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

Right Bochdalek congenital diaphragmatic hernia: a tertiary center’s experience over 13 years

Abstract Background Right Bochdalek congenital diaphragmatic hernia (RB-CDH) is far less common than left Bochdalek congenital diaphragmatic hernia, accounting for only 13% of cases. There are limited published data on the outcomes and survival rate of RB-CDH. We aimed at investigating the clinical characteristics and analyzing the risk factors of survival in neonates with RB-CDH treated in our center over a period of 13 years. Results Fifteen infants with RB-CDH were identified. Most of the patients were full term (74%). The mean birth weight was 2.90± 0.72 kg. The ratio of male to female was 2:1. The mean APGAR score at 1 min was 5.31±2.34, and 7.30±1.59 at 5 min. Ten patients (67%) were imaged by antenatal ultrasound. Eleven patients (73.33%) survived to go for surgical repair. The hernia sac was found in 5 patients (45%). Most hernial defects were closed in a primary fashion. The mean age at the operative repair was 8.11±9.90 days. The average NICU stay for all patients was 40.47±50.38 days. The mean follow-up period was 20.45±9.34 months. Three patients had postoperative complications. The total survival rate in neonates with RB-CDH was 9/15 (60%). Nine out of 11 (82%) neonates survived after surgical repair. Four patients (27%) died before surgical repair. Ventilation-related bilateral pneumothorax was a contributing cause of death in three patients. Birth weight was found lower in the non-survivor’s group (P &lt; 0.05). Moreover, the degree of pulmonary hypertension was more severe among non-survivors. No statistical significance was observed between other variables and mortality. Conclusion We found that low birth weight and the presence of severe PHTN were risk factors for mortality in neonates with RB-CDH. These results are in line with previous studies on prognostic factors in CDH. Ventilator-related pneumothorax appears to be a significant contributing cause of death. Long-term follow-up studies of infants born with RB-CDH are needed as small number of cases limits large-volume RB-CDH studies. </jats:sec

FACTORS ASSOCIATED WITH PSYCHOLOGICAL OUTCOMES OF HEALTHCARE WORKERS DURING THE COVID-19 PANDEMIC AND ITS EFFECTS ON QUALITY OF LIFE

Purpose: This study aimed at assessing the factors associated with psychological outcomes among HCWs in Saudi Arabia (SA) during the pandemic. It also aims to determine the factors affecting their QoL.&#x0D; Methodology: In this descriptive cross-sectional study, all HCWs who are working in direct and indirect contact with COVID-19 cases in tertiary hospitals of SA were invited voluntarily to complete the validated web-based survey during the study period. A total of 1,182 HCWs from different regions across SA and different specialties including physicians, nurses, pharmacists, health educators, technicians, and others responded to this study between the 1st of June and the 31st of July 2020. Psychological risk factors were evaluated using Patient Health Questionnaire depression scale; and the Generalized Anxiety Disorder (GAD-7) anxiety scale. QoL was assessed using the World Health Organization Quality of Life Questionnaire (WHOQOL). Socio-demographic data were summarized with frequency and percentages. The overall anxiety, depression, WHOQOL scores of the study participants were calculated according to mean value, SD, and median. The association between socio-demographic factors and anxiety, depression scales were examined using independent samples t-tests, one-way ANOVA, and the chi-square test (for categorical depression/ anxiety variables severe depression/severe anxiety against mild/moderate/moderately severe). While those factors and WHOQOL domains were examined using one-way ANOVA.   Multivariate analysis was used to identify the front-line work predictors of depression and anxiety.&#x0D; Findings: Poor QoL scores were observed, especially in the physical and psychological health domains. In general, low QoL was significantly higher among workers who reported higher levels of anxiety and depression. The observed factors affecting the psychological health and QoL were age, gender, living with children and/or older people, occupation, years of experience, participation in front-line work.&#x0D; Unique contribution to theory, practice and policy: Specific characteristics of HCWs may act as protective or risk factors with regard to depression, anxiety, and QoL. Targeted interventions could mitigate the negative effects of front-line work to maintain medical professionals’ optimal psychological and physical health .More research is needed to further determine how the COVID-19 pandemic and front-line work affect HCWs' mental and physical well-being</jats:p

Safety &amp;amp; Cost-Effectiveness of Primary Neonatal Posterior Sagittal Ano-recto Plasty (PNPSARP)

Abstract Background: Early repair of Anorectal malformation (ARM) within 6 months may be one of the factors that improve fecal continence. Delayed and multiple-stage repairs require dilatation, strict bowel preparation, fasting and total parenteral nutrition (TPN). PNPSARP requires neither bowel preparation nor parenteral nutrition. We believe it can be achieved within 72 hours of life.Aim: To evaluate the safety, feasibility and cost effectiveness of PNPSARP within 72 hours of life versus delayed or multiple-stage repair of vestibular and perineal fistula. Material &amp; Methods: A retrospective study was carried out of all newborns with ARM at our institute between August 2016 and August 2019. PNPSARP within 72 hours of life was compared with delayed or multiple-stage repair. Neither bowel preparation nor parenteral nutrition was required in the PNPSRP group. Perioperative complications and costs were evaluated. Results: Eight PNPSARP were compared with 7 delayed or multiple stage repair over the study period. Four babies (50%) were operated at day 1 post delivery in the PNPSARP group. Mean operative time (MOT) was 109 minutes (68-155). Mean follow up period was 22 months (12-36). One girl with a vestibular fistula had wound infection. This group had a good outcome with no morbidity, high satisfaction rate and low costs in comparison to delayed or multiple-stage repair.Conclusions: PNPSARP for perineal and vestibular fistula with supportive ancillary services in the first few days of life appears to be safe and cost effective with minimal morbidity. PNPSARP is now the standard technique in our unit.</jats:p