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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Cuerpos extraños en vías aéreas

Foreign body aspiration into the airways is defined as the accidental introduction to the larynx, trachea and bronchia of an organic or inorganic object that affects the child�s respiration. This is a potentially fatal event. It is a common accident in children under 2 years of age, and it ranks fourth among the causes of mortality by asphyxia in children. The use of bronchoscopic techniques in children has significantly reduced mortality rates. The inhaled foreign bodies can be classified as organic or inorganic, with the former being the most common. Infants are at risk due to their exploring instinct, mouthing or the habit of putting objects into their mouths, inadequate or inapt swallowing, and parents� negligence. Clinically, foreign body aspiration is suspected upon the sudden onset of choking symptoms, followed by stridor, difficult breathing and fever, and may be confused with respiratory infections or asthma attacks. Some objects may remain lodged in the airways even for years. Diagnosis is made based on clinical manifestations and supported by diagnostic procedures such as chest and neck X-ray (PA and Lat) when up to 19% of the object is radiopaque. In cases of inorganic objects, atelectasis, over-distention or non-specific findings may be common. Treatment for extraction is by rigid Bronchoscopy in a hospital setting. What should never be done is introduce any fingers in the mouth, swing the child head-down or shake the child, give the child back blows, venoclysis or oral administration of medicine or other liquids, or remove the child from its mother�s arms.La aspiración de Cuerpo extraño en la vía aerea se define como el ingreso de manera accidental a laringe, tráquea y bronquios de un objeto sea orgánico o inorgánico y que produce efectos en la respiración del niño. Se trata de un evento potencialmente fatal. Es un accidente frecuente en niños menores de 2 años, siendo la cuarta causa de mortalidad por asfixia en niños, con el uso de las técnicas de Broncoscopía en niños su mortalidad ha disminuido de manera importante. Los cuerpos extraños aspirados pueden ser clasificados como orgánicos e inorgánicos, siendo los primeros más comunes, y hacen al lactante un sujeto de riesgo por su instinto explorador, el habito de llevarse objetos a la boca, mala deglución, y el descuido de los padres, clínicamente se sospecha por el inicio súbito de un cuadro de ahogamiento, posteriormente estridor, dificultad respiratoria y fiebre y puede confundirse con infecciones respiratorias o cuadros asmáticos. Algunos objetos pueden permanecer incluso años. El diagnostico se fundamenta en la clínica y se apoya con elementos diagnósticos como la radiografía de tórax y cuello en AP y L , hasta en un 19% es objeto es radiopaco. En objetos orgánicos puede ser normal, atelectasia, sobre distensión o inespecífico el hallazgo. El tratamiento es la extracción por Broncoscopía rígida en medio hospitalario, lo que no se debe hacer es Meterle los dedos en la boca, ponerlo de cabeza o sacudirlo, golpear la espalda, poner venoclisis o tomar productos, retirarlo de los brazos maternos

Cuerpos extraños en vías digestivas

Defined as the introduction of an object into the digestive tract. Approximately 55% of the objects that children put into their mouth and swallow will be excreted. Ingestion is a frequent accident, and the nature of the object, its size and the time it has remained in the child�s system shall determine the treatment to be followed. The majority of ingested objects are inorganic (coins, toy parts, button batteries), and some are organic (food remnants). The body has 4 natural strictures, the most significant occurring at the cricopharyngeal segment. If the object is able to pass this point, it normally is excreted, unless there is another unknown pathologic stricture (e.g. stenosis due to reflux). Extraction is undertaken by means of direct laryngoscopy and fine-point forceps, may require rigid or flexible endoscopy and a small percentage of patients are kept in the hospital for observation. In the case of button batteries, immediate extraction or surgery is warranted if there are any signs of perforation.Se define como el ingreso de un objeto a el tubo digestivo, aproximadamente el 55% de los objetos que el niño lleva a su boca serán deglutidos y excretados. La ingesta es un accidente frecuente, la naturaleza del objeto, su tamaño y el tiempo de duración en el organismo determinaran su tratamiento. La mayoría de los objetos ingeridos son inorgánicos (monedas, partes de juguetes, pilas de botón), y algunos orgánicos (restos de alimento). El organismo cuenta con 4 estrecheces naturales , siendo la mas importante a nivel de Cricofaríngeo, cuando el objeto rebasa esta porción habitualmente es excretado, a menos que exista otra estreches patológica no advertida ( por ejemplo: estenosis por reflujo). La extracción es muy común con laringoscopia Directa y pinza de caimán, puede requerir endoscopia rígida o flexible , un pequeño porcentaje se deja a observación, y en el caso de las pilas de botón se requerirá extracción inmediata o cirugía si producen signos de perforación

Ingestión de sustancias químicas en esófago, análisis de las complicaciones tempranas y tardías, en el manejo de los mismos; una revisión de 70 casos.

ANTECEDENTES: La ingestión de sustancias químicas en los niños se ha convertido en un problema de salud en México debido al número creciente de pacientes que son atendidos en nuestros centros asistenciales y a las consecuencias que para el seno familiar y social que conlleva. OBJETIVO: El objetivo del presente trabajo es presentar la experiencia en un hospital de concentración con pacientes lesionados que ingirieron substancias químicas en el esófago, su tratamiento, complicaciones y la mortalidad. MATERIAL Y METODOS: Se trata de un estudio prospectivo, descriptivo, observacional en el que se analizaron los expedientes de todos los pacientes ingresados por esta causa, entre Enero de 2008 a Marzo del 2009. A la totalidad de pacientes se les realizó historia clínica, laboratorio y gabinete, evaluación endoscópica, con variables de sexo, edad, tiempo de evolución y contacto con la sustancia, tipo de sustancia, maniobras previas al ingreso, tratamiento medico y quirúrgico, complicaciones y mortalidad. El seguimiento basado en la clínica, esofagograma control, programa de rehabilitación esofágica, tratamiento definitivo. Todos los resultados fueron sometidos a análisis estadístico con medidas de tendencia central. RESULTADOS: Se atendieron 70 pacientes; 42 niños y 28 niñas, un rango de edad entre 11 meses y 20 años. De primera vez 36 y subsecuentes 34. La sustancia química ingerida más frecuente fue sosa caustica liquida en el 82.8%; la esofagoscopia con fines diagnósticos y pronósticos se realizó entre las 24 horas y en 60 días la mas tardía después de la ingestión de esta el 55% normal, y 45% lesiones moderadas y severas. Las complicaciones cuidados intensivos 9 casos (12.8%) , 3 (4.2%) en evento agudo: Mediastinitis (1), Quemadura Vía Aérea; finado (1), Bronconeumonía (1). De 34 subsecuentes 6 (8.5%) desarrollaron complicaciones secundarias a rehabilitación esofágica, 3 fracaso programa dilataciones, 2 Absceso Cerebral y 1 perforación esofágica en espera de substitución al momento de este reporte. DISCUSIÓN: La ingestión de sustancias químicas constituye un verdadero problema de salud, lograr disminuir su incidencia se hace necesario. Donde la esofagoscopia precoz constituye un elemento de indudable valor diagnóstico y pronóstico en la evolución, tratamiento y complicaciones futuras

Diagnostic Images of the Ocular Fundus Using a Low-Cost Portable Endoscope in Premature Patients at Risk of Developing Retinopathy of Prematurity

The purpose of this article is to describe how fundus images are obtained using a low-cost device: the “Visual Ear Wax Cleaner Tool” portable endoscope (Soonhua Inc., China) connected to a smartphone, after installation of free applications (“Inskam” and “CameraFI”) using the smartphone screen as a monitor and after medication mydriasis, local anesthesia, and blepharostat placement. With this endoscope, video recording and fundus imaging are easily performed, for the case of patients at the risk of developing retinopathy of prematurity (ROP), facilitating timely screening in order to start treatment in patients who require it. This fundus imaging technique shares certain similarities with the RetCam® (Clarity, Pleasaton California) system, which performs real-time fundus imaging providing the ability to record and document findings and capture images from the video footage, with high quality and definition, although with a smaller angle of vision. The capture of images using a smartphone allows storing and sharing the images. These are devices which are generally accessible and portable and which use simplified energy sources, requiring very simple training. The low-cost, easy-to-learn technique and quick sharing of images through communication networks make this a tool to be considered for the practice of telemedicine