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

Quality assessment of non-roof harvested rainwater in industrial layouts of Enugu, South East Nigeria

Abstract Non-roof harvested rainwater was studied in Enugu industrial layouts of Emene and Iva Valley to determine the quality of the water. The determination was based on physicochemical parameters and concentration of 7 heavy metals, namely copper (Cu), chromium (Cr), nickel (Ni), manganese (Mn), zinc (Zn), lead (Pb) and cadmium (Cd). The physicochemical parameters of the rainwater: pH, colour, turbidity, total dissolved solids, conductivity were determined using Hanna water quality checker, and the anions nitrate, sulphate, chloride and phosphate were analysed in accordance to standard methods. The concentrations of Cu, Cr, Ni, Mn, Zn, Pb and Cd were determined using FS240 Agilent Atomic Absorption Spectrophotometer. The mean values (mg/l) of the metals: Cu, Cr, Ni, Mn, Zn, Pb and Cd in Emene sample are as follows: 0.12 ± 0.01, 0.10 ± 0.02, 0.37 ± 0.02, 0.03 ± 0.01, 0.15 ± 0.01, 0.58 ± 0.11 and 0.17 ± 0.07, while Iva Valley sample recorded 0.08 ± 0.01, 0.04 ± 0.01, 0.82 ± 0.06, 0.09 ± 0.02, 0.26 ± 0.01, 0.48 ± 0.04 and 0.31 ± 0.08, respectively. Some of these values are within or above the standard limit of World Health Organization (WHO) and Nigeria Standard for Drinking Water Quality (NSDWQ). It is important to note that these metals are toxic, persistence and have the potential to bioaccumulate. Therefore, non-roof harvested rainwater is not ready to consume water without some form of treatment. Monitoring, treatment and awareness on the harvesting and use of rainwater should be emphasized

Correlation of Intravesical Prostatic Protrusion with Severity of Lower Urinary Tract Symptoms in Men With Symptomatic Benign Prostatic Hyperplasia at University of Nigeria Teaching Hospital, Ituku-Ozalla Enugu

Background Benign prostatic hyperplasia (BPH) is one of the causes of lower urinary tract symptoms (LUTS) in men above 50 years of age. It is known that the severity of LUTS (degree of bladder outlet obstruction) does not correlate with the size of the prostate gland in BPH. Severity of LUTS due to BPH can be assessed using the internationally validated international prostate symptom score (IPSS). There are some concerns that the IPSS is subjective and may pose some challenges to the poorly educated patients in our environment during administration. Intravesical prostatic protrusion may be an objective index of degree of bladder outlet obstruction in men with BPH measured using abdominopelvic ultrasound. So the objective of this study is to evaluate for any correlation between IPP and IPSS in men with symptomatic BPH. Objective The objective of the study is to assess the correlation between IPP and IPSS. Patients and Methods A hospital based cross-sectional study of new patients with symptomatic LUTS of BPH, who presented to the Urology clinics of University of Nigeria Teaching Hospital Ituku-Ozalla Enugu. Ethical approval was obtained from the ethical committee of the hospital and informed consent from patients. After evaluation (including IPSS, PSA, and FBC, S/E/Ur/Cr, Urinalysis and M/C/S), participants had abdominopelvic ultrasonography measurement of IPP and midline sagittal image of the prostate (at bladder Volume of > 100mls) using Prosound model SSD 3500 with an abdominal probe frequency of 3.5MHz (Versana Essentials) IPP was divided into three grades (Grade I: 0-4.9mm; Grade II: 5.0-9.9mm; Grade III: 10.0mm and above). Data was analyzed using SPSS Version 20 (IBM, SPSS, Chicago, IL, USA). The Pearson correlation was used to assess correlation where necessary. P- value <0.005 was considered significant. Results Two hundred and seventy four men with a mean age of 64.76+/- 9.04 years were included in the study. Most of the participants had highest educational level of primary education 145 (52.9 %). The average IPSS, IPP, PSA Total were 15.90+/- 4.74 SD, 9.49+/- 2.98 SD, 6.13+/- 1.83 respectively. There is significant positive correlation between IPP and IPSS (r = 0.451; P < 0.001), and a statistically significant negative correlation between IPP, IPSS (r = - 0.742; P < 0.001), (r = - 0.500; P < 0.001) respectively and Qmax. Conclusion There was a significant positive correlation between IPP and IPSS. Intravesical prostatic protrusion may be used to help assess severity of lower urinary tract symptoms in men with BPH

Spontaneous Rectovesical Fistula Secondary to Castration-resistant Prostate Cancer

Introduction: Rectovesical fistula (RVF) is an abnormal communication between the rectum and the urinary bladder. This condition has a negative impact on the patient’s quality of life due to the associated morbidity. The patient may present with complaints of passage of urine per rectum, pneumaturia, fecaluria, recurrent cystitis, pyelonephritis, or urosepsis. Method and Material: We present a case of a 61-year-old man with histologically diagnosed prostate cancer who developed passage of urine per rectum about two years after bilateral total orchidectomy. He defaulted on follow-up and presented with castration-resistant prostate cancer. Results: On performing a micturiting cystourethrogram/retrograde urethrogram under fluoroscopic guidance, the contrast media were seen passing from the bladder into the large bowel hence establishing a diagnosis of RVF. Conclusion: The patient was counseled for a diverting colostomy but he declined. He has an intact anal sphincter and therefore is presently continent of both stool and urine per rectum. Unfortunately, he is financially unable to afford any of the treatment options for castration-resistant prostate cancer