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

Effect of Losartan and Amlodipine on Lung Function Status in Hypertensive Patients: A Randomized Control Trial

Introduction: Essential hypertension is associated with altered pulmonary function. Antihypertensive medication and lung function are also associated. Losartan (angiotensin II receptor blocker) and amlodipine (calcium channel blocker) are commonly used antihypertensive drugs.&#x0D; Objectives: To evaluate the effects of antihypertensive drugs on lung function status in patients with essential hypertension.&#x0D; Materials and Methods: This prospective observational study was carried out in the Department of Physiology of Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka, from July 2012 to June 2013 on 100 newly diagnosed hypertensive patients without any antihypertensive medication (group B, age 30-55 years). They were selected from the Out Patient Department (OPD) of Cardiology, BSMMU, Dhaka. Age, sex and BMI matched 50 apparently healthy normotensive subjects were also studied as control (group A). Based on treatment, these study subjects were divided into two groups (B1 and B2). Group B1 included 50 patients received losartan 50 mg daily and B2 included 50 patients received amlodipine 5 mg daily. They were observed once before the treatment (B1a and B2a), after 3 months of medication (B1b and B2b) and after 6 months of medication (B1c and B2c). For assessing lung function status, Forced Vital Capacity (FVC), Forced Expiratory Volume in 1st second (FEV1) and Peak Expiratory Flow Rate (PEFR) were measured with a RMS computer based Spirometer.&#x0D; Results: Mean FVC, FEV1 and PEFR were significantly lower in newly diagnosed hypertensive patients in comparison with that of healthy normotensive. Mean FVC, FEV1 and PEFR were found significantly higher in the group taking losartan and amlodipine for 6 months when compared to newly diagnosed but lower than those of controls.&#x0D; Conclusion: Reduced lung function occurs in newly diagnosed hypertensive patients which was improved by treatment with losartan and amlodipine.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 42-44</jats:p