Onfalopagus parasitic fusioned twin: A case report.

INTRODUCTION AND IMPORTANCE: The parasitic fetus is a kind of siamese twin, in which one of the twins is reabsorbed and some parts of the body can remain attached to the other twin. It is a very rare event, with a birth incidence that varies from 0.05 to 1.47 cases per 100,000. CASE PRESENTATION: This paper reports the case of a parasitic twin diagnosed at 34 weeks of gestational age. Preoperative ultrasonography was performed and the absence of communication between vital organs and the parasite was observed, and surgery was scheduled at 10 days of life. A multidisciplinary team performed the surgical procedure and the child was discharged from the intensive care unit after 3 months. CLINICAL DISCUSSION: After diagnosis and birth, it is essential to investigate the anomalies found for future surgical programming, and cases of twins who do not share vital organs, for example, heart or brain, have higher survival rates. The treatment is surgical and the objective of the surgery must be resection of the parasite. CONCLUSION: The diagnosis still in the gestational period is essential to plan the best mode of delivery and neonatal care, as well as define the surgical schedule. The hospital must be tertiary and the presence of a multidisciplinary team is necessary to perform the surgery in order to present the highest success rates.

CT scan in the evaluation of pediatric abdominal trauma.

OBJECTIVE: to assess the need of computed tomography (CT) for the definition of management in pediatric abdominal trauma. METHODS: observational retrospective study with patients under 18 years old victims of blunt or penetrating abdominal trauma that underwent CT of the abdomen and pelvis at admission. We evaluated CT scan findings, indications and management. We calculated the sensitivity, specificity, positive predictive value and negative predictive value of clinical variables and energy of trauma for findings on CT. RESULTS: among the 236 patients included in our study, 72% (n=170) did not present abnormal findings on CT. It was performed surgical treatment in 15% (n=10), conservative treatment in 54,5% (n=36) and 27% (n=18) did not receive treatment for abdominal injuries. In the assessment of CT indications, 28,8% (n=68) presented no justifications. In this group, 91% (n=62) did not show any abnormal findings. Among the six patients with positive findings, half were selected for conservative treatment, while the rest did not need any treatment for abdominal injuries. The presence of abdominal pain, hemodynamic alterations and high energy blunt trauma had low positive predictive values when isolated, whereas the negative predictive values were higher. CONCLUSION: although CT is necessary in some instances, there is a possible high number of exams that did not make any difference in the management of the pediatric population.

Use of sildenafil and L-arginine in an experimental rat model for the prevention of neonatal necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) has a 45% mortality in neonatal intensive care units. This paper aimed to evaluate the isolated and combined effects of sildenafil and L-arginine in the prevention of necrotizing enterocolitis. Neonatal rats were fed formula milk and submitted to hypoxia under a 100% N2 atmosphere for 70 s. Then, animals were subjected to hypothermia (4 °C for 10 min), twice a day for 3 days. Forty neonatal rats were divided into five groups: negative control-not submitted to the protocol (n = 5), sildenafil group-NEC protocol (n = 9), L-arginine group-NEC protocol (n = 9), L-arginine and sildenafil group-NEC protocol (n = 9) and positive control-NEC protocol and intraperitoneal saline solution (n = 8). Jejunum and terminal ileus were removed for histopathologic and immunohistochemical Ki-67 analysis. Kruskal-Wallis test was used to analyze mortality, survival, body weight, intestinal injury score and Ki-67 proliferation index. All animals submitted to the protocol developed enterocolitis. Mortality rate was higher in group that received only L-arginine (p = 0.0293). The Ki-67 analysis showed a higher proliferative index in groups that received interventional drugs (p = 0.017). In conclusion, sildenafil and L-arginine were not effective to reduce intestinal injury.

CT scan in the evaluation of pediatric abdominal trauma / Tomografia computadorizada na avaliação do trauma abdominal pediátrico

ABSTRACT Objective: to assess the need of computed tomography (CT) for the definition of management in pediatric abdominal trauma. Methods: observational retrospective study with patients under 18 years old victims of blunt or penetrating abdominal trauma that underwent CT of the abdomen and pelvis at admission. We evaluated CT scan findings, indications and management. We calculated the sensitivity, specificity, positive predictive value and negative predictive value of clinical variables and energy of trauma for findings on CT. Results: among the 236 patients included in our study, 72% (n=170) did not present abnormal findings on CT. It was performed surgical treatment in 15% (n=10), conservative treatment in 54,5% (n=36) and 27% (n=18) did not receive treatment for abdominal injuries. In the assessment of CT indications, 28,8% (n=68) presented no justifications. In this group, 91% (n=62) did not show any abnormal findings. Among the six patients with positive findings, half were selected for conservative treatment, while the rest did not need any treatment for abdominal injuries. The presence of abdominal pain, hemodynamic alterations and high energy blunt trauma had low positive predictive values when isolated, whereas the negative predictive values were higher. Conclusion: although CT is necessary in some instances, there is a possible high number of exams that did not make any difference in the management of the pediatric population.

RESUMO Introdução: avaliar a necessidade da tomografia computadorizada (TC) para definição de condutas em trauma abdominal pediátrico. Métodos: estudo observacional retrospectivo com pacientes menores de 18 anos vítimas de trauma abdominal contuso ou penetrante e que realizaram TC de abdome e pelve na admissão. Avaliou-se achados das tomografias, condutas e justificativas para indicação da TC. Foram calculados sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de fatores clínicos e energia do trauma para alterações na TC. Resultados: dentre os 236 pacientes incluídos, 72% (n=170) não apresentaram alterações na TC. Foi realizado tratamento cirúrgico em 15% (n=10), tratamento conservador em 54,5% (n=36) e 27% (n=18) não receberam tratamento por lesões abdominais. Na avaliação das indicações de TC, 28,8% (n=68) não apresentavam nenhuma justificativa, sendo que nesse grupo 91% (n=62) resultaram em ausência de achados. Dentre os seis pacientes com achados positivos, metade recebeu tratamento conservador, enquanto o restante não necessitou de tratamento por lesões abdominais. A presença de dor abdominal, alteração hemodinâmica e trauma contuso de alta energia apresentaram baixos valores preditivos positivos de forma isolada, enquanto os valores preditivos negativos foram mais altos. Conclusão: apesar de a TC ser necessária e justificável em alguns casos, há um possível excesso de tomografias dispensáveis para definição de condutas em população pediátrica.

Twin-twin transfusion syndrome - a University Hospital experience with intrauterine treatment.

INTRODUCTION: twin-to-twin transfusion syndrome (TTTS), defined by combination of polyhydramnios-oligohydramnios, is the most prevalent (5%-35%) of the abnormalities due to placental vascular anastomoses and the most lethal (80%-100% mortality) if untreated. Fetoscopic laser ablation of abnormal vasculature using the Solomon technique is the gold standard approach. It consists of interrupting the intertwin blood flow. OBJECTIVES: to present our initial experience at the Fetal Surgery Service of the Hospital de Clinicas of the Federal University of Parana (HC-UFPR) and to compare our results with those reported in the literature. METHODS: we conducted a retrospective analysis of pregnancies who had undergone laser ablation, assessing data on Quintero's staging, gestational age at diagnosis and at the time of the procedure, placental position, immediate post-procedure survival, and survival after the neonatal period. We then compared these data with the most recent data available in the literature. RESULTS: we analyzed ten TTTS cases. The diagnosis was performed before the 26th week of pregnancy (median 20.8 weeks) and treatment occurred in a median of 9.5 days later. The distribution by the Quintero's staging was of three cases in stage II, five in stage III, and two in stage IV. In 50% of the gestations, at least one of the fetuses survived through the neonatal period. CONCLUSION: the treatment of TTTS in the HC-UFPR had a positive impact in the survival of the affected fetuses, although the results were worse than the ones reported in the literature, probably due to the delay in referencing the patients to our service, leading to a prolonged interval between diagnosis and treatment.

Carotid-Esophageal Fistula Treated By Endovascular Approach.

The carotid-esophageal fistula is a rare and serious complication of the metallic esophageal prosthesis. A high index of suspicion is required for early diagnosis and treatment, decreasing the morbidity and mortality rate of this severe complication. We report a case of a 4-year-old boy presenting severe upper gastrointestinal bleeding due to a carotid-esophageal fistula, secondary to deployment of an esophageal metallic prosthesis for treatment of a recurrent stenosis. The carotid pseudo-aneurism was successfully treated with stents and coils. Although endovascular treatment is a safe and effective option, arterial stenting in children needs further studies with long-term follow-up.

Twin-twin transfusion syndrome - a University Hospital experience with intrauterine treatment / Síndrome da transfusão feto-fetal - experiência de um hospital universitário com tratamento intrauterino

ABSTRACT Introduction: twin-to-twin transfusion syndrome (TTTS), defined by combination of polyhydramnios-oligohydramnios, is the most prevalent (5%-35%) of the abnormalities due to placental vascular anastomoses and the most lethal (80%-100% mortality) if untreated. Fetoscopic laser ablation of abnormal vasculature using the Solomon technique is the gold standard approach. It consists of interrupting the intertwin blood flow. Objectives: to present our initial experience at the Fetal Surgery Service of the Hospital de Clinicas of the Federal University of Parana (HC-UFPR) and to compare our results with those reported in the literature. Methods: we conducted a retrospective analysis of pregnancies who had undergone laser ablation, assessing data on Quintero's staging, gestational age at diagnosis and at the time of the procedure, placental position, immediate post-procedure survival, and survival after the neonatal period. We then compared these data with the most recent data available in the literature. Results: we analyzed ten TTTS cases. The diagnosis was performed before the 26th week of pregnancy (median 20.8 weeks) and treatment occurred in a median of 9.5 days later. The distribution by the Quintero's staging was of three cases in stage II, five in stage III, and two in stage IV. In 50% of the gestations, at least one of the fetuses survived through the neonatal period. Conclusion: the treatment of TTTS in the HC-UFPR had a positive impact in the survival of the affected fetuses, although the results were worse than the ones reported in the literature, probably due to the delay in referencing the patients to our service, leading to a prolonged interval between diagnosis and treatment.

RESUMO Introdução: a síndrome de transfusão feto-fetal (STFF), definida pela combinação polidrâmnio-oligohidrâmnio, é a mais prevalente (5 a 35%) das anormalidades associadas às anastomoses vasculares placentárias e tem a maior letalidade (80 a 100%) se não tratada. A ablação a laser destes vasos por via fetoscópica com a técnica de Solomon é o tratamento de escolha atual para a interrupção das anastomoses vasculares. Objetivo: apresentar a experiência inicial do Serviço de Cirurgia Fetal do Hospital de Clínicas da Universidade Federal do Paraná (HC-UFPR) e comparar nossos resultados com os da literatura. Métodos: foram revisados os prontuários de todas as pacientes submetidas ao procedimento de ablação a laser, sendo analisados os dados referentes ao estadiamento de Quintero, à idade gestacional ao diagnóstico e ao procedimento, à posição placentária, à sobrevida imediata pós-procedimento e sobrevida após o período neonatal. Os dados foram então comparados com os mais recentes disponíveis na literatura. Resultados: dez casos de STFF foram analisados. Todos diagnosticados antes da 26a semana (mediana 20,79) e o intervalo diagnóstico-tratamento teve mediana de 9,5 dias. A distribuição pelo estadiamento de Quintero foi: três casos no estádio II, cinco casos no III e dois casos no IV. Em 50% das gestações pelo menos um dos fetos sobreviveu ao período neonatal. Conclusão: o tratamento da STFF no HC-UFPR impactou positivamente a sobrevida dos fetos acometidos. Entretanto, nossos resultados estão aquém dos reportados na literatura, possivelmente pelo demora no referenciamento das pacientes, com intervalo aumentado entre diagnóstico e tratamento.

Early medical school graduation during the COVID-19 pandemic: preliminary assessment / Graduação antecipada do curso de medicina durante a pandemia de COVID-19: avaliação preliminar

Abstract: Introduction: The current outbreak of the new coronavirus or SARS-CoV-2, which causes COVID-19, was first reported to the World Health Organization on December 31, 2019, being declared a pandemic on March 11, 2020. As for the clinical spectrum of SARS-CoV-2 infection, it is a broad one, ranging from asymptomatic, mild upper respiratory tract disease to severe viral pneumonia with respiratory failure and death. With a chance of severe clinical presentation close to 25%, SARS-CoV-2 infection can lead to health service overload and increase the demand for material and human resources. Aiming to increase the availability of health professionals directly involved in care during the pandemic, the Ministry of Education authorized the early graduation for students pursuing careers in health, including medicine. Objective: The aim of this article is to obtain preliminary results of the impact of early graduation for medical students during the COVID-19 pandemic. Method: Observational and cross-sectional study, carried out by applying a questionnaire with 13 questions, five of which used a Likert scale of assessment, six in multiple choice format and two descriptive, via Google Forms, applied to medical students from the universities of Curitiba-PR that graduated earlier in mid-year 2020, due to the COVID-19 pandemic. Results: 113 recently graduated students answered the questionnaire.101 participants reported that they are working as physicians and, among them, 63.36% stated that they are working directly in the treatment of COVID-19 cases. Regarding the importance of an early graduation, most participants fully agree or agree, while only three participants totally disagree. More than half of the interviewees do not feel harmed by the early graduation. However, 43.3% believe they have failed to acquire important information for their training. Finally, regarding their performance in the pandemic, 79.6% consider important their role in the fight against COVID-19 pandemic. Conclusion: The study shows that, at first, the efforts to give the Class of 2020 an early graduation were successful, since these new physicians are contributing to alleviate workforce shortages and provide better care for patients during the pandemic.

Resumo: Introdução: O atual surto do novo coronavírus ou Sars-CoV-2, causador da Covid-19, foi relatado pela primeira vez à Organização Mundial da Saúde, pela China, em 31 de dezembro de 2019, sendo declarada pandemia em 11 de março de 2020. Quanto ao espectro clínico da infecção pelo Sars-CoV-2, ele é amplo, variando de quadro assintomático, doença leve do trato respiratório superior, a pneumonia viral grave com insuficiência respiratória e morte. Com uma chance de apresentação clínica grave próxima a 25%, a infecção pelo Sars-CoV-2 pode levar à sobrecarga dos serviços de saúde e aumentar a demanda tanto por recursos materiais como humanos. Para aumentar a disponibilidade de profissionais da área da saúde envolvidos diretamente no atendimento durante a pandemia, o Ministério da Educação autorizou a antecipação da formatura para estudantes de várias áreas da saúde, incluindo Medicina. Objetivo: O objetivo do presente artigo é realizar uma avaliação preliminar do impacto da antecipação da graduação para os formandos de Medicina durante a pandemia de Covid-19. Método: Trata-se de estudo observacional e transversal realizado por meio da aplicação de questionário com 13 perguntas: em cinco, utilizou-se escala Likert de avaliação; em seis, adotou-se o formato de múltipla escolha; e duas foram descritivas. O questionário foi enviado, via Formulário Google, a alunos de Medicina das universidades de Curitiba, no Paraná, formados no primeiro semestre de 2020, que anteciparam a outorga de grau em razão da pandemia de Covid-19. Resultados: Responderam ao questionário 113 formandos, dos quais 101 relataram que já atuam como médicos. Destes, 63,36% afirmaram que estão trabalhando diretamente no atendimento de casos de Covid-19. Sobre a importância da antecipação da outorga de grau, a maioria dos participantes concorda totalmente ou concorda, e apenas três participantes discordam totalmente. Mais da metade dos entrevistados não se sentem prejudicados com a antecipação da outorga de grau. Contudo, 43,3% acreditam que deixaram de adquirir informações importantes em sua formação. Por fim, quanto ao fato de trabalharem na pandemia, 79,6% consideram importante a atuação de médicos recém-formados no combate à Covid-19. Conclusão: Este estudo mostra que, a princípio, os esforços para a antecipação de formatura foram bem-sucedidos, já que os novos médicos estão contribuindo para aliviar a pressão imposta pela falta de profissionais e promover um melhor cuidado aos pacientes durante a pandemia.

Kaposiform hemangioma of jejunum in a newborn: A case report and review of literature.

INTRODUCTION: Kaposiform hemangioendothelioma is a rare tumor, of vascular origin, which predominates in childhood. Although it is frequently a vascular cutaneous anomaly, it is known that some cases can involve bones, mediastinum and retroperitoneum, being even rarer when it occurs in the small intestine, representing only 0.05% of all intestinal neoplasms. PRESENTATION OF CASE: Female patient, 21 days old, born at 38 weeks, is admitted to the hospital due to bilious vomiting, dehydration and major abdominal distension. An X-ray of the acute abdomen suggests type I jejunal atresia. An exploratory laparotomy was performed, with the presence of a stenotic area in the proximal jejunum, which was chosen for resection of the stenotic area and end-to-end terminal anastomosis, with post-pyloric jejunostomy. The presence of kaposiform hemangioma was confirmed by immunohistochemistry, and the patient had no further complications. DISCUSSION: The presence of hemangiomas in childhood is frequent, is but it very rare when it appears in the gastrointestinal location, as reported in the present case. A common presentation is intestinal bleeding, being manifested as anemia or, sometimes, acute and potentially fatal anemia. Other forms of rare presentation include intussusception, perforation and obstruction, the latter being out patient's last manifestation. The diagnosis of this alteration can be difficult, and often performed only in the intraoperative period of an exploratory laparotomy. CONCLUSION: The presence of bilateral vomiting and intestinal obstruction in newborns opens the possibility of a wide range of possible diagnoses, such as the presence of intestinal atresia. Kaposiform intestinal hemangioma is an uncommon cause in these clinical manifestations, but it should be included in the differential diagnosis.

Bladder Urothelial Carcinoma in a Child: Case Report and Review of Literature.

Bladder urothelial carcinoma (UC) it is the fifth most prevalent carcinoma in humans, nevertheless in children and young adults it's very rare. It usually occurs in older adults. Literature on UC in pediatric population is limited and important information (risk factors, follow-up protocols, etc.) are poorly defined. We present an 11-year-old boy with a painful macroscopic hematuria. Ultrasound revealed a heterogeneous intravesical mass without extravesical extension, which was confirmed by computed tomography (CT) and magnetic resonance imaging (MRI). The first biopsy was compatible with urothelial papilloma. After 1 year, he returned with a bigger mass. Transurethral resection of the bladder (TURB) was performed and immunohistochemistry showed low-grade papillary UC with a high-grade component, with tumor free margin. Tumor had mutations in the BRAF and KRAS genes. Two and a half years after the resection the patient has no recurrence. Less than 1% of bladder UC occur in the first two decades of life. Gross hematuria is a common symptom. Ultrasound is generally the first diagnostic tool. MRI is also helpful, but cystoscopy allows definitive diagnosis. Transurethral resection of the bladder (TURB) is the standard treatment, with good results and low recurrence rate, and it was the treatment of choice for our patient, that remains free of disease. The BRAF and KRAS gene mutations were never described before in pediatric UC. There are only few cases in literature of pediatric UC that present a tumor genetic profile; therefore, our case report adds more information to this very rare disease in children.

Open Versus Laparoscopic Splenectomies in Children: A Comparative Study Performed at a Public Hospital in Brazil.

Introduction: In pediatric population, the two most common indications for splenectomy include traumatic rupture and hematological diseases such as hereditary spherocytosis, idiopathic thrombocytopenic purpura, sickle cell disease, and autoimmune hemolytic anemia. Traditionally, splenectomy has been an open procedure; however, since the first laparoscopic splenectomy was reported in 1991, the minimally invasive laparoscopic approach has become increasingly popular. In most public hospitals in Brazil, where vessel sealing devices are not available, most surgeons seem to prefer open splenectomy to guarantee intraoperative safety and improved outcomes. Objectives: To compare outcomes between open and laparoscopic splenectomy in children in a public hospital in Brazil. Materials and Methods: Retrospective study conducted between January 2010 and June 2018. Patients from 0 to 14 years old who underwent open or laparoscopic splenectomy at the University Hospital of Federal University of Paraná were included. Clinical, laboratory, imaging, and surgical data were collected. Results: For 8 years, 35 patients underwent splenectomy. Mean age was 4 years old and 54% were female. Of the 35 subjects, 69% had sickle cell anemia and 23% spherocytosis. The most common indication for surgery was a previous episode of splenic sequestration. The 13 laparoscopic surgeries were performed without harmonic scalpel or other vessel sealing devices. During the laparoscopic procedure, 2 patients experienced intraoperative complications: bleeding and prolonged surgical time due to technical problems with the equipment. Mean operative time was higher in laparoscopy group than in open group (186 minutes versus 66 minutes). Oral feeds began earlier on the laparoscopic group. Postoperatively, there were more complications on the open group, and no reoperations. There was only one fatality, likely secondary to fulminant sepsis, which occurred 34 days after the surgery in a patient who was undergoing prophylactic oral antibiotics therapy. Discussion: Performing laparoscopic splenectomy without harmonic scalpel or other vessel sealing devices is feasible, but it implicates in a significantly higher surgical time. Laparoscopic splenectomy had earlier oral feeds and fewer complications than open surgery.

Management of traumatic urethral injuries in children using different techniques: A case series and review of literature.

INTRODUCTION: Most pediatric urethral injuries are a result of pelvic fracture after high-impact blunt trauma, mainly due to motor vehicle accidents. The management of urethral injuries depends on if the rupture is complete or partial as well as the timing of surgical intervention. PRESENTATION OF CASES: Three male children with urethral trauma caused by motor vehicles accidents are presented in this article. Preoperative suprapubic catheterization was initially carried out in all patients. Each patient then received one of three different techniques during the deferred time to surgical intervention: anterior sagittal transanorectal approach (ASTRA) for end-to-end urethral anastomosis, perineal approach for urethroplasty using buccal mucosa, and urethroplasty with preputial skin flap. The three techniques were successfully performed. DISCUSSION: In the initial management suprapubic cystostomy has been a good solution in urgent situations. Deferred urethroplasty is the procedure of choice for the definite treatment of posterior urethral distraction defects. The anterior sagittal transanorectal approach provides excellent exposure of the posterior urethra and retrovesicular region, and allows the surgeon to perform dissection under direct vision. CONCLUSION: It's very important for the pediatric urologist to be familiar with the different techniques available in order to choose the best approach for each particular patient.

Correlation between selected angiogenic markers and prognosis in pediatric adrenocortical tumors: Angiogenic markers and prognosis in pediatric ACTs.

BACKGROUND/PURPOSE: Pediatric adrenocortical tumor (ACT) remains a challenging disease. Tumor weight and disease stage are still the most used indicators to prognosis and guidance of clinical decisions. Histology has not added meaningful data for risk stratification and management. ACT is metabolically active, highly vascularized, locally invasive and has the propensity to produce distant metastasis. Our objective was to correlate the expression of vascular endothelial growth factor (VEGF) and intratumoral microvessel density (MVD) with clinical and prognostic aspects in pediatric ACT. PROCEDURE: In 27 tumors, immunohistochemical expression of VEGF, CD105 (endoglin) and CD34 was analyzed. MVD was determined by CD34 and CD105 antibodies. MVD and VEGF expression was correlated with clinical characteristics and outcome. Normal pediatric glands were used as controls. RESULTS: Endoglin MVD was significantly higher and CD34 MVD was significantly lower in ACT than control. The VEGF expression did not differ between groups. Cytoplasmic staining for endoglin was correlated with hypertension in ACT. Endoglin MVD greater than 1 mv/field, CD34 MVD less than 32 mv/field and VEGF expression levels above 4.8% were associated with clinical and biological indicators of poor prognosis. CONCLUSIONS: Endoglin and CD34 MVD values are potential histological markers to refine the histologic classification of pediatric ACT.

Anterior sagittal approach without splitting the rectal wall.

INTRODUCTION: The anterior sagittal transrectal approach (ASTRA) has already become popular to treat lesions in the proximal urethra such as trauma, duplicity and stenosis, prostatic utricle, urethral-vaginal fistulas and urogenital sinus anomalies. It provides much better exposure than the traditional perineal approach. Morbidity caused by this technique could be potentially decreased if the anterior sagittal access were to be made without sectioning the rectum. We report our initial experience using anterior approach without rectal sectioning for the treatment of three different types of pelvic disorders. PRESENTATION OF CASE: Anterior sagittal access without sectioning the rectal wall was carried out in three different clinical cases - a vaginoplasty in a female patient with congenital adrenal hyperplasia; to treat paradoxical urinary incontinence in a patient with proximal hypospadias (46XY karyotype) and another one with gonadal dysgenesis (46XO/XY karyotype). DISCUSSION: Several surgical techniques have been reported to repair congenital or acquired lesions in the posterior urethra with high morbidity and no guarantees of adequate and safe surgical exposition. ASTRA provides an excellent exposure, splitting only the anterior rectal wall. In this study, the anterior sagittal approach was applied without splitting the rectal wall to repair different posterior urethral anomalies, providing excellent exposure without compromising the fecal continence mechanism. CONCLUSION: The anterior sagittal approach without splitting the rectum is a feasible procedure which provides excellent exposure to the posterior urethra in most cases and leads to less morbidity as it avoids the splitting and suturing of the rectum anterior wall.

Apple-peel intestinal atresia: enteroplasty for intestinal lengthening and primary anastomosis.

Apple-peel atresia (or Type-IIIb intestinal atresia) is an unusual type of jejunoileal atresia. They present with jejunal atresia near the ligament of Treitz and a foreshortened small bowel. Many surgical options have been used, but the optimal method of repair remains unclear. We present a case of a newborn with apple-peel intestinal atresia managed by enteroplasty for intestinal lengthening and primary anastomosis.

Renal tumor and trauma: a pitfall for conservative (correction of conversative) management.

PURPOSE: Conservative management has been largely used for renal trauma. Although this approach is safe and highly recommended, it can hide a pre-existing unknown condition, such as tumors or urinary malformations. A high index of suspicion is needed for early recognition of these conditions. We present four cases treated at the Pediatric Oncology Institute - Federal University of São Paulo, which have been initially treated conservatively for renal trauma. MATERIALS AND METHODS: We reviewed all 218 renal cases of renal tumors treated at our institution in a 22-year period, searching for associated trauma events. RESULTS: Four cases of renal tumors were initially treated conservatively for blunt renal trauma of low energy mechanism. Patients ' ages ranged from 7 to 12 years old. Two patients had no previous symptoms, one patient had hematuria and another had an abdominal mass. Computerized Axial Tomography (CT) of the abdomen revealed disparate magnitude of the renal bleeding to the low energy mechanism of trauma. All patients underwent surgical treatment. Kidney specimens showed Wilms tumor in three cases and renal carcinoma in one. CONCLUSIONS: The association between renal tumors and trauma should be suspected when renal trauma hemorrhage on abdominal CT scan does not match the low energy mechanism of blunt abdominal trauma. The key for a successful diagnosis of renal tumor or congenital malformations is the high index of suspicion for these conditions.

Mordedura canina: 140 casos em 6 meses / Dog bites: 140 cases in 6 months

O presente estudo é do tipo série prospectiva de casos e compreendeu 140 pacientes consecutivos atendidos inicialmente na emergência do Hospital do Trabalhador no período de maio a novembro de 2001. Oitenta e quatro por cento dos pacientes procediam da cidade de Curitiba; 65 por cento eram homens. A idade mais atingida foi entre 0 e 10 anos (25,7 por cento), sendo a mediana de 23 anos. Trinta e um por cento dos cäes tinham história anterior de ataque a outras pessoas. A face doi atingida em 31 pacientes (22,1 por cento) sendo 22 (71 por cento) destes, menores de 10 anos.Os membros superiores foram atingidos 102 vezes e o inferior 51. As crianças foram as mais atingidas, sendo o membro superior, membro inferior e face respectivamente os mais afetados. Quinze pacientes (10,7 por cento) necessitaram de internamento para tratamento cirúrgico, demonstrnado maior gravidade em nossa casuística do que o visto na literatura (4 por cento)