Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Implementation of a soft tissue infection management protocol perianal in pediatric patients with oncological pathology from the Department of Pediatric Surgery of the Central Military Hospital in the period covered between June 2017 and December 2019

La infección de tejidos blandos perianales en pacientes pediátricos con patología oncológica es una de las complicaciones infecciosas más frecuentes con altas tasas de morbimortalidad. La asociación con el manejo quimioterapéutico y la inmunosupresión de dichos pacientes hacen del enfoque diagnóstico y terapéutico un reto, por lo que, en el Servicio de Cirugía Pediátrica del Hospital Militar Central, se estableció un Protocolo de Manejo para la Infección Perianal de Tejidos Blandos en la población entre los 0 – 15 años desde el año 2017. Se realizó un estudio de serie de casos, de los pacientes entre 0-15 años con patología oncológica quienes requirieron valoración y manejo de infección perianal de tejidos blandos por el Servicio de Cirugía Pediátrica del Hospital Militar Central. Pacientes en quienes se realizó valoración y manejo en el periodo de junio 2017 a diciembre 2019. Se describió y caracterizó la evolución de los pacientes oncológicos en quienes se implementó el protocolo instaurado reportando tiempo de evolución, medicamentos utilizados, necesidad de manejo quirúrgico y unidad de cuidado intensivo pediátrico, demostrando la ausencia de mortalidad.Portada 1 Índice de Contenido 2 Resumen 3 Introducción 5 Identificación y formulación del problema 8 Objetivos 10 Metodología 11 Plan de análisis 13 Aspectos éticos 14 Resultados 15 Discusión 19 Conclusión 21 Referencias Bibliográficas 22The Perianal soft tissue infection in pediatric patients with oncological pathology is one of the most frequent infectious complications with high rates of morbidity and mortality. The association with chemotherapeutic management and immunosuppression of these patients make the diagnostic and therapeutic approach a challenge, for which reason, in the Pediatric Surgery Service of the Central Military Hospital, a Management Protocol for Perianal Soft Tissue Infection was established in the population between 0 - 15 years of age since 2017. A case series study was carried out of patients between 0-15 years of age with oncological pathology who required evaluation and management of perianal soft tissue infection by the Pediatric Surgery Service of the Central Military Hospital. Patients in whom assessment and management were performed in the period from June 2017 to December 2019. The evolution of cancer patients in whom the established protocol was implemented was described and characterized, reporting evolution time, medications used, need for surgical management and pediatric intensive care unit, demonstrating the absence of mortality.Especializació

Prevención de lesiones: una estrategia de salvación para la sociedad Moderna

Los programas de prevención en salud pública han disminuido la incidencia de las lesiones y eventos fatales que ocurren en la población joven, involucrada en las colisiones de tráfico en Bogotá - Colombia. Estos programas se basan en la aplicación de la matriz de Haddon. En este artículo se revisan los aspectos y resultados sobre prevención de lesiones que ha venido realizando la Secretaría de Tránsito y Transporte de Bogotá con la colaboración de la Secretaría Distrital de Salud y El Fondo de Previsión Vial Naciona