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

Morphometric analysis of the cervical intervertebral foramina: Establishment of a normative database in Jordanians using 3-D reconstructed computed tomography images

Abstract Purpose Despite overwhelming clinical importance, no accurate threshold values of linear measurements of cervical intervertebral foramina exist that signify the switch of cases from asymptomatic to symptomatic state. The pattern of change of relevant morphometric values with regard to different parameters remain inconclusive. In Jordan, morphometric analysis of normal cervical intervertebral foramina is still absolutely lacking. We intend to establish a normative database of the linear measurements of the cervical intervertebral foramina in a representative sample of normal Jordanian population. Age-, gender-, vertebral level-, and laterality-dependent differences of these measurements are to be explored. Methods Parasagittal computerized tomographic images of 320 normal Jordanians, 16–37 years of age, were stratified according to age and gender, three-dimensionally reconstructed, and foraminal height and width at the levels C2/C3 through C7/T1 were bilaterally measured and statistically analyzed. Results The overall average foraminal height and foraminal width measured: 10.15, 8.09, 8.00, 8.18, 8.43, and 7.97, and 6.34, 5.73, 6.03, 6.11, 6.83, and 7.33 (in mm), for the levels C2/C3 through C7/T1, respectively with mean ratio Width/Height was 0.77. A consistent reciprocal cranio-caudal pattern of decrease of height and increase of width was evident. Males showed consistently higher height and width values with level of significance reached at upper and lower intervertebral levels. Although statistically insignificant, the Adolescent age group showed the highest values of height and width among all other age groups. Significant side-related differences were lacking. Conclusions The linear parameters of normal cervical intervertebral foramina in Jordanians correspond well with other published studies, and follow differential, gender- and age-dependent, craniocaudal pattern of change relative to multiple variables.</jats:p

Neuronal Cell Types in the Spinal Trigeminal Nucleus of the Camel Brain.

Neurons in the spinal trigeminal nucleus of a camel were morphologically studied by the Golgi impregnation method. The neurons were classified based on the size and shape of their cell bodies, the density of their dendritic trees, and the morphology and distribution of their appendages. At least 12 morphological types of neurons were found in the camel spinal trigeminal nucleus, including the following: stalked, islets, octopus-like, lobulated, boat-like, pyramidal, multipolar, round, oval, and elongated neurons. These neurons exhibited large numbers of various forms of appendages that arise not only from their dendrites but also from their cell bodies. Moreover, neurons with unique large dilatations especially at their dendritic branching points were also reported. The neurons reported in this study displayed an array of different sizes and shapes and featured various forms of appendages arising from cell bodies and dendrites. Such morphologically distinctive neuronal cell types might indicate an evolutionary adaptation to pain and temperature processing pathways at the level of the spinal trigeminal nucleus in camels, which traditionally live in a very harsh climatic environment and are frequently exposed to painful stimuli.This project was funded by Deanship of Research at the Jordan University of Science and Technology (JUST). Open Access funding is supported by Qatar University and Qatar National Library

Neuronal Cell Types in the Spinal Trigeminal Nucleus of the Camel Brain

Neurons in the spinal trigeminal nucleus of a camel were morphologically studied by the Golgi impregnation method. The neurons were classified based on the size and shape of their cell bodies, the density of their dendritic trees, and the morphology and distribution of their appendages. At least 12 morphological types of neurons were found in the camel spinal trigeminal nucleus, including the following: stalked, islets, octopus-like, lobulated, boat-like, pyramidal, multipolar, round, oval, and elongated neurons. These neurons exhibited large numbers of various forms of appendages that arise not only from their dendrites but also from their cell bodies. Moreover, neurons with unique large dilatations especially at their dendritic branching points were also reported. The neurons reported in this study displayed an array of different sizes and shapes and featured various forms of appendages arising from cell bodies and dendrites. Such morphologically distinctive neuronal cell types might indicate an evolutionary adaptation to pain and temperature processing pathways at the level of the spinal trigeminal nucleus in camels, which traditionally live in a very harsh climatic environment and are frequently exposed to painful stimuli.</jats:p