Injury patterns from major urban terrorist bombings in trains: the Madrid experience.

BACKGROUND: Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI. METHODS: We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS. RESULTS: The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h. CONCLUSIONS: Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.

[Management endourologic of pyeloureteral junction stenosis]. / Tratamiento endourológico de la estenosis pieloureteral congénita.

OBJECTIVES: To report our experience with endourologic methods in the treatment of pyeloureteral stenosis in children. MATERIALS AND METHODS: From July 2004, 7 patients from 9 months to 15 years old with pyeloureteral junction stenosis (PUJ) diagnosis underwent endourologic repair. An endourological dilatation was made under radioscopic control. The procedures consist of an initial cystoscopy with a retrograde placement of catheter (4 or 5 Fr) and the guide wire (0,014''-or 0,035''). The high pressure balloon (3 to 5 Fr) was then railroad over the wire and positioned across the stenosis for dilatation. A double J stent (3 to 6 Fr) was then introduced, remaining it during 6 weeks. RESULTS: There was no intraoperative complications. Median inhospital stay was 2 days (range, 2 to 8). The double J stent was removed without complications. All patients are asymptomatic with improvement in excretion times (MAG3 renography) and antero-posterior renal pelvis diameter (ultrasound measurement). CONCLUSIONS: Balloon dilatation is a viable option in the management of PUJ obstruction even in children under one year old, with minimal morbidity.

Estrategia terapéutica en la extrofia de cloaca femenina / Therapeutic strategy in cloacal exstrophy

La extrofia de cloaca femenina enfrenta al cirujano pediá- trico con un reto en el que está implicada la reconstrucción del tracto genitourinario y digestivo así como su manejo funcional. El objetivo de nuestro trabajo es presentar nuestra experiencia en el manejo de las malformaciones genitales en niñas con extrofia de cloaca así como de la continencia urinaria y fecal. Revisamos las historias clínicas de las pacientes tratadas en nuestro centro en las que se ha llegado a una corrección definitiva del espectro malformativo de la extrofia de cloaca. En las tres pacientes se ha realizado un cierre del cuello vesical y un estoma cateterizable continente a través del cual llevan a cabo un programa de autocateterismo vesical intermitente, manteniéndose secas. Con respecto a la integración psicosexual, las tres pacientes están satisfechas con el resultado cosmético obtenido, aunque sólo una de ellas mantiene relaciones sexuales. El manejo de la extrofia de cloaca femenina debe tener en cuenta tanto los factores anatómicos como funcionales. La reconstrucción genital en niñas con extrofia de cloaca requiere un plan ajustado en cada paciente y en ocasiones realizar varias intervenciones hasta que la paciente esté satisfecha con el resultado tanto cosmético como funciona (AU)

Cloacal exstrophy is a complex multisistemic anomaly thatinvolves gastrointestinal and genitourinary issues. The aim of our paper is to report our experience in dealing with genital reconstruction and faecal and urinary continence in patients with female cloacal anomalies. We reviewed the clinical records from the three patients we have achieved a final reconstruction. We recorded the surgical management and both functional and anatomic results. The three of them required a bladder neck closure associated with a continent stoma, they are dry with intermittent catheterization and free of upper urinary complications. Genital reconstruction required a unique plan for each one, according to their anatomy and their cosmetic desires. One of the patients reported satisfactory sexual intercourse. Management of patients with cloacal exstrophy has major concerns about urinary and fecal continence and about genital reconstruction and function. Knowing the long-term results may help to develop management strategies and improve counselling for patients who have undergone reconstruction (AU)

Tratamiento endourológico de la estenosis pieloureteral congénita / Management endourologic of pyeloureteral junction stenosis

Objetivo: Presentamos nuestra experiencia en el tratamiento endourológico de la estenosis pieloureteral (EPU) en niños. Material y Métodos: Revisamos 7 pacientes con EPU congénita (edades comprendidas entre 9 meses y 15 años) tratados mediante dilatación endourológica en nuestro centro desde Julio de 2004. El tratamiento se realizó mediante dilatación endourológica retrógrada bajo control radioscópico. En todos se realizó cistoscopia, se tutorizó el uréter (4Fr ó 5Fr), realizándose pielografía retrógrada y colocación de guía ureteral de 0,014´´ ó 0,035´´. Se realizó la dilatación de la EPU mediante balón de alta presión con perfil de 3Fr ó 5 Fr. Se colocaron stents tipo doble J de 3Fr, 4Fr, 4,8Fr ó 6 Fr, manteniéndolo durante 6 semanas. Resultados: En ningún caso hubo complicaciones intraoperatorias. La mediana de estancia hospitalaria fue 2 días (2-8 días). La retirada del stent tipo doble J se llevó a cabo sin incidencias a las 6 semanas de forma ambulatoria. Todos los pacientes permanecen asintomáticos, con disminución del diámetro anteroposterior de pelvis en el seguimiento ecográfico y mejoría del patrón obstructivo en el renograma. Conclusiones: El tratamiento de la EPU congénita mediante dilatación endourológica retrógrada es posible incluso por debajo del año de edad. La estancia hospitalaria es mínima, sin existir complicaciones intraoperatorias

Objetives: To report our experience with endourologic methods in the treatment of pyeloureteral stenosis in children. Materials and Methods: From July 2004, 7 patients from 9 months to 15 years old with pyeloureteral junction stenosis (PUJ) diagnosis underwent endourologic repair. An endourological dilatation was made under radioscopic control. The procedures consist of an initial cystoscopy with a retrograde placement of catheter (4 or 5 Fr) and the guide wire (0,014´´or 0,035´´). The high pressure balloon (3 to 5 Fr) was then railroad over the wire and positioned across the stenosis for dilatation. A double J stent (3 to 6 Fr) was then introduced, remaining it during 6 weeks. Results: There was no intraoperative complications. Median inhospital stay was 2 days (range, 2 to 8). The double J stent was removed without complications. All patients are asymptomatic with improvement in excretion times (MAG3 renography) and antero-posterior renal pelvis diameter (ultrasound measurement). Conclusions: Balloon dilatation is a viable option in the management of PUJ obstruction even in children under one year old, with minimal morbidity

[Costoplasty in scoliosis surgery]. / Papel de la costoplastia en la cirugía de la escoliosis.

The rib hump is a protrusion of the apicals ribs of the convex side of the toracic scoliosis and it is due to the torsional deformity that appears in scoliosis. It originates a great cosmetic deformity that although improves with the correction of the scoliosis, it appears again by the costal elasticity. For this reason, in cases of important deformity it is necessary to associate a costoplasty for its definitive improvement. 10 cases of Idiopatic Scoliosis with 75.5 degrees of average and rib hump of 22.1 degrees were analysed. A resection of apicals ribs without stabilization in the same surgical act were done; the correction of the curve was 34.6 degrees (55%) and of the hump 8.1 degrees (64%); there were no important complications and the postoperative evolution was normal. The average follow up was 21,9 months, only in 1 case a slight deterioration of the hump was detected, although in all the cases the ribs recovered. In conclusion, costoplasty breaks the vertebro-bicosto-esternal ring. For that reason it is effective for the improvement of the costal hump without adding morbidity to the correction of the scoliosis.

[The paraurethral cyst or Skene's duct cyst in the female newborn]. / Quiste parauretral de Skene en niña recién nacida.

The paraurethral cyst or Skene's duct cyst is a rare congenital anomaly in the female newborn. It appears like a round, yellow or orange-colored cystic mass on either side of the urethral meatus. The reported incidence is 1 in 2.000 to 7.000 female births. The low frequency of the Skene's duct cyst and the little awareness of it and its benignity may lead to wrong diagnosis that underestimates its incidence. There are authors that agree with surgical treatment of paraurethral cyst to obtain an early resolution, even though a majority agrees to manage conservatively.

Papel de la costoplastia en la cirugía de la escoliosis / costoplaty in scoliosis surgery

La giba costal es una prominencia de las costillas apicales del lado convexo de la escoliosis torácica y obedece a la deformidad torsional que ocurre en la escoliosis. Origina una gran deformidad cosmética que, aunque mejora con la corrección de la escoliosis, recidiva al cabo del tiempo por la elasticidad costal, por ello, en casos de deformidad importante se debe asociar una costoplastia para su mejoría definitiva. Se analizan 10 casos intervenidos de escoliosis idiopática con 75,5º de media y giba costal de 22,1º en los que se practicó resección de costillas apicales sin estabilización en el mismo acto quirúrgico; la corrección de la curva fue a 34,6º (55%) y de la giba a 8,1º (64%); no hubo complicaciones importantes y el postoperatorio fue normal. El seguimiento medio fue 21,9 meses apreciándose solamente en 1 caso un leve deterioro de la giba, aunque en todos los casos las costillas se rehicieron. En conclusión, la costoplastia rompe el anillo vértebro-bicosto-esternal, por lo que es efectiva para la mejoría de la giba costal sin añadir morbilidad a la corrección de la escoliosis (AU)

The rib hump is a protrusion of the apicals ribs of the convex side of the toracic scoliosis and it is due to the torsional deformity that appears in scoliosis. It originates a great cosmetic deformity that although improves with the correction of the scoliosis, it appears again by the costal elasticity. For this reason, in cases of important deformity it is necessary to associate a costoplasty for its definitive improvement. 10 cases of Idiopatic Scoliosis with 75.5º of average and rib hump of 22.1º were analysed. A resection of apicals ribs without stabilization in the same surgical act were done; the correction of the curve was 34.6º (55%) and of the hump 8.1º (64%); there were no important complications and the postoperative evolution was normal. The average follow up was 21'9 months, only in 1 case a slight deterioration of the hump was detected, although in all the cases the ribs recovered. In conclusion, costoplasty breaks the vertebro-bicosto-esternal ring. For that reason it is effective for the improvement of the costal hump without adding morbidity to the correction of the scoliosis (AU)

Quiste parauretral de Skene en niña recién nacida / The paraurethral cyst or Skene´s duct cyst in the female newborn

El quiste parauretral o quiste del conducto de Skene es una rara anomalía congénita descrita en neonatos de sexo femenino. Se trata de una formación quística que se muestra como una tumoración redonda, amarillenta o anaranjada, que se presenta adyacente al meato externo uretral. Su incidencia en la población se cifra entre 1 de cada 2.000 y 1 de cada 7.000 recién nacidos vivos femeninos. Sin embargo, sólo se recogen 47 ejemplos anteriores en la literatura en inglés. Es posible que el desconocimiento de esta patología entre la población médica y su benignidad produzcan fallos diagnósticos que infravaloren esta incidencia. Aunque existen autores que apoyan el tratamiento quirúrgico del quiste para lograr su curación, más aún a partir de los 6 meses de edad, la mayoría se ponen de acuerdo en la indicación de un tratamiento expectante dada la tendencia a la resolución espontánea

The paraurethral cyst or Skene´s duct cyst is a rare congenital anomaly in the female newborn. It appears like a round, yellow or orange-colored cystic mass on either side of the urethral meatus. The reported incidence is 1 in 2.000 to 7.000 female births. The low frequency of the Skene´s duct cyst and the little awareness of it and its benignity may lead to wrong diagnosis that underestimates its incidence. There are authors that agree with surgical treatment of paraurethral cyst to obtain an early resolution, even though a majority agrees to manage conservatively

[Therapeutic strategy in cloacal exstrophy]. / Estrategia terapéutica en la extrofia de cloaca femenina.

Cloacal exstrophy is a complex multisistemic anomaly that involves gastrointestinal and genitourinary issues. The aim of our paper is to report our experience in dealing with genital reconstruction and faecal and urinary continence in patients with female cloacal anomalies. We reviewed the clinical records from the three patients we have achieved a final reconstruction. We recorded the surgical management and both functional and anatomic results. The three of them required a bladder neck closure associated with a continent stoma, they are dry with intermittent catheterization and free of upper urinary complications. Genital reconstruction required a unique plan for each one, according to their anatomy and their cosmetic desires. One of the patients reported satisfactory sexual intercourse. Management of patients with cloacal exstrophy has major concerns about urinary and fecal continence and about genital reconstruction and function. Knowing the long-term results may help to develop management strategies and improve counselling for patients who have under-gone reconstruction.

La nueva sanidad: el hospital que nos viene / New health care: the hospital to come

No disponible

[Congenital sternal cleft]. / Hendidura esternal congenita.

INTRODUCTION: Congenital sternal cleft is a rare malformation. Little more than one hundred cases have been published, and rarely more than two cases are published in a single publication. We present five new cases that show the entire spectrum of defects. METHODS: They were 3 males and 2 females. Age range between 1 day and 5 years of age. There were 2 supraxiphoid clefts (SC), 2 gladiolar defects and 1 xiphoid cleft. We evaluate the demographics, associated malformations, mode of treatments and results. RESULTS: The SC were not associated to congenital herat malformations, but with a many other malformative spectrum (anterior cervical web, hemangiomatosis, CNS malformations, coloboma and pectus excavatum). The two females had SC and were operated on the 24th and 30th days of age. The first one developed a superior vena cava síndrome for a few days after surgery and a moderate pectus excavatum that did not required surgery. A midline cervical web was also surgically repaired at 10 years of age. The second patient with SC was treated with interferon alfa-2a and local infiltration of corticosteroid for treatment of hemangiomatosis. Both patients had excellent final results (follow up 11 and 5 years respectively). Gladiolar clefts were observed durign surgical repair of congenital Herat malformations (ventricular septal defect and partial anomalous of pulmonary venous draninage). They were repaired by direct closure of the defect. The patient with the xiphoid cleft had associaed a Cantrell pentalogy. He died 4 days after operation because of extreme prematurity and pulmonary vascular hypertenion. CONCLUSIONS: 1) We have observed five new cases of sternal cleft. 2) Each anatomical variety had their own mode of presentation, a different malformative spectrum and clinical evolution that are based on a distinct embryonic origin. 3) Excluding the xiphoid clefts, the long term surviving is 100%, but they are associated with a great variety of other congenital defects.

Hendidura esternal congénita / Congenital sternal cleft

Introducción. La hendidura esternal congénita es una malformación infrecuente. Los casos publicados escasamente superan el centenar y rara es la publicación que muestra más de uno o dos casos. Presentamos nuestra experiencia con cinco nuevos casos más. Material y métodos. Se tratan de 3 varones y 2 mujeres con edades comprendidas entre un día de vida y los 5 años de edad. Se identificaron 2 hendiduras supraxifoideas, 2 gladiolares y una xifoidea. Se valoran los datos demográficos, malformaciones asociadas, tipo de tratamiento utilizado y resultados del mismo. Resultados. Las hendiduras supraxifoideas no se asociaron a cardiopatías pero sí a otra variedad de defectos (web cervical anterior, hemangiomatosis, lesiones del sistema nervioso central, coloboma y pectus excavatum). Las dos mujeres con hendiduras supraxifoideas se intervinieron a los 24 y 30 días de vida relizandose un cierre directo. La primera presentó como complicacines un sindrome de cava superior. Además desarrolló un pectus excavatum leve y una web cervical que tuvo que ser intervenida a los 10 años de edad para la resolución de la misma. La segunda paciente recibió tratamiento con interferón alfa2a e infiltración local de corticosteroides para controlar la hemangiomatosis que presentaba. En ambas el buen resultado de la cirugía incial se ha mantenido a largo plazo (5 y 1I años). Las hendiduras del gladiolo esternal se: detectaron incidentalmente en el curso de cirugía para la corrección de su cardiopatía (comunicación interventricular y drenaje venoso parcial anómalo) y se corrigieron sin material protésico. Solo falleció el paciente que presentaba una hendidura xifoidea, que además de mostrar una Pentalogía de Cantrell era un gran prematuro con hipoplasia pulmonar severa. Conclusiones. 1. Aportamos 5 nuevos casos de hendidura esternal en todo su espectro malformativo.2. Cada variedad tiene unas asociaciones y una evolución muy diferentes explicadas en base a su distinto origen embrionario.3. De la experiencia general y de la nuestra propia observamos que exceptuando las hendiduras xifoideas puras el resto presenta una supervivencia del 100 por ciento largo plazo, pero asociandose a una gran variedad de defectos (AU)

[Renal cell carcinoma in children]. / Carcinoma de células renales.

Renal cell carcinoma is infrequent in children; consequently it is important to communicate its diagnosis and follow up. The behavior of this type of tumor is better characterized in adults and in this setting the treatment of choice is surgical resection. However, chemo- and radiotherapy for metastatic tumors has not been well defined. Our objective was to report the experience of a single pediatric institution in the diagnosis and treatment of renal cell carcinoma and to review the literature on this subject. We retrospectively reviewed patients diagnosed with renal cell carcinoma in the last twenty years. Only three patients were found, and we describe their clinical features and therapeutic approach. Although renal cell carcinoma is rare in children, clinical suspicion of this disease in children older than 5 years with renal masses is very important since the diagnostic and therapeutic approach differs from that for Wilms' tumor. The main prognostic factors seem to be staging and complete resection. Multicenter collaboration is required to standardize the treatment of tumors in advanced stages and to define the role of allogeneic stem cell transplantation in metastatic tumors.

Carcinoma de células renales / Renal cell carcinoma in children

El carcinoma renal es poco frecuente en niños, por lo que es importante comunicar el diagnóstico y seguimiento de estos casos. Su comportamiento en adultos es más conocido, y se sabe que el tratamiento de elección es la extirpación quirúrgica. Sin embargo, el tratamiento de los tumores metastásicos con quimioterapia y/o radioterapia no está bien definido. Nuestro objetivo es aportar la experiencia de un centro en el diagnóstico y tratamiento del carcinoma renal pediátrico, así como revisar la bibliografía al respecto. Se revisan de forma retrospectiva los pacientes diagnosticados de carcinoma renal en los últimos 20 años. La muestra está formada por 3 niños, y se describen las características clínicas de los pacientes y su tratamiento. Se insiste en que aunque el carcinoma renal es una entidad rara en niños, es importante sospecharlo en pacientes mayores de 5 años con masas renales, ya que la aproximación diagnóstica y terapéutica difiere del tumor de Wilms. La estadificación y la resección completa parecen ser los factores pronósticos fundamentales. Es necesaria la colaboración de varios centros para la estandarización del tratamiento de los tumores en estadios avanzados, valorando el papel del trasplante alogénico de progenitores hematopoyéticos en tumores metastásicos (AU)

Genitales ambiguos: tratamiento quirúrgico / Ambigous genitalia: surgical treatment

Ante un recién nacido con genitales ambiguos, la prioridad debe ser asignar un sexo. Hay que considerar que tanto el diagnóstico como el plan de tratamiento son una urgencia. Un equipo multidisciplinario compuesto por neonatólogos, endocrinólogos, cirujanos pediátricos y genetistas, junto con los padres, debe decidir el sexo. La decisión depende de la anatomía del paciente, y suele ser femenino, ya que técnicamente es más fácil reconstruir los genitales como niña que como niño. Una vez asignado el sexo más apropiado, se realizarán los tratamientos quirúrgicos necesarios, siendo nuestra propuesta la corrección precoz (si es posible neonatal) y en un solo tiempo (AU)

Atención temprana a los accidentes de tráfico / Iinitial attention to trafic accidents

El objeto de este trabajo es presentar la sistemática de atención inicial a los pacientes politraumatizados conocida como regla de los ABC, desarrollada por el Colegio Americano de Cirujanos, que ha demostrado a lo largo de los años ser un método eficaz en la disminución de la morbi-mortalidad causada por los accidentes, así como las particularidades de su aplicación a los niños (AU)

Niña de 19 meses con neumonías de repetición / Recurrent pneumonia in a 19-month-old girl

No disponible

Alternativa a la aortopexia en el tratamiento de la traqueomalacia grave / An alternative to aortopexy in the treatment of severe tracheomalacia

El tratamiento clásico de la forma severa es la aortopexia. En la década de los ochenta comenzó a utilizarse para el tratamiento de la traqueomalacia recidivante o residual la implantación de prótesis intraluminales expandibles tipo Palmaz, diseñadas inicialmente para su uso en estenosis vasculares. Presentamos el caso clínico de un paciente con traqueomalacia grave, intervenido previamente de atresia de esófago con fístula traqueoesofágica distal, en el que debido a una cardiopatía congénita compleja acompañante se contraindicó la aortopexia, por lo que fue tratado de su malacia traqueal mediante la implantación de una prótesis tipo Palmaz. El empleo de este tipo de prótesis supone una alternativa eficaz a la cirugía convencional, debiendo hacer siempre una valoración individualizada en cada caso (AU)

Futuro del trasplante en el siglo XXI / Future of the transplant in the XXI century

No disponible