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

ICAR: endoscopic skull‐base surgery

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Maternal mortality and the metempsychosis of user fees in Liberia: A mixed-methods analysis

ABSTRACT: Liberia, a country recently afflicted by civil conflict and an epidemic of Ebola virus disease, has one of the highest rates of maternal mortality in the world. A biosocial analysis of this problem can help identify and address barriers impeding access to, and equitable delivery of, quality maternal health care. We analyzed 258 maternal death reviews reported to the National Public Health Institute of Liberia in 2017 and compared data with existing demographic and health statistics. Quantitative information on maternal death was contextualized with 44 in-depth interviews conducted among four groups of study participants. Forty percent of reported maternal deaths in 2017 occurred among women 25–34 years old; 36% were due to hemorrhage; 74% occurred at a health facility; and 29% occurred within 24 h after delivery. The number of deaths reported to the government of Liberia through maternal death reviews (n = 258) was substantially lower than the number expected based on the size of the population, crude birth rate, and the maternal mortality ratio. Qualitative findings highlighted inaccessible and unreliable transportation to health facilities; staff-related challenges, including staff attrition and burnout, inadequate training and clinical proficiency, staff absences, and neglect of patients; a lack of drugs and medical supplies; and the emergence of an inefficient and financially burdensome system of referrals by trained traditional midwives. Most notable was the finding that user fees for maternal health care in Liberia—eliminated in public facilities after the war—have resurfaced in the form of informal, out-of-pocket expenditures made by patients and their families. Keywords: Maternal mortality, User fees, Liberia, Structural determinants, Health equit

Erratum: On the role of artificial intelligence in medical imaging of COVID-19 (Patterns (2021) 2(6), (S2666389921000957), (10.1016/j.patter.2021.100269))

The corrected full text is available on Brunel University Reasearch Archive at: https://bura.brunel.ac.uk/handle/2438/26331.Copyright © 2021 The Author(s). (Patterns 2, 100269-1–100269-18; June 11, 2021). Due to an error in production, the references for this article were incorrectly numbered upon publication of the typeset paper, May 26, 2021. Since this is a meta-analysis, incorrect numbering of references may have caused misinterpretation of the conclusions. The corrected version of the article is available online as of June 5, 2021, and we sincerely apologize to our readers for any confusion that may have resulted from this error

Cytomorphological investigations in Oxyria digyna Hill. from the Kashmir Himalaya, India

In the present paper, detailed cytomorphological investigations in Oxyria digyna Hill. from Kashmir Himalaya—India have been reported for the first time. All the 14 investigated populations of O. digyna are diploid based on x = 7. Out of these in two populations 0–2B chromosomes have been recorded for the first time while 6 populations differed significantly in their meiotic characteristics. Meiotic abnormalities during male meiosis observed include inter PMC chromatin transfer (cytomixis). Non-synchronous disjunction of some bivalents, laggards and bridges at anaphases and telophases. Consequent to these meiotic anomalies, microsporogenesis in meiocytes is abnormal resulting in to dyads, triads and polyads with or without micronuclei. The overall effect is seen in reduced pollen fertility. Unreduced pollen grains were observed in some populations, which differed significantly in their size compared to the normal (reduced) pollen grains. It is observed that a smaller frequency of pollen grains differed morphologically in Aharbal and Yosmarg populations. The remaining eight populations showed regular meiotic course, normal microsporogenesis and high percentage of pollen fertility (95.09–99.09 %).Приводятся детальные цитоморфологические ис-следования Oxyria digyna Hill из Кашмира (Гималаи, Индия). Все 14 изученных популяций являются диплоидными, где x = 7. Из них в двух популяциях впервые описаны 0–2B хромосомы, тогда как шесть популяций сильно различались по своим мейотическим характеристикам. Аномалии мейоза при микроспорогенезе включали цитомиксис, несинхронное расхождение некоторых бивалентов, задержки и мосты в анафазах и телофазах. Возникающий в связи с этим аномальный микроспорогенез приводит к формированию диад, триад и полиад как с микроядрами, так и без них. Общим эффектом является снижение фертильности пыльцы. В некоторых популяциях наблюдали нередуцированные пыльцевые зерна, которые по величине значительно отличались от нормальных. В популяциях Aharbal и Yosmarg некоторые пыльцевые зерна отличались морфологи-чески. Оставшиеся восемь популяций проявляли нормальный ход мейоза, нормальный микроспорогенез и высокий процент фертильности пыльцы (95,09–99,09 %).The authors are grateful to the University Grants Commission, New Delhi for providing financial assistance under the DRS SAP III and DST programmes. Thanks are also due to the Head, Department of Botany, Punjabi University, Patiala for necessary laboratory facilities