Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

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 middle-income 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 low-income 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 low-income, 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

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

Cow's milk allergy non-responsive to amino acid-based formula? A successful transplanted patient with immune dysregulation, polyendocrinopathy, enteropathy, and X-linked syndrome

The wide variety of IPEX symptoms leads to diagnosis and treatment delay with fatal outcomes if left untreated before two first years of life. Cow's milk allergy non-responsive to amino acid-based formula must raise suspicion of this syndrome

In Vitro Analysis of Extracts of Plant Used in Mexican Traditional Medicine, Which Are Useful to Combat Clostridioides difficile Infection

Recently, a worrying acceleration of the emergence of antibiotic-resistant bacteria has been reported. The increase in antibiotic-associated diseases, such as Clostridioides difficile infection (CDI), has promoted research on new treatments that could be more effective and less aggressive for CDI patients. This study evaluates eight plants with antimicrobial activity commonly used in Mexican traditional medicine to evaluate their potential against C. difficile. We provide essential information about these plants&rsquo; activities and action mechanisms against C. difficile and their effect on different bacterial infection activities: motility, adherence, sporulation, and germination. The selected plants are rosemary, estafiate, rue, epazote, mint, toloache, ajenjo, and thyme. We used clinical isolates to test their activity against strains responsible for current outbreaks to provide more information about the clinical impact of these extracts. We found that thyme, ajenjo, and mint were the most effective against the isolates. We identified that the extracts affected protein synthesis. In addition, the extracts affect the strains&rsquo; motility, and some, such as thyme extract, affect adherence, whereas rue extract affects sporulation. These results led to the identification of new compounds beneficial to CDI treatment

Methylenetetrahydrofolate reductase gene 677CT polymorphism and isolated congenital heart disease in a mexican population [Polimorfismo 677CT del gen de la metilentetradihidrofolato reductasa y cardiopat�as cong�nitas aisladas en poblaci�n mexicana]

Introduction and objectives: The frequency of the 677C>T mutation in the methylenetetrahydrofolate reductase gene in Mexico is one of the highest worldwide. Some studies have shown that both the homozygous state of this mutation and a high homocysteine concentration are associated with congenital heart disease. The aim of this study was to determine whether this association exists in the Mexican population. Methods: Genotypes were analyzed in 60 patients with congenital heart disease and in their mothers, and the levels of homocysteine were determined in the latter group. The genotypes were compared with those of a control group (n=62) and of their mothers. All the possible mother-child genotype combinations were also compared. Results: There were no significant differences in allele or genotype frequencies between the patients with congenital heart disease and the controls or their respective mothers (P>.05). Although no significant differences were observed when the homocysteine concentrations in the presence of the CC or the TT genotype were compared, a clear trend was observed (P=.0621). We found no significant differences in homocysteine concentrations in relation to folic acid intake. The study cases and controls did not differ in terms of the possible combinations of mother-child genotypes. Conclusions: The frequencies obtained were consistent with those reported for Mexico. No significant differences were found between groups. Nor did we find any association between TT mutations in both the mother and child and hyperhomocysteinemia. There was no evidence of an association between any of the mother-child genotype combinations and congenital heart disease. Similar studies with larger numbers of patients are required to confirm or refute some of the trends observed in this report. � 2011 Sociedad Espa�ola de Cardiolog�a. Published by Elsevier Espa�a, S.L. All rights reserved

Paragonimosis in the Cajabamba and Condebamba districts, Cajamarca, Peru Paragonimíase nos distritos de Cajabamba e Condebamba, Cajamarca, Peru

Stool samples from 409 pre-school and school students, living in six villages of the Cajabamba and Condebamba districts, Cajamarca, Perú, were examined using wet preparations and Lumbreras' method, looking for Paragonimus eggs. Fecal and sputum samples from two children (0.5%) of 6 and 8 year-old showed eggs of Paragonimus. One hundred and twenty freshwater crabs, Hypolobocera chilensis eigenmanni, were collected from the Condebamba valley and 21 (17.5%) of them were infected with P. mexicanus (syn. P. peruvianus) metacercariae. Our results show the persistence of Paragonimus in human beings and in the main source of infection, the crabs.<br>As amostras de fezes de 409 pré-escolares e escolares de 6 localidades dos distritos de Cajabamba e de Condebamba, departamento de Cajamarca, Peru, foram avaliados pelo método de Lumbreras na busca de ovos de Paragonimus sp. Dois meninos (0,5%), de 6 a 8 anos de idade, revelaram ovos de Paragonimus sp. nas suas fezes, bem como nas amostras de escarro. O exame radiográfico de tórax mostrou lesões pulmonares. Foram coletados 120 caranguejos de rio, Hypolobocera chilensis eigenmanni, no vale de Condebamba , encontrando-se 21 (17,5%) infectados com metacercárias de P. mexicanus (sin. P. peruvianus). Nossos resultados revelam a persistencia de Paragonimus sp. na população na sua principal fonte de infecção, os caranguejos

Dépôts funéraires d’amphisbénidés ou “serpents à deux têtes” sur la plate-forme Uhle, Huacas de Moche, Pérou.

International audienceFourteen animal species have been identified in Mochica tombs (100-800 A.D.). Among them the discovery of amphisbaenids, a group of reptilesknown in South America as “culebras de dos cabezas” (two-headed snakes), stands as a new fact. Rests of Amphisbaena sp., in particular A. occidentalis, the only species actually present in this area, were found in five tombs of the Uhle’s Platform at Huacas de Moche site. This constitutes the first occurrence of these reptiles in Precolumbian archaeological sites from the western slope of the Andean Cordillera. The amphisbaenids were discovered in jars sitting by the side of the dead, indicating that they were intentional deposits and not intrusive vestiges. Amphisbaenids offerings are also known in North-West Argentina, in the Ciénaga culture (2000-1400 BP), and during the periods of Regional Development, Inca and Hispano-Natives (800-250 BP). This kind of offerings thus does not constitute an isolated cultural phenomenon, but should clearly be regarded within a wider temporal and space context. The Mochica iconographic register brings additional details and seems to indicate that these animals could have a link with death and sacrifice, but also with the Milky Way. The discovery of these taxa brings new data for nderstanding their ritual role and symbolic function in Mochica culture tombs.Catorce especies animales fueron identificadas en las tumbas mochicas (100-800 d.C.). Entre ellos, el descubrimiento de anfisbenios, un grupo de reptiles conocidos en América del Sur como «serpientes o culebras de dos cabezas», es un hallazgo nuevo. Restos de Amphisbaena sp., en particular A. occidentalis, la única especie actualmente presente en esta área, fueron encontrados en cinco tumbas de la Plataforma Uhle en el sitio Huacas de Moche. Esto constituye la primera mención de estos reptiles en sitios arqueológicos precolombinos de la vertiente occidental de la Cordillera de los Andes. Los anfisbénidos fueron descubiertos en cántaros colocados al lado de los muertos, lo que indica que eran depósitos intencionales y no vestigios intrusivos. Se conocen también ofrendas de anfisbénidos en el noroeste de Argentina, en la cultura Ciénaga (2000-1400 BP), y durante los períodos de Desarrollo Regional, Inca e Hispano-Indígena (800-250 BP). Este tipo de depósitos no constituye unfenómeno cultural aislado, pero debe considerarse dentro de un contexto temporal y espacial más amplio. El registro iconográfico mochica aporta detalles adicionales y parece indicar que estos animales podrían tener un vínculo con la muerte y el sacrificio, pero también con la Vía Láctea. El descubrimiento de estos taxones ofrece nuevos datos para la comprensión de su papel ritual y de su función simbólica en las tumbas de la cultura Mochica.Quatorze espèces animales ont été identifiées dans les tombes mochicas (100-800 apr. J.-C.). Parmi eux, la découverte d'amphisbénidés, un groupe de reptiles connue en Amérique du Sud comme «culebras de dos cabezas» (serpent à deux-têtes), se présente comme un fait nouveau. Les restes d’Amphisbaena sp., en particulier A. occidentalis, la seule espèce actuellement présente dans cette zone, ont été trouvés dans cinq tombes de la Plate-forme Uhle sur le site de Huacas de Moche. Ceci constitue la première occurrence de ces reptiles dans des sites archéologiques précolombiens du versant ouest de la Cordillère des Andes. Les amphisbénidés ont été découverts dans des jarres,déposées à côté des corps des morts, indiquant ainsi qu’il s'agissait de dépôts intentionnels et non de vestiges intrusifs. Les offrandes d’amphisbénidés sont également connues dans le nord-ouest de l’Argentine, dans la culture Ciénaga (2000-1400 BP), et pendant les périodes de Développement régional, Inca et Hispano-Indigène (800-250 BP). Ce type d’offrandes ne constitue donc pas un phénomène culturel isolé, mais doit clairement être considérée dans un contexte temporel et spatial plus large. Le registre iconographique Mochica apporte des détails supplémentaires et semble indiquer que ces animaux pourraient avoir un lien avec la mort et le sacrifice, mais aussi avec la VoieLactée. La découverte de ces taxons apporte de nouvelles données pour la compréhension de leur rôle rituel et de leur fonction symbolique dans les tombes de la culture Mochica

Evolution of Pre-Columbian Metallurgy from the North of Peru’ Studied with a Portable Non-Invasive Equipment Using Energy-Dispersive X-Ray Fluorescence

On the north coast of present-day Peru, between the Andes and the Pacific Ocean, prospered approximately between 1000 BC and 1375 AD, several relevant cultures: Chavín (1000-200 BC), Vicús and Frías (200 BC - 300 AD), Moche (400 BC-700 AD), Sicán (700-1375 AD). These cultures are interconnected and characterized by a high metallurgical ability, demonstrated by the presence of beautiful artifacts on gold, silver and copper alloys. More than hundred metal artefacts from these cultures were analyzed with a portable equipment which uses the non-destructive and non-invasive technique of energy-dispersive X-ray fluorescence (EDXRF). Following objects were analyzed: (1) gold, silver and copper objects from the Chavín culture (Museo Municipal of Piura and and Museo Enrico Poli in Lima); (2) gold and silver objects from the Vicús and Frías cultures (Museo Municipal of Piura); (3) gold, silver and copper objects from the Moche culture (“Museo Tumbas Reales de Sipán”, “Museo de Sitio de Huaca Rajada” in Lambayeque and Museo Enrico Poli in Lima); (4) gold, silver and copper objects from the Sicán culture (Museum of Sicán, Ferrañafe). Portable equipments were employed, mainly composed of a small size X-ray tube and a thermoelectrically cooled, small size, Si-PIN or Si-drift X-ray detectors. The main characteristics of the EDXRF-technique is of being non destructive and multi-elemental. Standard samples of gold and silver alloys were employed for calibration and quantitative analysis. The aims of this campaign of analysis were: (1) to analyze a large number of objects; (2) to differentiate gold, gilded copper and tumbaga (this last being a poor gold alloy enriched at the surface by depletion gilding); (3) to correlate, when possible, composition of analyzed alloys to the specific culture; (4) to determine a possible evolution of metallurgy; (5) to better determine characteristics and beginning time of tumbaga production. It was determined that the analyzed artefacts are composed of gold, silver and copper alloys, of gilded copper or silver and tumbaga, the last being a poor gold-alloy rich on copper and enriched at the surface by depletion gilding, i.e. by removing copper from the surface. About 120 alloys were analyzed. In the case of gold, silver and copper alloys, their composition was determined by EDXRF-analysis by employing standard alloys. In the case of gilded copper (or gilded silver) and of copper based tumbaga, the ratios Cu(Kα/Kβ) andAu(Lα/Lβ) were determined from the X-ray spectra, first to clearly differentiate gold, gilded metal and tumbaga, and then to determine the gilding thickness. Concerning the correlation composition-culture, it seems that the Chavín did not use to mix copper in the gold alloy. This element, with a mean concentration of 1.5%, is only present in Au-alloys as in nature. Further, silver was measured in all cultures of the north of Peru at relatively high levels of purity, but by the Chavín was associated to Cu and Pb, by the Moche to Cu and Au, by the Sicán to Cu, Au, Pb and Br. Also copper was measured in all cultures of the north of Peru at high levels of purity. However, this element seems to contain small quantities of Zn by the Chavín, is almost pure by the Moche, and contains as by the Sicán. With reference to copper based tumbaga, it is not clear when it was “produced” for the first time in the north of Peru, may be by the Vicús; in any the largest number of tumbaga was produced by the Moche, and are characterized by a mean “equivalent” Au-thickness of ~2.5 μm