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

Índice de masa corporal como factor de riesgo para complicaciones posterior a procesos estéticos

The growing obesity pandemic is an undeniable public health problem. Among the management strategies, bariatric surgery has occupied a chief role in the last decade. This has increased the need of the population for esthetic procedures such as abdominoplasty and mastopexy, and many others, with the objective of improving patients’ body image. However, in addition to the inherent risk of any surgical procedure, overweight and obese patients have greater risk. It has been shown that body mass index (BMI) acts as a predictive factor for postoperative complications such as wound infections, longer hospital stays, increased reoperation rates, and higher mortality. Thus, it is important to assess the risk-benefit relationship in the preoperative evaluation, considering patients’ BMI along with any other risk factors that may be present. The objective of this review is to assess the clinical evidence showing that BMI is a risk factor for complications following esthetic procedures.La creciente pandemia de obesidad representa un problema innegable de salud pública. Entre las estrategias para manejarla, la cirugía bariátrica ha ocupado un papel protagónico en la última década. Esto ha incrementado la necesidad de la población por procedimientos estéticos como la abdominoplastia, mastopexia y muchos otros, con la intención de que el paciente se sienta tan a gusto como sea posible con su imagen corporal. Sin embargo, es importante considerar que además del riesgo inherente a cualquier procedimiento quirúrgico, se le debe añadir el riesgo agregado para los pacientes con sobrepeso y pacientes obesos. Se ha demostrado que el índice de masa corporal (IMC) actúa como un factor predictor para complicaciones posoperatorias como infección de la herida, estadías intrahospitalarias más largas, mayor tasa de reoperación y mayores tasas de mortalidad, por lo que es importante establecer relación riesgo beneficio en la valoración preoperatoria, tomando en consideración el IMC del paciente en conjunto con cualquier otro factor de riesgo que se pueda presentar. El objetivo de esta revisión es evaluar la evidencia clínica que afirma que el IMC es un factor de riesgo para complicaciones en los procedimientos estéticos

Importancia del cuidado de la calidad del sueño en los pacientes con síndrome metabólico

The metabolic syndrome (MS) is defined as the conglomeration of various metabolic disorders such as abdominal obesity, insulin resistance, hypertension, and hyperlipidemia. In consonance, these elements increase the risk for cardiovascular disease (CVD), type 2 diabetes mellitus, and other causes of mortality. MS has been recognized as a multifactorial entity; with circadian cycles (CC) among the contributing factors. Implementation of interventions related to sleep hygiene may be an especially powerful tool in this context, in particular for the control of conditions such as obesity, MS, and CVD, which constitute an overwhelming load for public health systems. These ones center on sleep duration and regularity, and the harmonization between sleep time and eating patterns, as well as nutritional contents. Due to the important community impact of cardiometabolic diseases and sleep disorders at present, the objective of this review is to revise the role of the latter and the modifications of the CC in the development of MS, and how the intervention through sleep hygiene measures may aid in the prevention of this process.El síndrome metabólico (SM) se define como la conglomeración de una serie de trastornos metabólicos como la obesidad abdominal, resistencia a la insulina, hipertensión arterial e hiperlipidemia. En conjunto, estos elementos incrementan el riesgo de enfermedad cardiovascular (ECV), diabetes mellitus tipo 2 y otras causas de mortalidad. El SM se ha reconocido como una entidad de etiología multifactorial; entre los elementos contribuyentes se han identificado los ciclos circadianos (CC). La implementación de intervenciones relacionadas con la higiene del sueño podría ser una herramienta especialmente poderosa en este contexto, en particular para el control de condiciones como la obesidad, el SM y la ECV, que constituyen un peso avasallante para los sistemas de salud pública. Estas se centran en la duración del sueño, su regularidad, y la armonía entre los horarios de sueño y los patrones alimentarios, al igual que la atención al contenido nutricional. Debido al importante impacto comunitario de las enfermedades cardiometabólicas y los trastornos del sueño en la actualidad, el objetivo de esta revisión es esclarecer el papel de estos y las modificaciones del CC en el desarrollo del SM y cómo la intervención a través de la atención a las medidas de higiene del sueño puede ayudar a prevenir este proceso

Enfermedad renal crónica como factor de riesgo para complicaciones posterior a la artroplastia de miembros inferiores

Arthroplasties of the lower limbs are some of the most common orthopedic surgical procedures which are utilized, mainly, in patients with osteoarthritis (OA). This is degenerative disorder characterized by inflammatory mechanisms which affect cell types in the joints and can alter the functionality of other organs such as the kidneys, and thus, lead to the development of chronic kidney disease (CKD). At the same time, scientific evidence has demonstrated that CKD is implicated in proinflammatory processes associated with both, the development and the progression of OA. Likewise, numerous studies support the role of CKD as a risk factor for complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA), such as wound infections, pneumonia, and cardiopulmonary events, as well as increased mortality rates and revision surgeries in these patients. In this scenario, orthopedic surgeons are advised to perform a correct perioperative assessment of patients with CKD in order to reduce post-operative risks of THA and TKA. The objective of this review article is to describe the relationship among OA, CKD, and arthroplasties of the lower limbs, as well as to collect and present the scientific evidence supporting the role of CKD as a risk factor for complications after these surgical procedures.Las artroplastias de miembros inferiores resaltan como los procedimientos quirúrgicos ortopédicos más comunes, los cuales son utilizados, principalmente, en pacientes con osteoartritis (OA). Este es un trastorno degenerativo caracterizado por mecanismos inflamatorios que, además de afectar a las estirpes celulares de las articulaciones, puede alterar el funcionamiento de otros órganos como los riñones y, con ello, conllevar al desarrollo de enfermedad renal crónica (ERC). Al mismo tiempo, evidencia científica ha demostrado que la ERC se ve implicada en procesos proinflamatorios asociados tanto al desarrollo como a la progresión de la OA. Del mismo modo, existen numerosos estudios que respaldan el rol de la ERC como un factor de riesgo de complicaciones posterior a artroplastia total de cadera (ATC) y artroplastia total de rodilla (ATR) como infecciones de las heridas, neumonía y eventos cardiopulmonares, así como se correlaciona con un incremento de las tasas de mortalidad y cirugías de revisión en estos pacientes. En vista de dicha problemática, se recomienda a los cirujanos ortopédicos que realicen un correcto asesoramiento perioperatorio de pacientes con ERC, para así disminuir los riesgos postquirúrgicos de la ATC y ATR. El objetivo del presente artículo de revisión es describir la relación que existe entre la OA, la ERC y las artroplastias de miembros inferiores, en conjunto con recolectar y exponer la evidencia científica que soporte el rol de la ERC como factor de riesgo para complicaciones en dichos procedimientos quirúrgicos