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

Congenital syphilis in an immunocompromised neonate: case report

Syphilis is a notifiable and preventable disease, congenital syphilis more so. Consequently, attention has been recently focused on prenatal diagnosis of foetal syphilis by the use of ultrasonography apart from the conventional serologic screening. Congenital syphilis has not been reported from the Kingdom of Lesotho. We report the case of a 3.0kg male neonate with florid joint and bone lesions of congenital syphilis associated with HIV infection seen at the Queen Elizabeth II Hospital, Maseru, Kingdom of Lesotho. Co-existing HIV infection influences the clinical manifestation of syphilis, the progression of neurosyphilis and the response to standard therapy. The baby had the recommended standard treatment with good response and he was followed-up for a period of twelve months with serologic screening and radiographic evaluation. East African Medical Journal Vol.80(12) 2003: 660-66

Ruptured false iliac artery aneurysm - a case report from Nigeria

A 23year old male Nigerian presented to the Nephrology unit of the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria with features of chronic renal failure secondary to chronic glomerulonephritis. He was referred to the surgical department of the hospital on account of severe torrential uncontrollable bleeding from an infected cannulation site. He was maintained on regular hemodialysis but developed femoral triangle sepsis at the cannulation site and aneurysm of the external iliac artery. The aneurysm later ruptured with severe jet exsanguinations bleeding. Exploration revealed a-4cm rent in the external iliac artery that was sutured with 6/0 prolene, interrupted, using clamp and suture technique. Perfusion was satisfactory in the immediate post-operative period. The patient was transfused with 11 pints of blood within 12 hours and had an uneventful post-operative period

Femoral hernias in children at the Olabisi Onabanjo University teaching Hospital, Sagamu, Nigeria

Objective: To ascertain the diagnostic accuracy and outcome of surgical treatment in Nigerian children referred for paediatric surgical opinion at the Olabisi Onabanjo University Teaching Hospital, Sagamu, South-west Nigeria. Design: A retrospective review of our practice experience over a 15-year period; between January, 1989 and December, 2003. Setting: The Olabisi Onabanjo University Teaching Hospital (OOUTH), serves as a referral centre for other government and private hospitals in and around the Ogun State, South-west Nigeria. The OOUTH, though a tertiary medical centre also receives patients who present directly at the General Out-Patient Clinics and the Emergency Units of the hospital. The catchment population is estimated at 7.5 million. Subjects: The medical records of all patients under 14 years of age with a final diagnosis of femoral hernia who presented between January, 1989 and December, 2003 were reviewed. Methods: The age, sex, mode of presentation, findings at surgery, procedure performed, immediate post-operative and 12 months follow-up details were recorded. Results: Seven of 1,213 (0.58%) patients with groin hernias within the study period had femoral hernias; four (57%) were girls and three (43%) were boys. Age range was 3 to 9 years. The mode of presentation in all the children was recurrent lump in the groin. Five patients (71%) had right sided lump while the lump was on the left side in two of the patients. The duration of symptoms ranged from two years to eight years. The provisional diagnosis by the referring general practitioners and paediatricians were incorrect in all seven patients. Five patients (71%) were correctly diagnosed preoperatively by the attending surgeon while two were thought to be inguinal hernias. Conclusion: The diagnosis of femoral hernia remains a challenging problem in childhood because of its rarity and similar clinical presentation as inguinal hernia. East African Medical Journal Vol.81(9) 2004: 447-44

Abdominal Masses in Children: A 10-Year Review

Background: Some childhood diseases present with abdominal masses alone or with other constitutional symptoms. The knowledge of the common causes of abdominal masses in children can assist in developing a protocol of management by clinicians. Objective: To describe the aetiology and presentation of abdominal masses in children. Methods: The hospital records of all cases of intra-abdominal masses in children managed between May 1998 and April 2008 were retrieved for analysis. Socio-demographic and clinical data were obtained and analysed using simple descriptive statistics. Results: A total of 93 children were included while those without clinical, radiological and intra-operative evidence of intra-abdominal masses were excluded from the study. There were 49 males (52.7%) and 44 (47.3%) females with male-to-female ratio of 1.1:1. The children were aged 1 day to 14 years; 15 (16.1%) were aged 6-9 years, >9-12 years and >12-14 years. The most common cause of abdominal masses was appendiceal mass/abscess in 29%, followed by hydronephrosis in 22.6% and nephroblastoma in 16.11%. The most common symptoms included abdominal pain (86.0%), fever (46.2%), vomiting (40.9%) and abdominal distension (32.2%). The mortality rate was 13%. Conclusion: Non-malignant conditions were mostly responsible for abdominal masses in children while abdominal pain, fever and vomiting were the leading presentations of abdominal masses in children

Aetiology of Abdominal Injuries in Children:- at Olabisi Onabanjo University Teaching Hospital, Sagamu A preliminary study,

The occurrence of abdominal injuries in children appear to be on the increase in our environment and; several aetiological factors have been implicated. To outline the aetiological factors responsible for abdominal injuries in children managed at our health institution. A two-year prospective study carried out between January 2007 and December 2008. Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria. All children that presented with abdominal injury. Children who were managed for abdominal injuries were studied prospectively for two years between January 2007 and December 2008. Data obtained from informants (parents, guardians, police, road safety corps members and passers-by) included sex, age, cause of injury, time and place of occurrence of injury, type and mechanism of injury were entered into a structured proforma. Analysis of data was done with SPSS version 15. Forty-nine children were studied, of which 38 (77.6%) were males, and 11 (22.4%) were females, with a male to female ratio of 3.5:1. Their ages ranged between 8 months and 14 years with a mean age of 8.84+3.057. Road traffic accident was the aetiological factor in 34 (69.4%) cases, vehicular accidents were responsible in 26 (76.5%) of the road traffic accidents while motorcycle related causes were seen in 8 (23.5%). Other aetiological factors were fall from height 7 (14.3%), gun shot and Blunt injury from blow/kick each were in 3 (6.1%) and stab wounds 2 (4.1%). Abdominal injuries in children in our study were caused mostly by road traffic accidents and falls. Other aetiological factors were stab wounds and assaults.Key words: Abdominal injuries, Aetiology, children