Are biopsies always necessary in upper and lower gastrointestinal endoscopy in children? A retrospective 10-year analysis.

Little attention has been given to the efficiency and validity of performing routine endoscopic biopsies in normal areas in children. This study aimed to investigate the need to perform routine biopsies in upper gastrointestinal endoscopy (UDE) and colonoscopy in normal areas by comparing macroscopy and histology. It was a 10-year retrospective analysis with the inclusion of 761 UDEs and 177 colonoscopies. Considering all segments, UDEs showed false-positive result rates of 73.11% and false-negative result rates of 14.34%. The histological results modified the initial management in 53.95% of patients. Considering all segments, colonoscopies showed false-positive result rates of 63.64% and false-negative result rates of 30.97%. The histological results modified the initial management in 34.45% of patients.Conclusion: If biopsies were obtained only in abnormal areas, the diagnosis would be lost in 53.95% of the patients in upper endoscopies and 85.7% of the colonoscopies, which justifies routine maintenance of biopsies in macroscopically normal areas in children. What is Known: • Little attention has been given to the efficiency and validity of endoscopic biopsies of normal areas during pediatric exams. • Only a few pediatric studies have correlated macroscopic and histological findings from endoscopic biopsies, and low sensitivity and specificity, as well as poor agreement, were reported. What is New: • Our study confirms the evidence that routine biopsies from macroscopically normal areas during upper and lower digestive endoscopies can lead to histopathological diagnoses and different medical management. • This is the first research on this topic in a Latin population, from a developing country, reassuring the results obtained in previous papers from other countries.

Acute aortic wall injury caused by aortic cross-clamping: morphological and biomechanical study of the aorta in a swine model of three aortic surgery approaches.

BACKGROUND: Aortic cross-clamping and balloon occlusion of the aorta could lead to damage to the aorta wall. OBJECTIVE: The aim of this study was to investigate changes to the aorta wall related to the method used to interrupt flow (clamping or balloon) in the different techniques available for aortic surgery. METHODS: Experiments were performed on 40 female pigs, weighing 25-30kg, which were randomly allocated to 4 study groups: S (n=10), no intervention (sham group); C (n=10), midline transperitoneal laparotomy for infrarenal abdominal aortic access with 60 min of cross-clamping; L (n=10), laparoscopic infrarenal abdominal aortic surgery with 60 min of cross-clamping; EV (n=10), remote proximal aortic control with transfemoral arterial insertion of aortic occlusion balloon catheter, inflated to provide continued aortic occlusion for 60min. After euthanasia, the aortas were removed and cross-sectioned to obtain histological specimens for light microscopic and morphometric analyses. The remaining longitudinal segments were stretched to rupture and mechanical parameters were determined. RESULTS: We observed a reduction in the yield point of the abdominal aorta, decrease in stiffness and in failure load in the aortic cross-clamping groups (C and L) compared with the EV group. CONCLUSIONS: Aortic cross-clamping during open or laparoscopic surgery can affect the mechanical properties of the aorta leading to decrease in resistance of the aorta wall, without structural changes in aorta wall histology.

Barium Enema Revisited in the Workup for the Diagnosis of Hirschsprung's Disease.

OBJECTIVE: To analyse the diagnostic capacity of barium enema (BE) in the diagnostic investigation for Hirschsprung's disease (HD) was analyzed for transition zone (TZ) identification and rectosigmoid index (RSI) ≤1.0 determination. PATIENTS AND METHODS: BE images were analyzed retrospectively by 2 examiners and the results were compared with the histopathology of rectal biopsies. RESULTS: TZ identification and RSI ≤1.0 were assessed separately and combined in 43 patients. Twelve (27.9%) patients had the diagnosis of HD based on rectal biopsies. TZ identification presented better diagnostic capacity for the 2 examiners than RSI ≤1.0. However, interexaminer agreement was higher for RSI ≤1.0 than for TZ identification. The combination of TZ identification and RSI ≤1.0 increased the sensitivity (83.3%-92.3%) and the negative predictive value (90.4%-92.3%). CONCLUSION: Therefore, the high diagnostic sensitivity of TZ identification combined to RSI ≤1.0 reinforces the usefulness of these BE parameters in the screening for Hirschsprung's disease.

Biocellulose-based hydrogel dressing as a strategy for the management of chronic arterial wounds.

PURPOSE: To evaluate using a biocellulose-based hydrogel as an adjuvant in the healing process of arterial ulcers. METHODS: A prospective single group quasi-experimental study was carried out with chronic lower limb arterial ulcer patients. These patients received biocellulose-based hydrogel dressings and outpatient guidance on dressing and periodic reassessments. The primary outcomes were the ulcer-healing rate and product safety, which were assessed by ulcer area measured in photographic records of pre-treatment and posttreatment after 7, 30, and 60 days. Secondary outcomes were related to clinical assessment by the quality-of-life scores (SF-36 and EQ-5D) and pain, evaluated by the visual analogue scale (VAS). RESULTS: Seventeen participants were included, and one of them was excluded. Six patients (37%) had complete wound healing, and all patients had a significant reduction in the ulcer area during follow-up (233.6mm2 versus 2.7mm2) and reduction on the score PUSH 3.0 (p < 0.0001). The analysis of the SF-36 and EQ-5D questionnaires showed a statistically significant improvement in almost all parameters analyzed and with a reduction of pain assessed by the VAS. CONCLUSIONS: The biocellulose-based hydrogel was safe and showed a good perspective to promoting the necessary conditions to facilitate partial or complete healing of chronic arterial ulcers within a 60-day follow-up. Quality of life and pain were positively affected by the treatment.

Developing an Animal Model for Swenson Transanal Endorectal Pull-Through: A New Possibility for Training and Research Purposes.

As far as we know, no report uses the Swenson transanal endorectal pull-through technique in an animal model. Our objective is to describe the use of this technique as an experimental model for training and research purposes. Ten Norfolk hybrid rabbits were randomly selected from our experimental laboratory, with a mean weight of 3539.3 (± 678.4) g. Neither colon preparation nor fast were used before the procedures. The surgical technique was based on the description performed by Levitt et al. (2013, J Pediatr Surg. 2013;48(11):2289-2295). Information related to the surgical procedures and the clinical evolution in the postoperative period were recorded and analyzed. There were no deaths or severe complications. The anesthetic and the surgical times were significantly higher for the first three animals of the experiment. Our animal model proved adequate to perform the transanal endorectal Swenson pull-through technique, allowing the training of surgical skills through a model similar to the human, with few anesthetic complications and good postoperative evolution, including postoperative follow-up. We believe that it will serve as a learning tool in many institutions that are continuously searching for improved new techniques and will support new researches in this area.

Transcutaneous Posterior Tibial Nerve Stimulation: An Adjuvant Treatment for Intractable Constipation in Children.

BACKGROUND: Functional constipation can lead to painful defecations, fecal incontinence, and abdominal pain, significantly affecting a child's quality of life. Treatment options include non-pharmacological and pharmacological approaches, but some cases are intractable and require alternative interventions like neuromodulation. A subtype of neuromodulation, called Transcutaneous Posterior Tibial Nerve Stimulation (TPTNS), comprises electrical stimulation at the ankle level, by means of electrodes fixed to the skin. TPTNS is a minimally invasive, easy-to-apply technique that can potentially improve constipation symptoms in the pediatric population by stimulating the sacral nerves. AIM: To evaluate the clinical results and applicability of TPTNS as an adjuvant treatment for children and adolescents with functional constipation. METHODS: Between April 2019 and October 2021, 36 patients diagnosed with functional constipation according to the Rome IV Criteria were invited to participate in the study. The study followed a single-center, uncontrolled, prospective cohort design. Patients received TPTNS for 4 or 8 weeks, with assessments conducted immediately after the periods of TPTNS and 4 weeks after the end of the intervention period. The data normality distribution was determined by the Shapiro-Wilk test. The Wilcoxon test and Student's t-test for paired samples were used to compare quantitative variables, and the McNemar test was used to compare categorical variables. RESULTS: Of the 36 enrolled patients, 28 children and adolescents with intractable function constipation completed the study, receiving TPTNS for 4 weeks. Sixteen patients (57.1%) extended the intervention period for 4 extra weeks, receiving 8 weeks of intervention. TPTNS led to significant improvements in stool consistency, frequency of defecation, and bowel function scores, with a reduction in abdominal pain. Quality of life across physical and psychosocial domains showed substantial enhancements. The quality of life-related to bowel habits also improved significantly, particularly in lifestyle, behavior, and embarrassment domains. The positive effects of this intervention are seen relatively early, detected after 4 weeks of intervention, and even 4 weeks after the end of the intervention. TPTNS was well-tolerated, with an adherence rate of approximately 78%, and no adverse effects were reported. CONCLUSIONS: TPTNS is an adjuvant treatment for intractable functional constipation, improving bowel function and quality of life. The effects of TPTNS were observed relatively early and sustained even after treatment cessation.

Transcutaneous Neuromodulation for Constipation and Fecal Incontinence in Children: A Systematic Review and Meta-Analysis.

INTRODUCTION: Constipation is a disorder with a multifactorial origin. Constipation has a varied clinical presentation, including infrequent defecation of bulky stools and episodes of retentive fecal incontinence. Neuromodulation has been used to treat many health problems, with promising results. OBJECTIVE: To conduct a systematic review of randomized clinical trials based on the effects of transcutaneous neuromodulation in treating constipation and retentive fecal incontinence in children and adolescents. METHODS: A systematic review of randomized clinical trials was performed. Medline (PubMed), PEDro, SciELO, Cochrane (CENTRAL), Embase, and Scopus databases were searched from March 2000 to August 2022. We included clinical trials evaluating transcutaneous neuromodulation in children with constipation and fecal incontinence compared or associated with other types of treatment. Two reviewers independently selected relevant studies, assessed the methodological quality, and extracted the data. RESULTS: Three studies with 164 participants were included in this review. Two meta-analyses were generated based on these studies. These analyses revealed that transcutaneous neuromodulation is an effective adjuvant treatment modality that improves children's constipation and retentive fecal incontinence. The methodological quality of the included studies was classified as high based on the assessment of the quality of evidence, with a high degree of confidence based on the GRADE system. CONCLUSIONS: Transcutaneous neuromodulation is an effective adjuvant treatment modality for children with constipation and retentive fecal incontinence.

Quantitative analysis validation for sclerotherapy treatment of lower limb telangiectasias.

BACKGROUND: The evaluation of sclerotherapy efficacy for lower limb telangiectasias, which is the standard treatment for such condition, is commonly assisted by scores based on before and after pictures. This method is marked by its subjectivity, which impairs the precision of studies on the subject, making it unfeasible to evaluate and compare different interventions. We hypothesize that a quantitative method for evaluating the effectiveness of sclerotherapy for lower limb telangiectasias may present more reproducible results. Reliable measurement methods and new technologies may become part of the clinical practice in the near future. METHODS: Before and after treatment photographs were analyzed using a quantitative method and compared with a validated qualitative method based on improvement scores. Reliability analysis of the methods was performed, applying the intraclass correlation coefficient (ICC) and kappa coefficient with quadratic weights (Fleiss Cohen), for analysis of inter-examiner and intra-examiner agreement in both evaluation methods. Convergent validity was evaluated by applying the Spearman test. To assess the applicability of the quantitative scale, the Mann-Whitney test was used. RESULTS: A better agreement between examiners is shown for the quantitative scale, with a mean kappa of .3986 (.251-.511) for qualitative analysis and a mean kappa of .788 (.655-.918) for quantitative analysis (P < .001 for all examiners). Convergent validity was achieved by correlation coefficients of .572 to .905 (P < .001). The quantitative scale results obtained between the specialists with different degrees of experience did not show statistical difference (seniors: 0.71 [-0.48/1.00] × juniors: 0.73 [-0.34/1.00]; P = .221). CONCLUSIONS: Convergent validity between both analyses has been achieved, but quantitative analysis has been shown to be more reliable and can be applied by professionals of any degree of experience. The validation of quantitative analysis is a major milestone for the development of new technology and automated, reliable, applications.

Agreement between histopathological and intraoperative classifications for pediatric appendicitis and its relationship with the post-operative clinical outcome.

Introduction: Some studies have shown poor agreement between intraoperative and histopathological classifications for appendicitis, despite their routine use in clinical practice. Objective: To investigate the agreement between histopathological and intraoperative classifications for pediatric appendicitis and evaluate the predictive potential of these classifications for the post-operative outcome. Methods: A retrospective, longitudinal, observational single-center study, carried out with 485 patients up to15 years of age, with a confirmed diagnosis of acute appendicitis by histopathological evaluation. The histopathological results classified the appendices as uncomplicated appendicitis when there was confirmation of the diagnosis of appendicitis without necrosis or perforation and complicated appendicitis when there was extensive necrotic tissue in the outer layer of the appendix or signs of perforation. The intraoperative findings were classified as uncomplicated appendicitis when the appendix presented with hyperemia and edema or fibrinous exudate and complicated appendicitis when the appendix showed necrosis, abscess, or perforation. The kappa index determined the agreement and the prediction relationships using a generalized linear model. Results: 43.9% of cases were classified as complicated appendicitis by histopathological evaluation and 49.7% by intraoperative classification. The agreement analysis between the histopathological and intraoperative classification showed a moderate agreement, with a Kappa index of 0.419 (0.337-0.501). There was an association (P < 0.05) between the intraoperative classification and the post-operative clinical outcomes (time to start feeding, fever, intraabdominal collection, length of stay, the need for antibiotic therapy changing, and need for ICU). There was no association between histopathological classification and post-operative outcomes. Conclusion: The agreement between the two classifications was moderate, and the intraoperative classification was able to predict the post-operative clinical outcomes.

Urinary Bladder Patch Made with Decellularized Vein Scaffold Seeded with Adipose-Derived Mesenchymal Stem Cells: Model in Rabbits.

BACKGROUND: To evaluate tissue regeneration of the urinary bladder after the implantation of a decellularized vein sown with autologous adipose-derived mesenchymal stem cells (ASC) on luminal surfaces. METHODS: New Zealand rabbits (n = 10) were distributed in two groups: Group Bioscaffold alone (G1)-decellularized vena cava (1 cm2) was implanted, and Group Bioscaffold plus ACSs (G2)-decellularized vena cava (1 cm2) containing ASCs were implanted. ASCs were expanded, characterized, and maintained for one week in culture with a decellularized vein scaffold. The implants were performed under general anesthesia using a continuous suture pattern. Afterward, 21 d (day) specimens were collected and analyzed by hematoxylin and eosin (HE) histology and scanning electron microscopy (SEM). RESULTS: The integrity of the urinary bladder was maintained in both groups. A superior regenerative process was observed in the G2 group, compared to the G1 group. We observed a greater urothelial epithelialization and maturity of the mucosa and submucosa fibroblasts. Furthermore, SEM demonstrated a notable amount of urothelial villus in the G2 group. CONCLUSION: Decellularized vena cava scaffolds were able to maintain the integrity of the urinary bladder in the proposed model. In addition, ASCs accelerated the regenerative process development, observed primarily by the new urothelial epithelization and the maturity of mucosa and submucosa fibroblasts.

Challenges in the diagnosis of intestinal neuronal dysplasia type B: A look beyond the number of ganglion cells.

Intestinal neuronal dysplasia type B (IND-B) is a controversial condition among gastrointestinal neuromuscular disorders. Constipation is its most common clinical manifestation in patients. Despite intense scientific research, there are still knowledge gaps regarding the diagnostic criteria for IND-B in the histopathological analysis of rectal biopsies. The guidelines published in the past three decades have directed diagnostic criteria for quantifying the number of ganglion cells in the nervous plexus of the enteric nervous system. However, it is very complex to distinguish numerically what is pathological from what is normal, mainly because of the difficulty in determining a reliable control group composed of healthy children without intestinal symptoms. Thus, a series of immunohistochemical markers have been proposed to assist in the histopathological analysis of the enteric nervous system. Several of these markers facilitate the identification of other structures of the enteric nervous system, in addition to ganglion cells. These structures may be related to the etiopathogenesis of IND-B and represent new possibilities for the histopathological diagnosis of this disease, providing a view beyond the number of ganglion cells. This review critically discusses the aspects related to the disease definitions and diagnostic criteria of this organic cause of constipation.

Exploring pooled analysis of pretested items to monitor the performance of medical students exposed to different curriculum designs.

Several methods have been proposed for analyzing differences between test scores, such as using mean scores, cumulative deviation, and mixed-effect models. Here, we explore the pooled analysis of retested Progress Test items to monitor the performance of first-year medical students who were exposed to a new curriculum design. This was a cross-sectional study of students in their first year of a medical program who participated in the annual interinstitutional Progress Tests from 2013 to 2019. We analyzed the performance of first-year students in the 2019 test and compared it with that of first-year students taking the test from 2013 to 2018 and encountering the same items. For each item, we calculated odds ratios with 95% confidence intervals; we also performed meta-analyses with fixed effects for each content area in the pooled analysis and presented the odds ratio (OR) with a 95% confidence interval (CI). In all, we used 63 items, which were divided into basic sciences, internal medicine, pediatrics, surgery, obstetrics and gynecology, and public health. Significant differences were found between groups in basic sciences (OR = 1.172 [CI95% 1.005 CI 1.366], p = 0.043) and public health (OR = 1.54 [CI95% CI 1.25-1.897], p < 0.001), which may reflect the characteristics of the new curriculum. Thus, pooled analysis of pretested items may provide indicators of different performance. This method may complement analysis of score differences on benchmark assessments.

Quantification of adhesion of mesenchymal stem cells spread on decellularized vein scaffold.

PURPOSE: To evaluate methods that improve adipose-derived stem cells (ASCs) population in decellularized biological venous scaffold for tissue engineering in blood vessels, a model in rabbits. METHODS: The ASC was expanded until the third passage. Inferior vena cava (IVC) was submitted to the decellularization process using 1% sodium dodecyl sulfate (SDS) or 2% sodium deoxycholate (SD) to compose 12 study groups (G): pure SD or SDS, exposed or not to 1% TritonX-100 (TX-100) and exposed or not to poly-l'lysine and laminin (PL). Scaffolds were covered with 1 × 105 or 1 × 106 ASCs diluted in 10 µL Puramatrix™. The histological analysis was done by cell counting in hematoxylin and eosin (HE) and nuclei count in immunofluorescence (IF) with 4',6-Diamidine-2'-phenylindole dihydrochloride (DAPI). RESULTS: The study of groups in HE and IF showed similar results. For both analyses,IVC-SD-1 × 106 ASC and IVC-SD-PL-1 × 106 ASC provided the best results. The IF technique showed better sensitivity than HE, with a weak agreement between them. CONCLUSIONS: Decellularizing agent and the number of ASC influence scaffolds cellularization response and the best protocols as those ones using SD with or without the addition of PL.

What should be the treatment for intestinal neuronal dysplasia type B? A comparative long-term follow-up study.

PURPOSE: To present the long-term follow-up outcomes of patients with intestinal neuronal dysplasia type B (IND-B) managed either conservatively or surgically. METHODS: We conducted an ambispective, observational, longitudinal, and comparative study. Clinical data were reviewed at the start of treatment. After a minimum period of five years, the patients participated in semi-structured interviews in which the bowel function score (BFS) was applied to assess intestinal function, a proposed intestinal symptom index (ISI) to assess clinical symptoms, and a classification of clinical prognosis to assess treatment success. Comparisons between the two types of treatment were performed by evaluating pre- and post-treatment criteria. RESULTS: Fifty patients diagnosed with IND-B were included in the study. Thirty-eight patients underwent surgical treatment (26 elective surgical treatment for primary colorectal resection and 12 emergency colostomies for intestinal obstruction or enterocolitis). Twelve patients were managed conservatively. With the exception of the patients who required an emergency operation (n = 12), the two groups were composed of patients with severe constipation who had similar clinical and functional characteristics at the time of IND-B diagnosis. A better clinical response was observed in patients submitted to conservative treatment, with a greater increase in the BFS (16.5 [-4/+18] versus 4 [-15/+17]; p = 0.001), indicating better bowel function and a more pronounced drop in ISI (-6 [-7/-4] versus -4 [-6/+1]; p = 0.015), suggesting fewer symptoms. The percentage of patients who had a successful treatment was higher in the group treated conservatively (72.7% versus 42.3%; p = 0.03). CONCLUSION: Conservative management showed better long-term outcomes than surgical management in children with IND-B.

Ultrastructural analysis of bone formation around dental implants in nondiabetic rats, severe diabetics not controlled and controlled with insulin.

PURPOSE: To evaluate bone formation through ultrastructural analysis around titanium implants in severe alloxanic uncontrolled diabetic rats, and controlled with insulin, in comparison with nondiabetic rats. METHODS: Thirty-six male Wistar rats, weighing between 200 and 300 g, divided into three experimental groups: normal control group (G1), a diabetic group without treatment (G2), and a diabetic group treated with insulin (G3). The animals received titanium implants in the right femur, and osseointegration was evaluated at 7, 14, and 21 days after surgery, through ultrastructural analysis using scanning electron microscopy. RESULTS: The ultrastructural analysis showed a dense bone structure in the G1, few empty spaces and a small number of proteoglycans; G2 presented bone matrix with a loose aspect, irregular arrangement, thin trabeculae, empty spaces and a large number of proteoglycans; G3 obtained similar results to G1, however with a higher number of proteoglycans. CONCLUSION: Severe diabetes caused ultrastructural changes in bone formation, and insulin therapy allowed an improvement in osseointegration, but it was not possible to reach the results obtained in the control group.

A protocol for an interventional study on the impact of transcutaneous parasacral nerve stimulation in children with functional constipation.

INTRODUCTION: Transcutaneous parasacral nerve stimulation (TPNS) via electrodes placed over the sacrum can activate afferent neuronal networks noninvasively, leading to sacral reflexes that may improve colonic motility. Thus, TPNS can be considered a promising, noninvasive, and safe method for the treatment of constipation. However, there is no published study investigating its use in children with functional constipation. This is a single-center, prospective, longitudinal, and interventional study designed to assess the applicability and clinical outcomes of TPNS in functionally constipated children. PATIENT CONCERNS: Parents or guardians of patients will be informed of the purpose of the study and will sign an informed consent form. The participants may leave the study at any time without any restrictions. DIAGNOSIS: Twenty-eight children (7-18 years old) who were diagnosed with intestinal constipation (Rome IV criteria) will be included. INTERVENTIONS: The patients will be submitted to daily sessions of TPNS for a period of 4 or 8 weeks and will be invited to participate in semistructured interviews at 3 or 4 moments: 1 week before the beginning of TPNS; immediately after the 4 and/or 8 weeks of TPNS; and 4 weeks after the end of the intervention period. In these appointments, the aspects related to bowel habits and quality of life will be assessed. OUTCOMES: This study will evaluate the increase in the number of bowel movements and stool consistency, the decrease in the number of episodes of retentive fecal incontinence, and the indirect improvement in the overall quality of life. CONCLUSION: we expect that this study protocol can show the efficacy of this promising method to assist the treatment of children with functional constipation.

MicroRNA expression profiles in the esophagus of children with caustic stenosis: A pathway towards esophageal cancer?

BACKGROUND: Eighty percent of caustic ingestions occur in children and esophageal neoplasms may develop as a late complication of such injury. The identification of biomarkers is a promising strategy to improve early diagnosis of esophageal cancer or caustic lesions that are at an increased risk of progression. STUDY DESIGN/AIMS: This study aimed at identifying global microRNA (miRNA) expression changes in esophageal mucosa from children with caustic stenosis. The study included 27 biopsy samples from 15 patients. Samples were divided into two groups, according to the time elapsed after injury (N = 15 in Group A, with less than five years of follow-up and N = 12 in Group B, with more than five years of follow-up). miRNA expression profiles were determined in each lesion, compared with normal esophageal tissues from control group. We used the TaqMan Human MicroRNA Arrays (Thermo Fisher) platform. Furthermore, bioinformatic algorithms were used to identify miRNA target genes and biological pathways including miRNAs and their target genes potentially associated with esophageal disease. RESULTS: Thirteen miRNAs were significantly deregulated (9 over- and 4 underexpressed) in patients from Group A. In patients from Group B, two miRNAs were over- and two were underexpressed. Of note, miR-374 and miR-574 were deregulated in Group B patients and have been linked to esophageal tumorigenesis. We identified signal transduction and transcription factor networks with genes strongly related to development and progression of esophageal cancer. CONCLUSION: miRNAs identified here contribute to a better understanding of pathways associated with malignant transformation from caustic stenosis to neoplastic lesions. This study may serve as a basis for validation of miRNAs, including miR-374 and miR-574, as potential biomarkers of early cancer detection.

Combinations of laxatives and green banana biomass on the treatment of functional constipation in children and adolescents: a randomized study.

OBJECTIVES: Evaluate the effect of combinations of green banana biomass and laxatives in children and adolescents with chronic constipation. METHODS: This was a randomized study of 80 children and adolescents with functional constipation according to the Rome IV Criteria, who were divided into five groups: (1) green banana biomass alone; (2) green banana biomass plus PEG 3350 with electrolytes; (3) green banana biomass plus sodium picosulfate; (4) PEG 3350 with electrolytes alone; and (5) sodium picosulfate alone. Primary outcome measure was the reduction of the proportion of patients with Bristol Stool Form Scale ratings 1 or 2. Secondary outcome measures were: increase of the proportion of >3 bowel movements/week and reduction of the proportion of fecal incontinence, straining on defecation, painful defecation, blood in stool, abdominal pain, and decreased laxative doses. RESULTS: On consumption of green banana biomass alone, a statistically significant reduction was observed in the proportion of children with Bristol Stool Form Scale rating 1 or 2, straining on defecation, painful defecation, and abdominal pain. Conversely, no reduction was observed in fecal incontinence episodes/week, blood in stool, and no increase was observed in the proportion of children with >3 bowel movements/week. The percentage of children who required decreased laxative dose was high when green banana biomass was associated with sodium picosulfate (87%), and PEG 3350 with electrolytes (63%). Green banana biomass alone and associated with laxatives was well tolerated, and no adverse effects were reported. CONCLUSION: Green banana biomass is advantageous as an adjunct therapy on functional constipation, mainly for reducing doses of laxatives.

Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital. / Implementação de um modelo de triagem cirúrgica para casos urgentes em um hospital terciário.

OBJECTIVE: to evaluate the applicability of the "Timing of Acute Care Surgery" (TACS) color classification system in a tertiary public hospital of a developing country. METHODS: we conducted a longitudinal, retrospective study in a single center, from March to August 2016 and the same period in 2017. We opted for the selection of four surgical specialties with high demand for emergencies, previously trained on the TACS system. For comparisons with the previous classifications, we considered emergencies as reds and oranges and urgencies, as yellow, with an ideal time interval for surgery of one hour and six hours, respectively. RESULTS: non-elective procedures accounted for 61% of the total number of surgeries. The red, orange and yellow classifications were predominant. There was a significant improvement in the time before surgery in the yellow color after the TACS system. Day and night periods influenced the results, with better ones during the night. CONCLUSION: this is the first study to use the TACS system in the daily routine of an operating room. The TACS system improved the time of attendance of surgeries classified as yellow.

OBJETIVO: avaliar a aplicabilidade do sistema de classificação de cores "Timing of Acute Care Surgery" (TACS) em um hospital público terciário de um país em desenvolvimento. MÉTODOS: estudo longitudinal, retrospectivo, de um único centro, de março a agosto de 2016 e o mesmo período em 2017. Optou-se pela seleção de quatro especialidades cirúrgicas com alta demanda de urgências, as quais foram previamente treinadas sobre o sistema TACS. Para comparação com as classificações prévias de urgência e emergência, emergências foram consideradas como vermelhas e laranjas e urgências como amarelas, com intervalo de tempo ideal para cirurgia de uma hora e de seis horas, respectivamente. RESULTADOS: os procedimentos não eletivos representaram 61% do número total de cirurgias. As classificações vermelha, laranja e amarela foram predominantes. Houve melhora significativa do tempo para a cirurgia na cor amarela após o sistema TACS. Períodos diurnos e noturnos influenciaram os resultados, com melhores resultados durante o período noturno. CONCLUSÃO: este é o primeiro estudo que usou o sistema TACS no dia a dia de um centro cirúrgico, e demonstrou que o sistema TACS melhorou o tempo de atendimento das cirurgias classificadas como amarelas.

Transcutaneous posterior tibial nerve stimulation in children and adolescents with functional constipation: A protocol for an interventional study.

INTRODUCTION: A vast majority of children with functional constipation respond to the standard medical treatment. However, a subset of patients may present with an unsatisfactory response and only minor improvement of symptoms. Transcutaneous posterior tibial nerve stimulation (PTNS) involves electrical stimulation of the posterior tibial nerve at the level of the ankle, transcutaneously through electrodes fixated on the overlying skin. Stimulation of the tibial nerve can modulate urinary and defecatory function through the stimulation of sacral nerves. Thus, transcutaneous PTNS can be considered a very promising, noninvasive, and safe method to be used in the pediatric age group. However, there is still no published study that has investigated its use in children for the treatment of intestinal constipation. This is a single-center, prospective, longitudinal, and interventional study designed to assess the applicability and clinical outcomes of transcutaneous PTNS in children with functional intestinal constipation. Children will be submitted to daily sessions of transcutaneous PTNS for a period of 4 weeks. All children will also be invited to participate in semistructured interviews, 1 in each of the 3 assessments: 1 week before the start of the intervention; immediately after the 4 weeks of intervention; and 4 weeks after the end of the intervention period. In these interviews, the aspects related to bowel habits and quality of life will be assessed. This project aims to evaluate the clinical outcomes of transcutaneous PTNS in children with functional intestinal constipation and the applicability of this kind of treatment. CONCLUSIONS: This protocol intended to demonstrate the efficacy of this promising method to increase the number of bowel movements and the stool consistency, to reduce the number of episodes of retentive fecal incontinence, and to indirectly improve the overall quality of life.