Zero deforestation and degradation in the Brazilian Amazon.

Brazil's main goal is zero deforestation and degradation (ZDD) in the Amazon. Existing policies do not consider the region's heterogeneity. Integrated sectoral policies are necessary for consolidating sustainable subregional territories. To protect the world's largest tropical forest while improving local people's lives, government agencies must overcome funding shortfalls and gaps in coordination.

The distribution and conservation of areas with microendemic species in a biodiversity hotspot: a multi-taxa approach.

Background: Microendemic species are species with very small geographic distributions (ranges). Their presence delimitates areas with microendemic species (AMs), denoting a spatial unit comprising at least one population of at least one microendemic species. AMs are assumed to be distributed distinctively and associated with specific ecological, historical, and anthropogenic attributes. However, the level of influence of these factors remains unclear. Thus, we studied the distribution patterns of microendemic species within the Brazilian Atlantic Forest to (a) identify the region's AMs; (b) evaluate whether ecological (latitude, altitude, distance from the coastline), historical (climate stability), and anthropogenic (ecological integrity) attributes distinguish AMs from non-AMs; and (c) assess the conservation status of the Atlantic Forest's AMs. Methods: We mapped the ranges of 1,362 microendemic species of angiosperms, freshwater fishes, and terrestrial vertebrates (snakes, passerine birds, and small mammals) to identify the region's AMs. Further, spatial autoregressive logit regression models were used to evaluate whether latitude, altitude, distance from the coastline, Climate Stability Index, and ecological integrity can be used to discern AMs from non-AMs. Moreover, the AMs' conservation status was assessed by evaluating the region's ecological integrity and conservation efforts (measured as the proportion of AMs in protected areas). Results: We identified 261 AMs for angiosperm, 205 AMs for freshwater fishes, and 102 AMs for terrestrial vertebrates in the Brazilian Atlantic Forest, totaling 474 AMs covering 23.8% of the region. The Brazilian Atlantic Forest is a large and complex biogeographic mosaic where AMs represent islands or archipelagoes surrounded by transition areas with no microendemic species. All local attributes help to distinguish AMs from non-AMs, but their impacts vary across taxonomic groups. Around 69% of AMs have low ecological integrity and poor conservation efforts, indicating that most microendemic species are under threat. This study provides insights into the biogeography of one of the most important global biodiversity hotspots, creating a foundation for comparative studies using other tropical forest regions.

Influence of Resistance Training Exercise Order on Acute Thyroid Hormone Responses.

The present study aimed to compare the exercise order of an acute bout of resistance exercise (RT) on acute thyroid hormonal responses. Eight (n = 8) healthy men were randomly separated into two experimental groups: A) the order from multi- to single-joint exercises (MJ-SJ) and B) the order from single- to multijoint exercises (SJ-MJ). For all exercises in both orders, the subjects were submitted to 3 sets of 10 repetitions, with rest intervals of 2 minutes between sets and 3 minutes between exercises. Blood samples were collected at rest and 0, 15, 30, 60 and 120 min after the end of the exercise session. In thyroidstimulating hormone (TSH), differences between groups (MJ-SJ < SJ-MJ) were observed within 15 minutes after the session. In 3,5,3'-triiodothyronine (T3), differences between groups were observed between 30 (MJ-SJ > SJ-MJ) and 120 minutes (MJ-SJ < SJ-MJ) after the session. In 3,5,3',5'-tetraiodothyronine (T4), differences between groups (MJ-SJ > SJ-MJ) were observed within 15 minutes after the RT session. The order of RT exercises significantly changes the hormonal responses of TSH, T3 and T4. In addition, the exercise order should be chosen according to the individual's objectives.

Composition, richness and nestedness of gallery forest bird assemblages in an Amazonian savanna landscape: lessons for conservation.

Gallery forests are important to the maintenance of a substantial portion of the biodiversity in neotropical savanna regions, but management guidelines specific to this forest type are limited. Here, we use birds as study group to assess if: (1) functional traits can predict the abundance and occupancy of forest species within a savanna landscape, (2) habitat structures influence the taxonomic, functional, and phylogenetic diversity of forest assemblages, and (3) less diverse gallery forest assemblages are a nested subset of more diverse assemblages living near continuous forests. Then, we propose strategies on how gallery forests can be managed to maintain their species assemblages amidst the fast expansion of human activities across tropical savanna landscapes. We studied 26 sites of gallery forests in an Amazonian savanna landscape and found that: (1) habitat specificity is the only functional trait that predicts species abundance and occupancy across a landscape; (2) phylogenetic diversity is negatively correlated with understory foliage density; (3) the percentage of forests and savannas around sites is positively correlated with both phylogenetic and functional diversity; (4) increasing human activities around gallery forest negatively influences taxonomic and functional diversity; and (5) forest bird assemblages are not distributed at random across the landscape but show a nested pattern caused by selective colonization mediated by habitat filtering. Our combined findings have three implications for the design of conservation strategies for gallery forest bird assemblages. First, maintaining the connectivity between gallery forests and adjacent continuous forests is essential because gallery forest bird assemblages are derived from continuous forest species assemblages. Second, because most species use the savanna matrix to move across the landscape, effectively managing the savanna matrices where gallery forests are embedded is as important to maintaining viable populations of forest bird species as managing the gallery forest themselves. Third, in savanna landscapes planned to be used for agriculture production, protecting gallery forests alone is not enough. Instead, gallery forests should be protected with surrounding savanna buffers to avoid the detrimental effects (edge effects and isolation) of human activities on their biodiversity.

Interactive machine learning for soybean seed and seedling quality classification.

New computer vision solutions combined with artificial intelligence algorithms can help recognize patterns in biological images, reducing subjectivity and optimizing the analysis process. The aim of this study was to propose an approach based on interactive and traditional machine learning methods to classify soybean seeds and seedlings according to their appearance and physiological potential. In addition, we correlated the appearance of seeds to their physiological performance. Images of soybean seeds and seedlings were used to develop models using low-cost approaches and free-access software. The models developed showed high performance, with overall accuracy reaching 0.94 for seeds and seedling classification. The high precision of the models that were developed based on interactive and traditional machine learning demonstrated that the method can easily be used to classify soybean seeds according to their appearance, as well as to classify soybean seedling vigor quickly and non-subjectively. The appearance of soybean seeds is strongly correlated with their physiological performance.

A climate-change vulnerability and adaptation assessment for Brazil's protected areas.

Brazil hosts the largest expanse of tropical ecosystems within protected areas (PAs), which shelter biodiversity and support traditional human populations. We assessed the vulnerability to climate change of 993 terrestrial and coastal-marine Brazilian PAs by combining indicators of climatic-change hazard with indicators of PA resilience (size, native vegetation cover, and probability of climate-driven vegetation transition). This combination of indicators allows the identification of broad climate-change adaptation pathways. Seventeen PAs (20,611 km2 ) were highly vulnerable and located mainly in the Atlantic Forest (7 PAs), Cerrado (6), and the Amazon (4). Two hundred fifty-eight PAs (756,569 km2 ), located primarily in Amazonia, had a medium vulnerability. In the Amazon and western Cerrado, the projected severe climatic change and probability of climate-driven vegetation transition drove vulnerability up, despite the generally good conservation status of PAs. Over 80% of PAs of high or moderate vulnerability are managed by indigenous populations. Hence, besides the potential risks to biodiversity, the traditional knowledge and livelihoods of the people inhabiting these PAs may be threatened. In at least 870 PAs, primarily in the Atlantic Forest and Amazon, adaptation could happen with little or no intervention due to low climate-change hazard, high resilience status, or both. At least 20 PAs in the Atlantic Forest, Cerrado, and Amazonia should be targeted for stronger interventions (e.g., improvement of ecological connectivity), given their low resilience status. Despite being a first attempt to link vulnerability and adaptation in Brazilian PAs, we suggest that some of the PAs identified as highly or moderately vulnerable should be prioritized for testing potential adaptation strategies in the near future.

Evaluación de la Vulnerabilidad y Adaptación al Cambio Climático de Áreas Protegidas en Brasil Resumen Brasil alberga la mayor extensión de ecosistemas tropicales dentro de áreas protegidas (AP), que protegen la biodiversidad y sustentan a poblaciones humanas tradicionales. Evaluamos la vulnerabilidad al cambio climático de 993 AP brasileñas terrestres y costeras-marinas mediante la combinación de indicadores de riesgo de cambio climático con indicadores de la resiliencia de AP (tamaño, cobertura de vegetación nativa y la probabilidad de transición en la vegetación como consecuencia del cambio climático). Esta combinación de indicadores permite la identificación de amplias rutas de adaptación al cambio climático. Diecisiete AP (20,611 km2 ) fueron altamente vulnerables y se localizaron principalmente en el Bosque Atlántico (7 AP), El Cerrado (6) y la Amazonía (4). Doscientos cincuenta y ocho AP (756,569 km2 ), localizadas principalmente en la Amazonía, tuvieron vulnerabilidad media. En la Amazonía y el oeste de El Cerrado, el severo cambio climático proyectado y la probabilidad de transición de vegetación dirigida por el clima incrementó la vulnerabilidad, a pesar del estado de conservación generalmente bueno de las AP. Más de 80% de las AP con vulnerabilidad alta o media son manejadas por poblaciones indígenas. Por lo tanto, además de los riesgos potenciales para la biodiversidad, también hay amenazas para el conocimiento tradicional y las formas de vida de la gente que habita en esas AP. En por lo menos 870 AP, principalmente en el Bosque Atlántico y la Amazonía, la adaptación podría suceder con poca o ninguna intervención debido al bajo riesgo de cambio climático, estatus de resiliencia alta, o ambos. Por lo menos 20 AP en el Bosque Atlántico, El Cerrado y la Amazonía deberían ser objetivo de intervenciones mayores (e.g., mejoramiento de la conectividad ecológica), dada su estatus de resiliencia baja. A pesar de que es un primer intento para vincular vulnerabilidad y adaptación en AP brasileñas, sugerimos que algunas de las AP identificadas como alta o moderadamente vulnerables se deben priorizar para probar posibles estrategias de adaptación en un futuro próximo.

Extinction risk of narrowly distributed species of seed plants in Brazil due to habitat loss and climate change.

In a world where changes in land cover and climate happen faster than ever due to the expansion of human activities, narrowly distributed species are predicted to be the first to go extinct. Studies projecting species extinction in tropical regions consider either habitat loss or climate change as drivers of biodiversity loss but rarely evaluate them together. Here, the contribution of these two factors to the extinction risk of narrowly distributed species (with ranges smaller than 10,000 km2) of seed plants endemic to a fifth-order watershed in Brazil (microendemics) is assessed. We estimated the Regional Climate Change Index (RCCI) of these watersheds (areas with microendemics) and projected three scenarios of land use up to the year 2100 based on the average annual rates of habitat loss in these watersheds from 2000 to 2014. These scenarios correspond to immediate conservation action (scenario 1), long-term conservation action (scenario 2), and no conservation action (scenario 3). In each scenario, areas with microendemics were classified into four classes: (1) areas with low risk, (2) areas threatened by habitat loss, (3) areas threatened by climate change, and (4) areas threatened by climate change and habitat loss. We found 2,354 microendemic species of seed plants in 776 areas that altogether cover 17.5% of Brazil. Almost 70% (1,597) of these species are projected to be under high extinction risk by the end of the century due to habitat loss, climate change, or both, assuming that these areas will not lose habitat in the future due to land use. However, if habitat loss in these areas continues at the prevailing annual rates, the number of threatened species is projected to increase to more than 85% (2,054). The importance of climate change and habitat loss as drivers of species extinction varies across phytogeographic domains, and this variation requires the adoption of retrospective and prospective conservation strategies that are context specific. We suggest that tropical countries, such as Brazil, should integrate biodiversity conservation and climate change policies (both mitigation and adaptation) to achieve win-win social and environmental gains while halting species extinction.

Factores pronósticos y sobrevida en pacientes menores de 18 años con tumores de la familia del sarcoma de Ewing: experiencia de 10 años / Prognostic factors and survival in patients under 18 years of age with Ewing sarcoma family tumors: a 10-year experience

Objetivo: Describir las características clínicas y epidemiológicas, y determinar los factores pronósticos, sobrevida libre de evento (SLE) y sobrevida global (SG) de los pacientes con tumores de la familia del Sarcoma de Ewing (TFSE). Materiales y métodos: Estudio retrospectivo llevado a cabo en pacientes menores de 18 años con TFSE, atendidos en la Unidad de Oncología Pediátrica y del Adolescente del Hospital Edgardo Rebagliati entre 2006 y 2016. El análisis descriptivo se realizó mediante distribución de frecuencias. Para el análisis de SLE y SG se utilizaron las curvas de Kaplan-Meier. Se efectuó un análisis univariado y multivariado según modelo de regresión de Cox para variables demográficas, clínicas y quirúrgicas, y factores pronósticos. La medida de fuerza de asociación se expresó en hazard ratio (HR) e intervalo de confianza al 95% (IC 95%), y se consideró p<0.05 para diferencias significativas. Resultados: Se presentaron 29 casos de TFSE. La mediana de edad fue de 9 años (rango 2-17), el 55% fueron varones. La localización más frecuente fue la pelvis (31%). El 59% presentaron metástasis al diagnóstico. La SLE a 3 años en TFSE localizados fue del 40.4% (±14.4 EE) y con metástasis, 14.6% (±12.2, EE). La SG a 3 años en TFSE localizados fue del 53.9% (±17.8 EE) y en enfermedad metastásica, 15.1 % (±9.7, EE). El tamaño tumoral ≥5cm (HR 14.84, p=0.01) y la presencia de metástasis al debut (HR 3.23, p=0.01) fueron factores pronósticos independientes de peor SG. No hubo diferencia significativa en relación con el pronóstico según el sexo, edad, tipo histológico, compromiso de los bordes quirúrgicos o localización del tumor. Conclusiones: Los TFSE son altamente agresivos. Los factores pronósticos que contribuyen a una menor SLE y SG son la presencia de metástasis al debut de la enfermedad y un tamaño tumoral ≥5cm.

Objective: To describe the clinical and epidemiological characteristics, and to determine prognostic factors, event-free survival (EFS) and overall survival (OS) of patients with Ewing sarcoma family tumors (ESFT). Materials and methods: A retrospective study conducted in patients under 18 years of age with ESFT, treated at the Unit of Pediatric and Adolescent Oncology of the Hospital Edgardo Rebagliati between January 2006 and June 2016. The descriptive analysis was performed by frequency distribution. Kaplan-Meier curves were used for EFS and OS analysis. Univariate and multivariate analyses were performed according to the Cox regression model for demographic, clinical and surgical variables, and prognostic factors. The measure of strength of association was expressed in hazard ratio (HR) and 95% confidence interval (95% CI), and p<0.05 was considered for significant differences. Results: There were 29 cases of ESFT. The median age was 9 years (range 2-17), 55% were males. The most frequent location was the pelvis (31%). Fifty-nine percent (59%) had metastasis at diagnosis. The 3-year EFS in localized ESTF was 40.4% (± 14.4 EE) and with metastasis was 14.6% (± 12.2, EE). The 3-year OS in localized ESTF was 53.9% (± 17.8 EE) and with metastatic disease was 15.1% (± 9.7, EE). The tumor size ≥5cm (HR 14.84, p=0.01) and the presence of metastasis at the onset of the disease (HR 3.23, p=0.01) were independent prognostic factors of worse OS. There was no significant difference in prognosis regarding the gender, age, histological type, involvement of surgical borders or location of the tumor. Conclusions: ESFT are highly aggressive. The prognostic factors that contribute to a lower EFS and OS are the presence of metastasis at the onset of the disease and a tumor size ≥5cm.

SAPS 3 score as a predictive factor for postoperative referral to intensive care unit.

BACKGROUND: Patients undergoing intermediate-risk surgery are typically taken to the ward postoperatively. However, some may develop complications requiring intensive care later. We aimed to evaluate the characteristics of patients undergoing intermediate-risk surgery who required late postoperative admission to the intensive care unit (ICU) and determine the predictors for this. METHODS: The study included patients undergoing intermediate-risk surgery with preoperative indication for ICU but who were taken to the ward postoperatively, because they appeared to be responding well. However, they required late ICU admission. ICU care and preoperative SAPS 3 score were evaluated. Palliative surgeries and patients readmitted to ICU were excluded. RESULTS: The study included 100 patients, 27 % of whom had late postoperative admission to the ICU. The preoperative SAPS 3 score was higher (45.4 ± 7.8 vs. 35.9 ± 7.4, P < 0.001) in patients who required delayed admission to the ICU postoperatively. Furthermore, they had undergone longer surgery (4.2 ± 1.9 vs. 2.7 ± 1.5 h, P < 0.001), and a greater proportion were gastrointestinal surgeries (14.8 vs. 5.5 %, P = 0.03) and intraoperative transfusion (18.5 vs. 5.5 % P = 0.04). In multivariate analysis, preoperative SAPS 3 and surgery duration independently predicted postoperative ICU admission, respectively (OR 1.25; 95 % CI 1.1-1.4 and OR 3.33; 95 % CI 1.7-6.3). CONCLUSION: The identification of high-risk surgical patients is essential for proper treatment; time of surgery and preoperative SAPS 3 seem to provide a useful indication of risk and may help better to characterize patients undergoing intermediate-risk surgery that demand ICU care.

Analysis of Prognostic Factors in High-Grade Osteosarcoma of the Extremities in Children: A 15-Year Single-Institution Experience.

BACKGROUND: The aim of this retrospective study was to define clinical and pathological features and prognostic factors among children and adolescents diagnosed with high-grade osteosarcoma of the extremities. METHODS: A total of 73 patients younger than 18 years diagnosed with primary osteosarcoma of the extremities between January 1998 and December 2013 were retrospectively evaluated. Prognostic factors, such as age, gender, primary tumor site, alkaline phosphatase and lactate dehydrogenase levels, metastatic disease, pathological fracture, histological response, and surgery type, were analyzed to evaluate their effects on overall survival (OS) and event-free survival (EFS). RESULTS: At a median follow-up of 30 months (1.5-152), OS and EFS at 5 years were 64.5 ± 8.1 and 48.5 ± 8.7% for patients with localized disease; and 16.2 ± 7.9 and 14.4 ± 7.3% for patients with initial metastatic disease, respectively. In patients with localized disease, conservative surgery was performed on 22 of 46 patients (43.5%), and there was no significant difference in survival rates among patients who had conservative vs. radical surgery (p = 0.65). Although tumor size (>12 cm) was significant prognostic factor in univariate analysis; multivariate analysis identified elevated levels of alkaline phosphatase (p = 0.033) and poor response to neoadjuvant chemotherapy (p < 0.001) only as independent prognostic factors. Age, histological type, pathological fracture, and primary tumor site did not significantly affect prognosis. CONCLUSION: Initial elevated presence of alkaline phosphatase in serum and poor histological response after neoadjuvant chemotherapy were significant factors for unfavorable prognosis. It is necessary to optimize staging and treatment intensification to improve survival rates, especially among patients with metastasis at initial presentation.

Natural gaps associated with oxidative stress in Willisornis poecilinotus (Aves: Thamnophilidae) in a tropical forest / Clareiras naturais associadas ao estresse oxidativo em Willisornis poecilinotus (Aves: Thamnophilidae) em uma floresta tropical

Natural disturbances in tropical forests modify the availability and quality of resources and alter the patterns of bird distribution. These environmental changes increase the metabolic rate and disrupt the redox balance promoting oxidative stress. This study aimed to compare the abundance of Willisornis poecilinotus between gaps and the understory of a forest with undisturbed canopy at Caxiuanã National Forest. The abundance was correlated with vegetation heights. The oxidative stress and the stress promoting factors were determined in both sites of sampling. We captured 81 specimens of W. poecilinotus. The number of captures was high in gaps. The specimens sampled at gaps showed high levels of oxidative stress. The biomarkers of oxidative stress were significantly correlated in gaps. The variability of oxidative stress and oxidative damage were explained only by site of sampling. These results suggest that gaps are stressors sites to W. poecilinotus, which probably can be due to an increase of metabolic rate to deal with new flight strategies of foraging and avoid predation.

Os distúrbios naturais nas florestas tropicais contribuem para heterogeneidade do habitat, alterando os padrões de distribuição das aves. Estas alterações no ambiente elevam o metabolismo, promovendo distúrbios no balanço redox, e em consequência o estresse oxidativo. O objetivo deste estudo foi comparar a abundância de Willisornis poecilinotus entre clareiras e sub-bosque de dossel intacto associando-a a altura da vegetação na Floresta Nacional de Caxiuanã. A seguir, foi avaliado o estresse oxidativo e os fatores promotores de estresse foram determinados nos ambientes selecionados. Foram capturados 81 espécimes de W. poecilinotus. O número de capturas foi superior nas clareiras, quando comparado ao sub-bosque de dossel contínuo. Os espécimes capturados nas clareiras apresentaram índices de estresse oxidativo significativamente elevados. Foi observada correlação significativa entre os marcadores de estresse oxidativo nas clareiras. As variações do biomarcador de dano oxidativo e do estresse oxidativo foram explicadas somente pelo sítio de amostragem. Estes resultados sugerem que as clareiras são sítios de estímulos estressores para W. poecilinotus o que provavelmente resulta da maior demanda metabólica para novas estratégias de forrageio e para evitar a predação.

Aspectos atuais no diagnóstico e abordagem da infecção do trato urinário / Current aspects in the diagnosis and approach to urinary tract infection

O objetivo deste artigo de revisão é apresentar as mais recentes diretrizes no manejo de infecção do trato urinário (ITU), salientando que há uma tendência atual a estudos de imagem menos agressivoseao uso mais restritivo da quimioprofilaxia. Tem surgido preocupação sobre a exposição desnecessária de radiação ionizante e o caráter invasivo de alguns procedimentos. Outro ponto discutido é a relação causal do refluxo vesicoureteral (RVU) e cicatrizes renais, o que tem sido o foco de vários estudos. Tem surgido preocupação sobre a exposição desnecessária dos pacientes à radiação ionizante e o caráter invasivo de alguns procedimentos. O risco de infecção também tem sido alvo de discussão. Com o aprimoramento da ultrassonografia pré-natal tem sido sugerida aabordagem top-down para investigação da ITU febril. Finalmente, aborda-se a associação do RVU e a disfunção do trato urinário inferior (DTUI) com a ITU.

The objective of this review article is to present the latest guidelines on the management of urinary tract infection (UTI) highlighting that there is a current trend towards less aggressive image studies and more restrictive use of chemoprophylaxis. The unnecessary exposure to ionizing radiation and the invasive nature of some procedures have raised concerns. Another point discussed is the causal relationship of vesicoureteral reflux (VUR) and renal scarring, which have been the focus of several studies. The risk of infection has also been the subject of discussion. With the improvement of prenatal ultrasound, the top-down approach to investigate febrile UTI has been suggested. Finally, the association between VUR and lower urinary tract dysfunction (LTUD) and UTI is also assessed.

Hidronefrose na criança / Hydronephrosis in children

A hidronefrose é uma afecção comum na criança e consiste na dilatação do sistema coletor renal, podendo ser congênita, e por isso denominada hidronefrose fetal, ou pode ser adquirida, o que é menos frequente. A hidronefrose fetal pode ser diagnosticada ainda na vida intrauterina, por meio da ultrassonografia obstétrica. Dilatações leves a moderadas podem resolver-se espontaneamente antes ou após o nascimento. Porém,dilatações maiores podem ser causa de infecção urinária, causar dano ao parênquima renal e provavelmente irão requerer tratamento cirúrgico. As principais causas de hidronefrose fetal que persistem após o nascimento são: estenose de junção ureteropélvica, refluxo vesicoureteral, estenose da junção ureterovesical, duplicações pieloureterais, associado ou não a ureterocele, e válvula de uretra posterior. Em relação à hidronefroseadquirida, a etiologia mais comum é a angulação do ureter proximal por vaso polar anômalo, porém também pode ser devida à ureterolitíase, que é incomum. Nesses casos normalmente diagnostica-se a hidronefrose devido à propedêutica de dor abdominal crônica recorrente em crianças maiores.Na conduta inicial na hidronefrose fetal, logo após o nascimento, deve-se realizar ultrassonografia das vias urinárias, para confirmar eclassificar o grau de hidronefrose. De acordo com os achados ultrassonográficos é que se decidirá se será necessário estender a propedêutica ou manter conduta expectante. Na condução subsequente dessas crianças é importante o acompanhamento do nefrologista-pediatra e do cirurgião-pediatra, convindo que sejam tratadas em centros especializados, com todos os recursos necessários para o diagnóstico e tratamento adequado.

Hydronephrosis is a common illness in children and consists in the dilatation of the renal collector system. It may be congenital, and in this case is called fetal hydronephrosis, or it can be acquired, which is less frequent. The fetal hydronephrosis may be diagnosed during the intrauterine life through obstetric ultrasound. Mild to moderate dilatations may resolve spontaneously before or after birth. However, larger dilatations can be causes of urinary tract infection, damage to the renal parenchyma, and may require surgical treatment. The main causes of persistent fetal hydronephrosis after birth are ureteropelvic junction stenosis, vesicoureteral reflux, ureterovesical junction stenosis, ureteric duplication associated or not with ureterocele, and posterior urethra valve. In relation to the acquired hydronephrosis, the most common etiology is the angulation of the proximal ureter resulting from an anomalous polar vessel; however, it can also be due to ureterolithiasis, which is uncommon. In these cases, the hydronephrosis is usually diagnosed as the result of propaedeuticsof chronic recurrent abdominal pain in older children. The initial conduct in cases of fetal hydronephrosis, shortly after birth, is the use of urinary tract ultrasound to confirm and classify the degree of hydronephrosis. The ultrasound findings will assist to decide if it is necessary to extend the propaedeutics or maintain a waiting conduct. The follow-up by a nephrologist and pediatric-surgeon in the subsequent treatment of these children is important when treated in specialized centers with all theneeded resources for proper diagnosis and treatment.

Adrenal insufficiency in association with congenital nephrotic syndrome: a case report.

Adrenal disorders in patients with congenital nephrotic syndrome (CNS) have seldom been reported, and the mechanisms that could explain this association are not known. The follow-up of a male infant diagnosed with CNS and primary adrenal insufficiency in his first year of life is the object of this paper.

Diagnostic accuracy of renal pelvic dilatation for detecting surgically managed ureteropelvic junction obstruction.

PURPOSE: In this study we evaluate the diagnostic accuracy of renal pelvic dilatation for detecting infants with prenatal hydronephrosis who will need surgical intervention for ureteropelvic junction obstruction during followup. MATERIALS AND METHODS: Between 1999 and 2010, 371 newborns diagnosed with isolated prenatal hydronephrosis were prospectively followed. The main event of interest was the need for pyeloplasty. Diagnostic odds ratio, sensitivity, specificity and diagnostic accuracy (assessed by AUC) of fetal renal pelvic dilatation and postnatal renal pelvic dilatation were evaluated. RESULTS: A total of 312 patients were included in the analysis and 25 (7.5%) infants underwent pyeloplasty. The diagnostic performance for detecting the need for pyeloplasty was excellent for all ultrasonography measurements. The AUC was 0.96 (95% CI 0.92-0.98) for fetal renal pelvic dilatation, 0.97 (95% CI 0.95-0.98) for postnatal renal pelvic dilatation and 0.95 (95% CI 0.92-0.97) for the Society for Fetal Urology grading system. A cutoff of 18 mm for fetal renal pelvic dilatation and a cutoff of 16 mm for postnatal renal pelvic dilatation had the best diagnostic odds ratio to identify infants who needed pyeloplasty. Considering a diagnosis to be positive only if fetal renal pelvic dilatation was greater than 18 mm and postnatal dilatation was greater than 16 mm, sensitivity was 100% and specificity was 86% (95% CI 80.7-89.9). CONCLUSIONS: Our findings suggest that the combination of fetal and postnatal renal pelvic dilatation is able to increase the diagnostic accuracy for detecting infants who need a more comprehensive postnatal investigation for upper urinary tract obstruction.

Exames de imagem na avaliação de anomalias urológicas em lactentes com hidronefrose fetal: avanços e controvérsias / Imaging for evaluation of urologic abnormalities in infants with fetal hydronephrosis: advances and controversies

Avanços recentes no diagnóstico pré-natal têm permitido o aprimoramento da detecção e o manejo das anormalidades do trato urinário. A ultrassonografia pré-natal permite o reconhecimento de anormalidades urológicas que somente seriam identificadas tardiamente, após o aparecimento de sintomas ou complicações. A uretrocistografia miccional pode ser reservada para casos selecionados. Exames de medicina nuclear devem ser realizados em casos de hidronefrose moderada e grave. O estudo consistiu de uma revisão da literatura atual sobre a abordagem pós-natal da hidronefrose fetal. Os dados obtidos foram confrontados com a experiência da Unidade de Nefrologia Pediátrica do HC/UFMG na conduta e no seguimento de crianças com diagnóstico de uropatias detectadas na investigação de hidronefrose fetal.

Recent advances in prenatal diagnosis resulted in an improvement of detection and management of urinary tract abnormalities. Prenatal ultrasonography allows to identify urological abnormalities that otherwise would not be seen until later in life, when complications occur. The voiding cystourethrogram can be reserved for selected patients. Nuclear medicine exams should be performed in cases of moderate and severe hydronephrosis. A review of the current literature on postnatal approach of prenatal hydronephrosis was performed. Data obtained were compared with the records of the Pediatric Nephrology Unit HC/UFMG regarding management and follow-up of children with uropathies detected while investigating for fetal hydronephrosis.