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

La ultrasonografía obstétrica y el diagnóstico de defectos de la pared abdominal en México

El artículo de sesión anatomoclínica de este número refleja dos problemas relativamente frecuentes a los que todos los pediatras estamos expuestos: la falta de diagnóstico prenatal de malformaciones congénitas y la referencia inadecuada de pacientes críticamente enfermos

Usefulness of Mobile Devices in Learning Within the Clinical Setting for Residents of Surgical Specialties in a Tertiary Care Pediatric Hospital

Abstract Background: Mobile learning refers to the use of mobile or wireless devices for learning purposes while on the move. It is a learning technique that can be applied in multiple contexts through social and content interactions. “Mobile” learners can use it as an educational technology in a variety of settings available at their convenience.In medicine, new technology offers the potential to enhance learning and patient care, although it also poses potential risks, such as superficial learning, failure to understand how to discriminate reliable sources of information, distraction, inappropriate use, and privacy-related issues. The aim of this study is to assess the usefulness of mobile devices for residents in the clinical settings of a hospital.Methods: Mixed method design on pediatric surgery residents. Quantitative data were analyzed via a simple discriminant analysis. Qualitative data were obtained using the focus group technique, with a subsequent triangulation of data.Results: All residents use devices for learning and communication. The triangulation analysis yielded the following categories: agile communication, search for data on drugs and prognosis, consultation of medical applications, limitations of devices, and inconsistencies between the official regulations and their advantages in clinical practice.Conclusions: We demonstrate the usefulness of mobile devices among surgical residents within the clinical care. Every hospital should regulate its policies for better use of devices.</jats:p

How the training of ultrasonographers influences the certainty of prenatal detection of congenital malformations of interest to the pediatric surgeon

Background: The training needed for doing obstetric ultrasounds is rarely reported. The aim of this study was to determine whether the training of the ultrasonographer influences the prenatal diagnostic certainty of some congenital malformations. Methods: We conducted a retrospective evaluation of antepartum sonographic findings of newborn infants found ultimately to have a congenital anomaly in a tertiary level pediatric reference center. Data were collected on admission for consecutive patients at a tertiary-level pediatric reference center. The mother´s pregnancy and birth demographic variables and those of the prenatal ultrasound (PUS) were analyzed and correlated with the final diagnosis. Results: Sixty-seven neonates were included. All cases underwent PUS with a mean of 4.6. Prenatal diagnosis was established in 24 cases (35.8%). Thirteen surgical anomalies were detected, particularly anorectal malformation and gastroschisis. The accuracy of PUS was associated with the training of the physician performing the PUS, whereby PUS with the greatest accuracy were performed by gynecologists and maternal-fetal specialists against radiologists and general practitioners (p = 0.005). Patients without an accurate prenatal diagnosis had a greater risk of presenting comorbidities (relative risk [RR]: 1.65, p = < 0.001, 95% confidence interval [CI]: 1.299-2.106). Conclusions: In our setting, prenatal diagnosis of these malformations is directly determined by the training of the person performing the ultrasound

Role of Procalcitonin in the Timely Detection of Ischemia and Necrosis in Children With Intestinal Obstruction

Abstract Introduction: Procalcitonin (PCT) has been studied for early identification of ischemia and/or necrosis (I/N) in children with intestinal obstruction (IO) secondary to adhesive small bowel obstruction (ASBO). However, the causes of IO in children are numerous. Purpose: To correlate the level of PCT with the presence of I/N.Results: Fifty-seven patients were analyzed. The incidence of I/N was 36%. PCT median was statistically higher in patients with I/N compared to those patients with normal intestine: 4.13 (13.9) vs 0.11 (0.28) ng/ml, p = &lt;0.001. A PCT threshold &gt;1.17 ng/ml for predicting I/N yielded a sensitivity of 90%, a specificity of 97%, a positive predictive value (PPV) of 95%, a negative predictive value (NPV) of 94%, p = &lt;0.001, relative risk (RR) 17.57 (95%CI, 4.54 – 67.90). Similarly, a PCT threshold &gt;1.41 ng/ml for predicting intestinal necrosis yielded a sensitivity of 92%, a specificity of 88%, a PPV of 72%, a NPV of 97%, p = &lt;0.001, RR 28.16 (95%CI, 3.98 – 119.12).Conclusions: This study corroborates the association of PCT with IN in children with IO and expands the evidence of its use in this field. Similarly, suggests a PCT threshold &gt;1.17 ng/ml and &gt;1.41 for predicting IN and intestinal necrosis respectively.</jats:p