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

A Huge Penile Fibroepithelial Polyp Treated with Partial Penectomy: A Case Report and Review of the Literature

Fibroepithelial polyps are benign tumors of mesodermal origin that usually arise on the surface of the skin and to a lesser extent in the urinary tract; however, their presence on the penis is extremely unusual. We report the case of a 73-year-old male with an extremely large broad-based penile fibroepithelial polyp (FEP) involving the penile shaft and glans penis associated with chronic condom catheter use and that was treated with partial penectomy. A review of the literature is included to highlight the rarity of this case. To the best of our knowledge, this is the largest mass of its kind to be reported on the penis.</jats:p

A Huge Penile Fibroepithelial Polyp Treated with Partial Penectomy: A Case Report and Review of the Literature

Fibroepithelial polyps are benign tumors of mesodermal origin that usually arise on the surface of the skin and to a lesser extent in the urinary tract; however, their presence on the penis is extremely unusual. We report the case of a 73-year-old male with an extremely large broad-based penile fibroepithelial polyp (FEP) involving the penile shaft and glans penis associated with chronic condom catheter use and that was treated with partial penectomy. A review of the literature is included to highlight the rarity of this case. To the best of our knowledge, this is the largest mass of its kind to be reported on the penis

Attitudes of Physicians in Jordan Toward Non-Disclosure of Health Information

Objectives: Our aim was to investigate the attitudes of physicians in Jordan toward non-disclosure and the differential attitudes of physicians who are “always truthful” and those who are not. Methods: Our report is based on the second subset of data from a cross-sectional study of the truth disclosure practices and attitudes of physicians in Jordan, which was conducted between January and August 2016. We selected 240 physicians from four major hospitals by stratified random sampling, and we invited them to complete a self-administered questionnaire regarding truth disclosure attitudes. We compared the attitudes of physicians who were “always” truthful and those who were not. Results: In total, 164 physicians (68%) completed the questionnaire, of whom 17 (10%) were “always truthful”, while the remaining 144 (90%) were not. Physicians who were “always truthful” were more likely to indicate that non-disclosure is “unethical” (77% v. 39%; p=0.009). Moreover, physicians who were “always truthful” were more likely to disagree that non-disclosure is beneficial for the physical and psychological health of patients (82% v. 55%; p=0.03). The majority of physicians agreed that all patients have the right to know their diagnosis, most patients prefer to know their diagnosis, and the introduction of legislation to enforce disclosure would positively affect medical practice in Jordan. Conclusion: The differential attitudes of physicians who were “always truthful” and those who were “not always truthful” suggest a rationale behind independent non-disclosure, namely that non-disclosure is ethically justifiable and beneficial for the physical and psychological health of patients.Keywords: Truth Disclosure • Physicians • Attitude • Jordan • Middle East • Cross-Sectional Studie

Attitudes of Physicians in Jordan Toward Non-Disclosure of Health Information

Objectives: Our aim was to investigate the attitudes of physicians in Jordan toward non-disclosure and the differential attitudes of physicians who are “always truthful” and those who are not. Methods: Our report is based on the second subset of data from a cross-sectional study of the truth disclosure practices and attitudes of physicians in Jordan, which was conducted between January and August 2016. We selected 240 physicians from four major hospitals by stratified random sampling, and we invited them to complete a self-administered questionnaire regarding truth disclosure attitudes. We compared the attitudes of physicians who were “always” truthful and those who were not. Results: In total, 164 physicians (68%) completed the questionnaire, of whom 17 (10%) were “always truthful”, while the remaining 144 (90%) were not. Physicians who were “always truthful” were more likely to indicate that non-disclosure is “unethical” (77% v. 39%; p=0.009). Moreover, physicians who were “always truthful” were more likely to disagree that non-disclosure is beneficial for the physical and psychological health of patients (82% v. 55%; p=0.03). The majority of physicians agreed that all patients have the right to know their diagnosis, most patients prefer to know their diagnosis, and the introduction of legislation to enforce disclosure would positively affect medical practice in Jordan. Conclusion: The differential attitudes of physicians who were “always truthful” and those who were “not always truthful” suggest a rationale behind independent non-disclosure, namely that non-disclosure is ethically justifiable and beneficial for the physical and psychological health of patients.Keywords: Truth Disclosure • Physicians • Attitude • Jordan • Middle East • Cross-Sectional Studies</jats:p