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

Actuated Wheelchair Assistance Enclosure

Executive Summary of ME 450 F13 Team 27 Final Reporthttp://deepblue.lib.umich.edu/bitstream/2027.42/101988/1/ME450F13Project27_Summary.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/101988/2/ME450F13Project27_Photo.jp

Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?

Introduction: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. Methods: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. Results: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. Conclusion: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar

Outcomes for Elderly Patients With Atypical Femoral Fractures Compared to Typical Femoral Fractures for Length of Stay, Discharge Destination, and 30-Day Mortality Rate

Introduction: Despite increasing recognition of atypical femoral fractures (AFFs), there’s conflicting evidence about incidence, aetiology, and short-term outcomes of these injuries. This study reports the incidence of AFFs at our center and compares the early postoperative outcomes against typical femoral fractures (TFFs). Methods: A retrospective observational cohort study of patients presenting to our trauma unit between November 2015 and July 2016 was undertaken. Inclusion criteria required radiologically confirmed proximal femoral fracture, which was then categorized as AFF or TFF. Primary outcome measures included length of stay, discharge destination, and 30-day mortality. Results: Two hundred thirty-nine patients presented to our trauma unit over 9 months with either a fractured neck of femur or proximal femoral fracture. A total of 122 were identified as pertrochanteric, subtrochanteric, or proximal femoral shaft fractures of which 25 (20.5%) displayed atypical radiographic features consistent with AFF. The 2 groups were similar for average age (TFF 85.3 years vs AFF 85.0 years), gender (19% vs 16% male gender), American Society of Anaesthesiology grade (3.0 vs 3.0), cognitive score (abbreviated mental test score = 7.03 vs 7.08), and preinjury place of residence (88.9% vs 92.0% lived in own home). Typical fractures were fixed with either dynamic hip screw or intramedullary nailing, all atypical fractures were fixed with intramedullary nailing. There was no statistical difference between the 2 groups for length of stay (12.8 days vs 14.3 days; P > .05), discharge to preinjury residence (45.1% vs 36%; P > .05), or 30-day mortality (8.1% vs 12%; P > .05). Discussion: In our predominantly geriatric population atypical radiographic features were observed in around 10% of patients presenting with proximal femoral fractures or fractured neck of femur. Previous studies have reported poor outcomes for pain, mobility, and length of stay after AFF. However, we observed no difference in short-term outcome measures when compared to patients with typical proximal femoral fracture patterns at our trauma unit. Conclusion: With modern principles of trauma care outcomes achieved following AFFs may be equivalent to typical femoral fractures in the geriatric population