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

Dr. Norman Bethune, an example of altruism in medicine and a precursor of medical internationalism

Background: the contribution of important personalities of the medical sciences to the improvement of the human health has been significant. Among them Norman Bethune has shone as one of the most important surgeons of the world and as an example of the noblest qualities of the medical profession. Objective: to introduce the life and work of the Canadian physician Henry Norman Bethune to the Cuban professional community, by means of the two most important features of his personality, altruism and internationalism.Methods: a research study on the life and work of the Canadian physician Henry Norman Bethune was carried out. Historical research methods were used, which included documentary review and interviews. The bibliography used in the study included printed, digital and audiovisual materials. Canadian experts and professors were interviewed.Results: Norman Bethune was a Canadian physician of the first half of the 20th century. Specialized in surgery, he shone for his skills and for the design of several surgical instruments that were used in his time. He fought for the health of the poor and expressed the need for implementing socialized medicine in his country. On a worldwide scale he was notable for his help to countries oppressed by fascism that needed medical care in times of war, what makes him deserve the designation of precursor of medical internationalism.Conclusions: the most important actions of the life and work of Norman Bethune were described, laying emphasis on the altruist and internationalist nature of his personality and his work as a physician

Intervención didáctica para la enseñanza de la farmacología en las clases de inglés con fines específicos

Se realizó un estudio cualitativo de intervención, con el objetivo de determinar el vocabulario relacionado con la farmacología, necesario para desarrollar las clases de inglés médico en la carrera de Medicina de la Universidad de Ciencias Médicas de Las Tunas. El grupo de estudio estuvo constituido por los estudiantes y profesores del 5to año de la carrera de Medicina del curso 2011-2012. Las variables fueron la preparación del colectivo de profesores, las afecciones clínicas incluidas en el programa, los grupos farmacológicos implicados y el nombre en inglés de medicamentos específicos. La información se obtuvo de los libros de textos y los trabajos independientes realizados por los estudiantes. Se constató que la preparación profesional de los docentes en el área de la farmacología depende de la disponibilidad de diccionarios actualizados y de los conocimientos que estos han ido adquiriendo de forma empírica. Se observó una tendencia en los estudiantes a relacionar nombres de medicamentos, cuyas pronunciaciones se desconocen, lo cual entorpece la adquisición correcta del contenido lingüístico en inglés. Se evidenció que cuando se trabajan los grupos farmacológicos con un limitado número de medicamentos específicos y reconocidos, se logra un mejor desempeño lingüístico en los estudiantes