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

Anti-Obesity Effects of Formulated Biscuits Supplemented with Date&rsquo;s Fiber; Agro-Waste Products Used as a Potent Functional Food

Superabundant date fruit production in Al-Qassim in the Kingdom of Saudi Arabia (KSA), a plentiful region for producing date syrup resulting in massive amounts of date fiber (DF), causes environmental issues with what is considered dietary waste. However, no food producer or researcher has thought of the valorization of DF by extracting the crude polysaccharides that can be converted to nanoparticles (flours) to increase its functional group and enhance its functionality. Using the DF was the primary goal, with the new biscuits used within the current study investigated as a potent integrated approach for controlling obesity levels and its effects. Obesity is one of the most important human problems worldwide, connected to many metabolic diseases, e.g., diabetes mellitus and cardiovascular disease. Its prevalence has recently increased among Saudi children and adolescents. An investigation of the biological effects of the formulated products was carried out by feeding the formulated biscuits with different DF levels (5, 10 and 15%) to obese albino rats, in addition to positive and negative control groups, to evaluate the effect of a reduced calorie product on controlling their body weight and health stats (lipid profile, blood sugars, kidney and liver functions). The collected data showed that the most positive results were obtained from rats fed diets supplemented with 10% DF biscuits. All TCHO, TrGs, HDL, and HDL were decreased to the best levels in this group compared to the positive control group (148.23, 145.30, 37.50, and 81.67 vs. 238.37, 199.07, 62.57, and 135.99, respectively). To conclude, DF supplementation presented anti-obesity properties in animal models; however, more epidemiological trials are needed

Valorization of Different Dairy By-Products to Produce a Functional Dairy–Millet Beverage Fermented with <i>Lactobacillus paracasei</i> as an Adjunct Culture

Fermented dairy products not only have a long shelf-life but also have beneficial nutritional values. The products are deficient in dietary fiber and certain bioactive compounds. Adding grains to dairy products is a widespread practice to improve the nutritional and economic aspects. In this work, we studied the effect of fermented millet–milk beverages (FMBs) using pearl millet grains and three different dairy by-products (sweet whey, sweet buttermilk, and skimmed milk). A control treatment prepared with water was also manufactured for comparison. Samples were continuously prepared and fermented using a commercial yogurt starter culture (YC-381) containing L. delbrueckii subsp. bulgaricus, Streptococcus thermophilus, and a pure strain of L. paracasei subsp. Paracasei. Four FMBs (water based: WB-FMB, whey based: WHB-FMB, buttermilk based: BMB-FMB, and skimmed milk based: SMB-FMB) were analyzed during cold storage at 4 °C for up to 15 days for chemical, microbiological properties, minerals content, antioxidant properties, glycemic index, and glycemic load on days 1, 8, and 15. The sensory characteristics of the FMBs were also evaluated during cold storage (4 °C/15 days). In general, the progression of acidity was slower in SMB-FMB and WHB-FMB samples during fermentation compared to in the BMB-FMB sample. The longest fermentation time was for the SMB-FBM sample (3 h), while the shortest was for the BMB-FMB sample (1.5 h). Reflecting the good manufacturing practices, all samples were free of coliform, mold, and yeast. No bacterial growth was detected in the WB-FMB sample at days 8 and 15 of storage, while the growth of Lactobacillus spp. and S. thermophilus was significantly higher (9.97 ± 0.01 and 9.48 ± 0.06, respectively) in the BMB-FMB sample compared to in the other three FMBs. The FMBs produced using dairy by-products had more antioxidant properties. All samples were better perceived during sensory evaluation by panelists than the water-based sample, except for the BMB-FMB sample, in which a bitter taste appeared. In the BMB-FMB sample, the proteolytic degree was significantly higher (4.8 ± 0.09) after 3 h of fermentation by about 460% than in the fresh sample. All samples had a low glycemic index and glycemic load. In addition, acidity progression was slower in SMB-FMB and WHB-FMB samples during fermentation and storage compared to the WB-FMB sample. Therefore, it could be recommended that it is more beneficial to prepare fermented millet–milk beverages using dairy by-products and suitable starter cultures under optimal fermentation conditions instead of using water to maximize the nutritional and economic aspects