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

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 middle-income 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 low-income 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 low-income, 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

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Prevalence of severe moral distress among healthcare providers in Saudi Arabia

Adel F Almutairi,1 Mahmoud Salam,1 Abdallah A Adlan,2 Abdullah S Alturki3 1Science and Technology Unit, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard health affairs, Riyadh, Saudi Arabia; 2Bioethics Section, King Abdullah International Medical Research center, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia; 3Research operations, King Abdullah International Medical Research center, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia Background: Moral distress is a serious problem in healthcare environments that requires urgent attention and management. It occurs when healthcare providers are unable to provide the care that they feel is right or take, what they believe to be, ethically appropriate actions for their patients. Thus, this study aims to examine moral distress among nurses and physicians working in tertiary teaching hospitals in Saudi Arabia, as well as to evaluate the level of association between moral distress and turnover. Methods: This cross-sectional study, which employed an anonymous 21-item Moral Distress Scale, was undertaken at a large medical institution located in different regions of Saudi Arabia. The data were analyzed using bi-variate analyses, and logistic regression. Results: Of the 342 participants, 239 (69.9%) were nurses/staff physicians and 103 (30.1%) were fellows/consultants. Approximately 24.3% of respondents experienced severe moral distress, whereas 75.7% reported mild moral distress. There was no statistically significant difference between men and women in terms of moral distress. Age was found to be a notable factor: moral distress was significantly higher in those younger than 37 years compared to those 37 years and older (P=0.015). Less than half of the participants (137, 42.8%) indicated their willingness to leave their jobs. A significant association was observed between severe moral distress and leaving the career (OR=3.16; P&lt;0.01). Job category was also an important factor: nurses/staff physicians were almost two times more likely (OR =1.95, P=0.038) to leave their positions compared to fellows/consultants. Conclusion: This study revealed that moral distress, which is a serious problem that compromises the well-being of caregivers, was a predictive variable for the intention of healthcare providers to leave their jobs. Therefore, it should be routinely examined, and efficient action plans should be implemented to alleviate its consequences. Keywords: burnout, MDS-R, organizational support, nurses, physician

Assessment of tear-evaporation rate in thyroid-gland patients

Ali Abusharaha,1 Abdulaziz A Alturki,1 Saud A Alanazi,1 Raied Fagehi,1 Naji Al-Johani,2 Gamal A El-Hiti,1 Ali M Masmali1 1Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh 11433, Saudi Arabia; 2Department of Endocrinology and Thyroid Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh 11433, Saudi Arabia Objective: To assess the tear-evaporation rate in thyroid-gland patients using a VapoMeter.Methods: Twenty thyroid gland patients aged 18&ndash;43 years (mean 34.3&plusmn;6.3 years) completed the study. Additionally, an age-matched control group of 20 patients aged 18&ndash;43 years (32.2&plusmn;5.1 years) was enrolled in the study for comparison purposes. An Ocular Surface Disease Index dry-eye questionnaire was completed, followed by a test to determine the tear-evaporation rate using the VapoMeter. The test was performed three times per subject by the same examiner. Two readings were obtained each time.Results: Significant differences (P&lt;0.05) were found between mean Ocular Surface Disease Index and tear-evaporation-rate scores within the study and control groups. The average tear-evaporation rate was much higher in the study group (median 41.2 [IQR 41.4] g/m2&middot;h) than the control group (15.7 [13.7] g/m2&middot;h). Moreover, the average Ocular Surface Disease Index score for thyroid-gland patients was much higher (15.6 [23.4]) compared to the control group (5.5 [7.50]).Conclusion: The tear-evaporation rate in thyroid-gland patients was found to be much higher than normal-eye subjects. Keywords: thyroid gland, thyroid-associated ophthalmopathy, Graves&rsquo;s ophthalmopathy, dry eye, tear-evaporation rate, evaporative dry eye&nbsp

Influence of COVID-19 on lifestyle behaviors in the Middle East and North Africa Region: a survey of 5896 individuals

Background: Coronavirus disease (COVID-19) pandemic has affected health and lifestyle behaviors of people globally. This project aims to identify the impact of COVID-19 on lifestyle behavior of individuals in the Middle East and North Africa (MENA) region during confinement. Methods: We conducted an online survey in 17 countries (Egypt, Jordan, United Arab Emirates, Kuwait, Bahrain, Saudi Arabia, Oman, Qatar, Yemen, Syria, Palestine, Algeria, Morocco, Libya, Tunisia, Iraq, and Sudan) from the MENA region on August and September 2020. The questionnaire included self-reported information on lifestyle behaviors, including physical activity, eating habits, smoking, watching television, social media use and sleep before and during the pandemic. Logistic regression was performed to analyze the impact of COVID-19 on lifestyle behaviors. Results: A total of 5896 participants were included in the final analysis and 62.8% were females. The BMI of the participants was 25.4 &plusmn; 5.8&nbsp;kg/m2. Around 38.4% of the participants stopped practicing any physical activities during the confinement (P &lt; 0.001), and 57.1% reported spending more than 2&nbsp;h on social media (P &lt; 0.001). There were no significant changes in smoking habits. Also, 30.9% reported an improvement in their eating habits compared with 24.8% reported worsening of their eating habits. Fast-food consumption decreased significantly in 48.8% of the study population. This direct/indirect exposure to COVID-19 was associated with an increased consumption of carbohydrates (OR = 1.09; 95% CI = 1.02&ndash;1.17; P = 0.01), egg (OR = 1.08; 95% CI = 1.02&ndash;1.16; P = 0.01), sugar (OR = 1.09; 95% CI = 1.02&ndash;1.16; P = 0.02), meat, and poultry (OR = 1.13; 95% CI = 1.06&ndash;1.20; P &lt; 0.01). There was also associated increase in hours spent on watching television (OR = 1.07; 95% CI = 1.02&ndash;1.12; P &lt; 0.01) and social media (OR = 1.09; 95% CI = 1.01&ndash;1.18; P = 0.03). However, our results showed a reduction in sleeping hours among those exposed to COVID-19 infection (OR = 0.85; 95% CI = 0.77&ndash;0.94; P &lt; 0.01). Conclusions: The COVID-19 pandemic was associated with an increase in food consumption and sedentary life. Being exposed to COVID-19 by direct infection or through an infected household is a significant predictor of amplifying these changes. Public health interventions are needed to address healthy lifestyle behaviors during and after the COVID-19 pandemic