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

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

Üç Olgu Nedeniyle Travma ve Komplikasyonların Adli Tıp Açısından Değerlendirilmesi

Bu çalışmada, travmaya uğrayan ve tedavi uygulaması sırasında nadir görülen komplikasyonlar gelişen üç farklı olgu özelinde travma ve sonrasında görülen komplikasyonlara adli tıp açısından yaklaşım tartışılacaktır. Olgular birbirinden farklı klinik tablolara sahip olsalar da travma sonrası komplikasyon gelişimi yönünden benzerlik göstermektedir. Birinci olgu; eğitim sırasında koluna basılması sonucu yumuşak doku travması tanısı alan, atel ve tıbbi tedavi uygulaması süresinde kompartman sendromu gelişmesiyle sol kol dirsek üstü amputasyonu yapılan bir askerdir. İkinci olgu da; araç içi trafik kazasında künt batın travmasına maruz kalan ve akut pankreatit gelişen bir erkek hastadır. Bu hastaya uygulanan tedavide, distal pankreatektomi ve ameliyatın cerrahi tekniği gereği dalak lezyonu olmamasına rağmen splenektomi yapılmıştır. Üçüncü olgu ise araç içi trafik kazası sonrasında gazlı gangren enfeksiyonu gelişen ve bacak diz altı seviyesinden amputasyon yapılan bir erkek hastadır. Olgularda travmaya bağlı yaralanma sonrası gelişen komplikasyonlar sonucu yapılan amputasyonlar ve splenektominin; travmanın sonucunda mı yoksa travma sonrasındaki tedavi ve bakım aşamalarının sonucunda mı olduğunun değerlendirilmesi önemlidir. Ancak uygulamada bu ayırımın yapılmasında bazı güçlükler yaşanmaktadır. Bu olgular bağlamında travmanın ve sonrasında gelişen komplikasyonların adli tıp açısından değerlendirilmesinde göz önüne alınması gereken ilkeler, ilgili literatür ışığında tartışılmıştır.</p

Medicolegal Approach to Child Physical Abuse in an Emergency Clinic

Child abuse is a global health problem. For this reason, it is important to perform suitable medical approaches in suspected cases of child abuse in the emergency room. The first consideration is performing life-saving medical approaches. Reporting the case to judicial authorities and the correlation of medical examination findings with medicolegal history are other important steps. We report a case of a 3-year-old male child who died after severe physical abuse. In suspected cases of child abuse, examination of the fundus is important. If death occurs, histopathological examination of eye globes must be performed to determine the cause of death. The present case was the first in which eye globe examination was performed in Izmir, Turkey. Autopsy findings revealed subdural hemorrhage and subarachnoid hemorrhage caused by blunt trauma. The cause of death was blunt head trauma, and the manner of death was listed as homicide. Except for microhemorrhages in the optic nerve sheath, no pathological finding was identified in the retina. Retinal hemorrhage can be seen in child abuse cases, and it is associated with a poor prognosis if present; however, the absence of retinal hemorrhage does not exclude child abuse. Crime scene investigation findings, witnesses' statements, medical records, and autopsy findings must all be taken into consideration in child abuse cases in a correlative and holistic manner

Medicolegal Approach to Child Physical Abuse in an Emergency Clinic

Child abuse is a global health problem. For this reason, it is important to perform suitable medical approaches in suspected cases of child abuse in the emergency room. The first consideration is performing life-saving medical approaches. Reporting the case to judicial authorities and the correlation of medical examination findings with medicolegal history are other important steps. We report a case of a 3-year-old male child who died after severe physical abuse. In suspected cases of child abuse, examination of the fundus is important. If death occurs, histopathological examination of eye globes must be performed to determine the cause of death. The present case was the first in which eye globe examination was performed in Izmir, Turkey. Autopsy findings revealed subdural hemorrhage and subarachnoid hemorrhage caused by blunt trauma. The cause of death was blunt head trauma, and the manner of death was listed as homicide. Except for microhemorrhages in the optic nerve sheath, no pathological finding was identified in the retina. Retinal hemorrhage can be seen in child abuse cases, and it is associated with a poor prognosis if present; however, the absence of retinal hemorrhage does not exclude child abuse. Crime scene investigation findings, witnesses' statements, medical records, and autopsy findings must all be taken into consideration in child abuse cases in a correlative and holistic manner