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ObjectivesThe optimal size of the health workforce for children’s surgical care around the world remains poorly defined. The goal of this study was to characterise the surgical workforce for children across Brazil, and to identify associations between the surgical workforce and measures of childhood health.DesignThis study is an ecological, cross-sectional analysis using data from the Brazil public health system (Sistema Único de Saúde).Settings and participantsWe collected data on the surgical workforce (paediatric surgeons, general surgeons, anaesthesiologists and nursing staff), perioperative mortality rate (POMR) and under-5 mortality rate (U5MR) across Brazil for 2015.Primary and secondary outcome measuresWe performed descriptive analyses, and identified associations between the workforce and U5MR using geospatial analysis (Getis-Ord-Gi analysis, spatial cluster analysis and linear regression models).FindingsThere were 39 926 general surgeons, 856 paediatric surgeons, 13 243 anaesthesiologists and 103 793 nurses across Brazil in 2015. The U5MR ranged from 11 to 26 deaths/1000 live births and the POMR ranged from 0.11–0.17 deaths/100 000 children across the country. The surgical workforce is inequitably distributed across the country, with the wealthier South and Southeast regions having a higher workforce density as well as lower U5MR than the poorer North and Northeast regions. Using linear regression, we found an inverse relationship between the surgical workforce density and U5MR. An U5MR of 15 deaths/1000 births across Brazil is associated with a workforce level of 5 paediatric surgeons, 200 surgeons, 100 anaesthesiologists or 700 nurses/100 000 children.ConclusionsWe found wide disparities in the surgical workforce and childhood mortality across Brazil, with both directly related to socioeconomic status. Areas of increased surgical workforce are associated with lower U5MR. Strategic investment in the surgical workforce may be required to attain optimal health outcomes for children in Brazil, particularly in rural regions.

Hepatoblastoma (HB) has different histological subtypes, with varying prognosis. Though the survival has drastically improved, subsets of patients are not responsive to therapy. Therefore, it becomes important to determine the factors which affect the behaviour of the tumour. This study was aimed to look at the histopathological subtypes and compare with immunohistochemical (IHC) expression of CK19, beta-catenin and EpCAM and survival.This study included 55 cases of HB. IHC expression of CK19, beta-catenin and EpCAM were correlated with histological subtypes, tumour behaviour, response to chemotherapy and survival.Most common epithelial subtype was fetal (43.2%) and mixed epithelial (54.8%) in pre- and post-chemotherapy groups respectively. Microvascular invasion (MVI) was present in 14/33 resected tumours. CK19 expression was seen in 54.2% and 72.2% of embryonal subtype, nuclear beta-catenin expression in 48.7% and 57.1% and EpCAM in 100% and 82.1% of tumours in pre- and post-chemotherapy groups, respectively. Fetal subtype had a lesser chance of MVI, recurrence, metastasis and death. Beta-catenin expression was associated with lower event free survival (EFS) and EpCAM with ≥50% viable tumour following chemotherapy (P=0.04). Age at diagnosis ≤2 years, male sex, alpha-fetoprotein10,000 IU/mL following chemotherapy, solitary tumour (P=0.001), size ≤5 cm, pretreatment extent of disease (PRETEXT) III, mitosis ≤2/10 high power fields (hpf), viable tumour50% (P=0.04) and absent nuclear expression of beta-catenin, predicted a higher EFS rate.Beta-catenin expression is associated with lower EFS and EpCAM expression with tumour viability. Multifocality and viable tumour ≥50% were significant factors predicting lower EFS. These factors should be included in the prognostication of HBs.

Rupture of the diaphragm may be traumatic or spontaneous. A spontaneous rupture occurring in a congenital eventration of the diaphragm is extremely rare. Only one such case has been reported previously. We report a case of a 5-month-old male infant who presented with acute life-threatening respiratory distress secondary to spontaneous rupture of a congenital diaphragmatic eventration.