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

Non-invasive ultrasonographic characterization of phenotypic changes during embryo development in non-anesthetized mice of different genotypes

This study aimed to determine phenotypic changes during embryo development in the mouse, and the influence of genetic background, by non-invasive real-time ultrasonography. Serial scannings were performed from Day 4.5 after the appearance of the vaginal plug in a total of 34 adult mice of different strains (9 BALB/c, 10 C57BL/6 and 15 CD1). Embryonic vesicle diameter was measurable from Day 4.5 of pregnancy. Images of embryos were obtainable from Day 5.5 of gestation onwards, and crown-rump length and trunk parameters (diameter and area) were measured. At more advanced stages, the positions of fetuses prevented accurate measurement of crown-rump length; therefore, head diameters (occipito-snout length and biparietal diameter) were used as an alternative index of fetal size. All measurements correlated highly with gestational age (P < 0.0005). No significant differences were observed between genotypes in early pregnancy, but during the last week of gestation trunk measurements were larger in CD1 embryos (P < 0.05) while head diameters were larger in C57BL/6 conceptuses (P < 0.05). There was a significant effect of genetic background on heart rate throughout pregnancy; although heart rate was similar in CD1 and C57BL/6 embryos (154.5 ± 2.8 and 147.8 ± 4.5 beats/min, respectively), it was significantly lower in BALB/c mice (127.0 ± 2.1; P < 0.005 vs. CD1 and C57BL/6). © 2008 Elsevier Inc. All rights reserved

Intrauterine growth retardation in endothelial nitric oxide synthase-deficient mice is established from early stages of pregnancy

The current study aimed to determine effects of deficiencies in nitric oxide synthase (NOS) 3 on embryo and fetal development by in vivo, noninvasive, real-time ultrasonographic assessment of phenotypic changes in Nos3-knockout pregnant mice and their wild-type counterparts. >From Day 4.5 of pregnancy onwards, embryonic vesicle diameters, crown-rump lengths, and trunk diameters were obtained by serial scanning of seven adult pregnant female mice, strain B6.129P2-Nos3tm1Unc/J, N9 generation backcrossing with C57BL/6J mice, homozygous for the disruption of the endothelial NOS gene (group Nos3 -/-), and 12 pregnant, wild-type C57BL/6J mice (group Nos3 +/+). All the measurements increased in both genotypes throughout gestation. However, embryo length and width were significantly larger in Nos3+/+ than in Nos3-/- mice from Day 8.5, and both longitudinal and transverse diameters of the entire gestational sacs were larger in Nos3+/+ mice from Day 10.5. Assessment of the relative growth of embryos/fetuses and gestational annexes showed different patterns among Nos3-/- and Nos3+/+ mice. Throughout pregnancy, the distance between the external limit of the gestational sac and the embryo in Nos3+/+ mice diminished in longitudinal sections, or remained unaffected in transverse sections. In Nos3-/- mice, there were significant increases (P &lt; 0.005) in the differences between embryo and gestational vesicle measurements in both longitudinal and transversal curves from Days 5.5 to 14.5, but from Day 14.5 of pregnancy onward, the changes were not significant. The results demonstrate that the processes of fetal growth retardation in the Nos3-/- mice are established from early pregnancy stages. © 2008 by the Society for the Study of Reproduction, Inc

Use of ultrasound imaging for early diagnosis of pregnancy and determination of litter size in the mouse

Precocity and efficiency of ultrasonography for pregnancy diagnosis and determination of litter size in mice were assessed on a total of 46 adult mice of different lines (19 BALB/c, 15 C57BL/6 and 12 CD1) from Day 4.5 after vaginal plug. Different commercial ultrasound machines and probes (linear versus sectorial; 7.5 MHz versus 10 MHz) were compared. The best images were obtained by the use of 10 MHz linear transducers. The first visualization compatible with pregnancy, specifically with the implantation sites, was observed at Day 4.5 in three animals. Presence of embryonic vesicles was differentiated at Day 5.5 in all the females. The embryos and remaining gestational structures inside the vesicles were clearly distinguished at Day 8.5. Data were validated not only after delivery but also by comparison with postmortem findings on crucial days (Days 4.5 and 8.5). The efficiency for counting the exact number of embryos was very low, due mostly to underestimation in highly prolific females. Conversely, the estimation of the range of the number of conceptuses, instead of the total number, was more accurate. Sensitivity, specificity and total efficiency reached 100% at Day 8.5. Ultrasonography can be accurately used as an alternative non-invasive technique for pregnancy diagnosis and determination of litter size in the mouse from very early stages of gestation, replacing other procedures currently used and increasing efficiency in animal management and research

A new method for induction and synchronization of oestrus and fertile ovulations in mice by using exogenous hormones

Four consecutive experiments were conducted to design and establish the effectiveness of different protocols for induction and synchronization of oestrus and ovulation in mice. Results showed that the highest synchronization degree and the highest fertility rates were obtained using two intraperitoneal doses of 0.5 μg of cloprostenol, three days apart, plus a single subcutaneous dose of 3 μg of progesterone coincidentally with the first injection of cloprostenol. Of the main advantages of the new method, we have to highlight the short time elapsed for appearance, and the high degree of synchronization of oestrus and ovulations (almost 100% of the animals responding to the treatment in 48 h; 78.4% with fertile mates at 24 h), plus the high fertility rate obtained after a programmed mating (100%). Overall, these yields are superior to those obtained by classical methods based on the use of male pheromones; hence the proposed protocol arises as an adequate alternative for reproductive management in mice

The effect of embryo and maternal genotypes on prolificacy, intrauterine growth retardation and postnatal development of Nos3-knockout mice

Mice deficient for endothelial nitric oxide synthase (NOS3-/-) may represent a good model for studying embryo loss and intrauterine growth retardation caused by vascular deficiencies. We determined the effects of embryo genotype (homozygous vs. heterozygous descendants with paternal or maternal source of the non-functional NOS3 allele) and maternal environment (NOS3-/- vs. wild-type NOS3+/+ females) on the appearance of estrus, fertility and prolificacy rates and live weight in the first week of life as well as phenotypic characteristics of offspring during the postnatal period. The results indicated that pregnancy outcomes and postnatal development of NOS3-/- mice seem to be related to deficiencies in fetal programming mainly determined by maternal genotype. © 2010 by the Society for Biology of Reproduction

The feasibility of ultrasound biomicroscopy for non-invasive and sequential assessment of ovarian features in rodents

The current study assessed the usefulness of in vivo high frequency ultrasound imaging (ultrasound biomicroscopy, UBM) for dynamic study of the ovarian structures in laboratory rodents. UBM imaging was performed, by using a 40 MHz probe, in 12 C57BL/6J female mice and four Wistars female rats at breeding age and during different reproductive periods. UBM provided outstanding images of both follicles and corporalutea in cycling and non-cycling rats and mice and was useful to evaluate the ovarian response after controlled ovarian stimulation in the mouse. Thus, UBM may be a very useful method for reproductive studies in rodents. Copyright © 2008 by the Society for Biology of Reproduction

Maternal age modulates the effects of early-pregnancy L-proline supplementation on the birth-weight of piglets

Previous results obtained in gilts maintained under experimental conditions suggest that amino acid supplementation during pregnancy may be a promising strategy for diminishing the incidence of embryo losses and low birth-weight newborn. The current study evaluated the effects of a short-term supplementation with L-proline, around implantational stages, on litter size and birth-weight of piglets in sows of different parities maintained under commercial farm conditions. There were no significant effects in mature sows with three or more parities, but the supplementation improved the reproductive efficiency of the high-prolific first-parity sows and of all the sows at second-parity. There were numerically higher litter size (of around two more live piglets; n.s.) and higher birth-weights (P < 0.05) in the supplemented animals. The results of this study indicate that the effects of L-proline supplementation on litter size and birth-weight are strongly modulated by the maternal characteristics; specifically by parity and prolificacy and that supplementation may be cost-efficient for the management of females with compromised energy balance; specifically, sows at second farrowing and highly-prolific primiparous gilts. © 2017 Elsevier B.V