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

Antibiosis and Tolerance to Five Species of Spittlebug (Homoptera: Cercopidae) in Brachiaria spp.: Implications for Breeding for Resistance.

CIAT- Outstanding Research Publication Award (ORPA) - 2004Several genera and species of spittlebugs (Homoptera: Cercopidae) are economic pests of Brachiaria spp. grasses in tropical America. To support current breeding programs aimed at obtaining multiple spittlebug resistance, we undertook a series of studies on antibiosis and tolerance as possible mechanisms of resistance to five major spittlebug species affecting Brachiaria spp. in Colombia: Aeneolamia varia (F.), Aeneolamia reducta (Lallemand), Zulia carbonaria (Lallemand), Zulia pubescens (F.), and Mahanarva trifissa (Jacobi). Four host genotypes, well known for their reaction to A. varia attack, were used to compare their resistance to other spittlebug species: CIAT 0654 and CIAT 0606 (susceptible) and CIAT 6294 and CIAT 36062 (resistant). CIAT 0654 and CIAT 36062 were used in antibiosis studies. Tolerance studies were conducted with CIAT 0654, CIAT 6294, and CIAT 36062. Sixty-five hybrid-derived clones were used to identify levels of multiple resistance to three spittlebug species. The levels of antibiosis resistance in CIAT 36062 clearly differed by spittlebug species and were classified as follows: very high for M. trifissa, high for A. varia and A. reducta, moderate for Z. pubescens, and absent for Z. carbonaria. Our results suggest the presence of true tolerance to Z. carbonaria in CIAT 6294 and CIAT 36062, true tolerance to Z. pubescens in CIAT 6294 and a combination of tolerance and antibiosis as mechanisms of resistance to Z. pubescens in CIAT 36062. Of the 65 hybrid clones tested with A. varia, A. reducta, and Z. carbonaria, 15 combined resistance to two species and three showed antibiosis resistance to all three spittlebug species