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Grover et al. reported that the mortality rate of preterm neonates with CDH (<34 weeks or birth weight <2000 g) was 50%, compared to 27% mortality rate for neonates >34 weeks [15]. In this study, 5 of our patients (33%) were preterm (<37weeks), 3 of them (60%) died. We found no significant difference in mean gestational age at birth between survivors and non-survivors. CDH is usually diagnosed immediately after birth with signs of respiratory distress and mediastinal shift on chest plain film [16]. All patients had respiratory distress features at birth, which is related to uncorrectable pulmonary hypoplasia and potentially reversible pulmonary hypertension [16]. A low Apgar score is usually associated with severe asphyxia and is a major independent predictor of mortality rate. However, our results suggest that the non-survivor group did not have statistically significant lower Apgar scores compared to the survivor group.Early prenatal diagnosis is important, as the mother should be referred to a tertiary care center for optimal care before birth. Most CDH defects are detected after 16 weeks of gestation. The prenatal detection rate varies in published studies, from 50 to 70% [17]. However, prenatal detection of CDH is uncommon in developing countries due to inadequate facilities and poor patient compliance [12]. In our study, 6/15 (40%) of the cases were diagnosed prenatally as RB-CDH. Three-dimensional estimation of the total fetal lung volume (TFLV), calculation of lung to head ratio (LHR), observed to expected lung head ratio (O/E LHR), and calculation of the lung to thoracic circumference ratio have been widely used as prognostic indicators [18, 19]. This study’s limitation is the unavailability of the antenatal ultrasonographic measurements (LHR and TFLV) in the medical records. Ramakrishnan and colleagues found that isolated CDH cases had better neonatal and 1-year survival rates, and chromosomal cases were associated with the worst survival rates [20]. Cardiac malformations are the most common associated anomalies. In a review of 4268 infants with CDH, approximately 18% of infants had an associated cardiac defect. Major cardiac lesions (excluding PFO, ASD, PDA) were associated with overall survival of 36% compared to infants with minor anomalies (67% survival) and those without cardiac defects (73% survival) [21]. In our review, none of the neonates had associated syndromes. Among the nonlethal cardiac malformations, ASD, VSD, and PFO predominated, similar to the findings reported by Sweed Y and colleagues [22]. Identification and management of pulmonary hypertension are critically important in the newborn period. CDH-associated pulmonary hypertension was graded—by echocardiography—into mild, moderate, and severe based on pressure gradient through ductus arteriosus. In our study, all non-survivors had signs of severe PHTN, whereas 3 out of 9 survivors (33.33%) had moderate to severe PHTN, with a P value of .027, which was statistically significant. The concept of gentle ventilation strategies (permissive hypercapnia) was introduced by Wung and colleagues in their 1995 retrospective, nonrandomized study to reduce iatrogenic lung injury from barotrauma; this ventilation strategy has been employed in most centers, including our center [23]. HFOV has also been utilized in the perinatal management of CDH to reduce pulmonary barotraumas. In this study, all patients received mechanical ventilation. Four out of nine (44.44%) survivors and 5/6 (83.33%) non-survivors received HFOV, with a P value of .286, which was statistically insignificant. HFOV was used for patients with refractory hypercapnia or high peak inspiratory pressures, and only one neonate required it postoperatively. HFOV may be a more effective mode of ventilatory support than conventional ventilation when used as an initial mode of therapy [24]. Extracorporeal membrane oxygenation (ECMO) is used if HFOV fails to maintain the goal physiologic parameters. Inhaled nitric oxide (iNO) was initiated at 20 ppm for all patients receiving HFOV. Usui et al. reported 14% incidence of pneumothorax among 510 neonates with CDH [25]. In our study, none of the neonates who had pneumothorax survived.Delayed surgical repair is the current management in most of the surgical centers. argue our point in this article [19]. When analyzing plastic surgery, we evaluate how comparable problems are handled elsewhere in the healthcare system, with the intention of arriving at consistency and identifying borderline cases. It is generally assumed that the objective of healthcare is not necessarily ideal or optimal health but rather acceptable health, given the health level of the society in question when operating under scarce resources. Therefore, it is assumed that Zcurrent level < Zreference level, implying that there could be levels of health above the reference level, and that different conditions can be equivalent to the reference level of health. Looking at that proposed definition, we find that there is both, what we might call a severity component of healthcare need, i.e. how far the patient is from the Zreference level in the current situation and to what extent the healthcare intervention Y can bring her closer to Zreference level, what we might call the effectiveness of treatment. Hence, our principle PSE, will have two aspects to consider, a severity and an effectiveness aspect. Functional and non-functional conditions Let us start by analyzing CJ1 (that functional conditions should be prioritized before non-fuctional conditions to public funding). The distinction between a functional and non-functional condition is common in plastic surgery, voicing the distinction between esthetic and reconstructive surgery from the AMA [11]. This distinction is far from clear, but in this article we will use it in the following way (drawing on the above conceptualization of health). A functional condition is one involving impairment of a physical function, where impairment will imply functioning outside of what is statistically normal for the population the patient belongs to (see below). A non-functional condition, by distinction, does not involve impairment of a physical function. Generally, in this article, non-functional conditions will imply a condition related to the appearance of the person. In some cases, as will be shown below, non-functional conditions Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 3 of 14 might indirectly result in physical dysfunction, e.g. when patients abstain from healthcare interventions since it would affect their appearance negatively or when it results in excessive weight loss or training. However, at this point we hope the distinction between physical dysfunction and problems related to appearance is clear enough for the analysis. Following this, it seems CJ1 aligns with PEN, i.e. functional conditions are indeed healthcare needs. The assumption is that a physical functional condition lowers health to a greater degree and is better suited for surgical treatment than non-functional conditions resulting from the experienced appearance of the patient [4, 20]. In other words that CJ1 aligns with PSE. Therefore, a functional condition warrants publicly funded plastic surgery to a greater extent than a non-functional condition. For example, qualifying for abdominoplasty requires more than the presence of a significant amount of excess skin and the associated suffering. The problem needs to exist in combination with a functional condition, such as eczema, infections, or micturition difficulties [3, 21]. Moreover, healthcare systems might perform breast reductions to alleviate back symptoms, although normally not breast augmentations, even when small breasts might cause some degree of suffering [3, 4, 22]. Experiencing a functional condition can obviously give rise to suffering, but it can also be a problem, despite patient experience (e.g., increased risk of premature death, a risk of future suffering). Additionally, the condition might introduce an objectively observable functional limitation, in which case it might be easier to objectively establish a healthcare need. For example, reducing breast size will relieve back strain, or abdominoplasty will remove the environment where eczema and infections thrive. Such reasoning makes it easier for both the patient and surgeon to classify the operation as medically warranted and not purely an esthetic intervention [23]. To define healthcare needs in terms of objectively quantifiable indications also provides the patient and surgeon with a feeling that the procedures are legitimate and offered in a consistent way according to the requirements of equity [23]. However, such a statement needs qualification. First, we need a standard for when a functional variation qualifies as a functional condition. Generally, finding such a standard requires identifying a range of variations outside of which the risk of a certain negative outcome is high enough. Another way to express this is in terms of statistical normality according to Boorse [24]. If an organ is functioning inside a range of what is statistically normal in a population, there is no problem; however, if there is a malfunction in relation to this range, there is a problem. Therefore, we need to define this range in order to identify when a healthcare intervention is warranted. Breast reduction to allow a patient to live with slightly smaller breasts that decrease back strain might not represent a large enough functional problem. Similarly, harboring excess skin with a small risk of eczema or infection might not be a large enough functional problem. Nevertheless, if there is a functional condition, but the patient does not experience or
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