA disease (63.2%), and were treated with concurrent chemoradiation (53.1%). The median follow-up time was 33.83 months (95% confidence interval [CI]: 30.43–37.50). Median overall survival (OS) was 27.97 months (95% CI: 21.57–31.73), and median progression-free survival was 11.23 months (95% CI: 10.70–12.77). The type of treatment was independently associated with OS and progression-free survival, whereas the types of health insurance and histology were independent predictors of OS only. Conclusions: Brazilian patients with stage III NSCLC with public health insurance are diagnosed later and have poorer OS. Nevertheless, patients with access to adequate treatment have outcomes similar to those reported in the pivotal trials. Health policy should be improved to make lung cancer diagnosis faster and guarantee prompt access to adequate treatment in Brazil.

OBJECTIVES: Chemical pleurodesis is an important therapeutic tool to control recurrent malignant pleural effusion. Among the various sclerosing agents, iodopovidone is considered effective and safe. However, in a recent study, ocular changes were described after iodopovidone was used in recurrent pneumothorax. The aim of the study was to evaluate the efficacy and morbidity of iodopovidone pleurodesis in an experimental model. METHODS: New Zealand rabbits were submitted to intrapleural injection of iodopovidone at concentrations of 2%, 4% and 10%. Biochemical (lactic dehydrogenase, proteins, triiodothyronine, free thyroxine, urea and creatinine) and immunological (Interleukin-8 [IL-8], VEGF and TGFβ) parameters were measured in the pleural fluid and blood. After 1, 3, 7, 14 and 28 days, groups of animals were euthanized, and macro- (pleura) and microscopic (pleura and retina) analyses were performed. RESULTS: An early pleural inflammatory response with low systemic repercussion was observed without corresponding changes in thyroid or renal function. The higher concentrations (4% and 10%) correlated with greater initial exudation, and maximum pleural thickening was observed after 28 days. No changes were observed in the retinal pigment epithelium of the rabbits. CONCLUSION: Iodopovidone is considered to be an effective and safe sclerosing agent in this animal model. However, its efficacy, tolerance and safety in humans should be further evaluated.

Com o advento de novas técnicas cirúrgicas para o tratamento das arritmias cardíacas, em especial da fibrilação atrial, como a cirurgia de Cox, o conhecimento das características e do trajeto das artérias coronárias atriais assumiu grande importância. O objetivo deste trabalho é o estudo desta circulação e a definição dos padrões de irrigação atrial. Para tanto, utilizamos 30 corações a fresco de indivíduos sem cardiopatia prévia, cujas artérias coronárias e ramos foram visibilizados através de injeção de resina vinílica corada com tinta laca preta, seguida de cuidadosa dissecção. Após avaliação macroscópica das peças, não foram encontrados padrões de irrigação uniforme dos átrios. Porém, a artéria do nó sinoatrial (ANSA), quando analisada isoladamente, revelou não apenas padrões de origem, como também padrões de trajeto. Foram descritos 7 padrões de origem e trajeto da ANSA, considerando-se pontos de referências da estrutura anatômica dos átrios. Os padrões descritos, diferente dos encontrados por outros autores, são de fácil interpretação e de aplicabilidade direta em técnicas cirúrgicas que abordam os átrios.Since the appearance of new surgical techniques such as Cox surgery employed for the treatment of cardiac arrhythmia, especially for atrial fibrillation, the knowledge of coronary artery characteristics and courses has been of increasing importance. The aim of this study was the analysis of this circulation and definition of atrial irrigation patterns. Hence, the coronary arteries of 30 normal human hearts were injected with colored resin and carefully dissected. After macroscopic evaluation of the hearts, no atrial irrigation patterns were found. However, when only the sinus atrial node was analyzed, it showed origin patterns as well as course patterns. Seven origin and route patterns of this artery are described, considering the anatomical structure of the atria as reference points. The described patterns, differently from others found in the literature, are easy to understand and apply in surgical techniques which deal with the atria.

OBJECTIVE: Pleural tuberculosis is the most frequently occurring form of extra pulmonary disease in adults. In up to 40% of cases, the lung parenchyma is concomitantly involved, which can have an epidemiological impact. This study aims to evaluate the pleural and systemic inflammatory response of patients with pleural or pleuropulmonary tuberculosis. METHODS: A prospective study of 39 patients with confirmed pleural tuberculosis. After thoracentesis, a high resolution chest tomography was performed to evaluate the pulmonary involvement. Of the 39 patients, 20 exhibited only pleural effusion, and high resolution chest tomography revealed active associated-pulmonary disease in 19 patients. The total protein, lactic dehydrogenase, adenosine deaminase, vascular endothelial growth factor, interleukin-8, tumor necrosis factor-α, and transforming growth factor-β1 levels were quantified in the patient serum and pleural fluid. RESULTS: All of the effusions were exudates with high levels of adenosine deaminase. The levels of vascular endothelial growth factor and transforming growth factor-β1 were increased in the blood and pleural fluid of all of the patients with pleural tuberculosis, with no differences between the two forms of tuberculosis. The tumor necrosis factor-α levels were significantly higher in the pleural fluid of the patients with the pleuropulmonary form of tuberculosis. The interleukin-8 levels were high in the pleural fluid of all of the patients, without any differences between the forms of tuberculosis. CONCLUSION: Tumor necrosis factor-α was the single cytokine that significantly increased in the pleural fluid of the patients with pulmonary involvement. However, an overlap in the results does not permit us to suggest that cytokine is a biological marker of concomitant parenchymal involvement. Although high resolution chest tomography can be useful in identifying these patients, the investigation of fast acid bacilli and cultures for M. tuberculosis in the sputum is recommended for all patients who are diagnosed with pleural tuberculosis.