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

Infección de Pasteurella multocida de un carcinoma escamoso de pulmón cavitado

Pasteurella multocida raramente se ha descrito como productor de enfermedad pulmonar en humanos. Su infección suele producirse tras la mordedura o arañazo de animales portadores. Se han comunicado algunos casos de neumonías, abscesos pulmonares, infecciones de las vías aéreas superiores e infección de bronquiectasias preexistentes, habitualmente en individuos en contacto directo con animales portadores y afectados de patología crónica debilitante. Es excepcional que P. multocida aparezca como comensal en la flora orofaríngea humana. Presentamos el primer caso publicado (Medline, 1966-2002) de un carcinoma escamoso de pulmón cavitado e infectado por P. multocida en un individuo de avanzada edad que negó el contacto con animales potencialmente portadores. Pensamos que la infección pulmonar por P. multocida en humanos está infradiagnosticada debido a la baja sospecha clínica y por la excelente susceptibilidad de este microorganismo a los antibióticos comúnmente utilizados

Efficacy and safety of ossein-hydroxyapatite complex versus calcium carbonate to prevent bone loss

Objective: This study aimed to compare the efficacy and safety of ossein-hydroxyapatite complex (OHC) versus calcium carbonate (CC) for preventing bone loss during perimenopause in current clinical practice.Methods: The prospective, comparative, non-randomized, open-label study included 851 perimenopausal women with basal bone mineral density (BMD) T-score ≥-2 standard deviations (SDs). Participants received either OHC (712 mg calcium/day) or CC (1000 mg calcium/day) over 3 years. BMD was evaluated by dual-energy X-ray absorptiometry at the lumbar spine (L2-L4) at baseline and after 18 and 36 months of follow-up. Adverse drug reactions (ADRs) were also recorded.Results: In women receiving OHC, BMD at the L2-L4 site remained stable over the 3-year follow-up period (mean [SD] change 0.00 [0.11] g/cm2). BMD in the CC arm decreased -3.1% (mean [SD] - 0.03 [0.11] g/cm2). Between-group differences were statistically significant (p < 0.001) and favored OHC. ADRs were more frequent in the CC group (7.7% vs. 2.7% in the OHC group; p = 0.001), affecting primarily the gastrointestinal system.Conclusion: OHC showed greater efficacy and tolerability than CC for bone loss prevention in perimenopausal women in real-world practice. As the daily dose of calcium was higher in the CC group, the differences might be linked to the ossein compound in OHC

The first reintroduction project for mhorr gazelle (Nanger dama mhorr) into the wild: Knowledge and experience gained to support future conservation actions

Reintroductions continue to be an important conservation action for endangered species. Until this, all reintroduction projects for Mhorr gazelle (Nanger dama mhorr) had remained at the stage where the animals live in fenced protected areas of different sizes. This study describes the first experience of reintroduction of a group of 24 Mhorr gazelle into the wild in the Safia Reserve, in Southern Morocco. The reintroduction was carried out in two phases: in the first one, the entire group was released; then, after an unexpected dogs attack event, part of them were kept safe until this problem was solved. Seven of the gazelles were monitored with telemetry collars, providing previously unavailable data on time allocation, daily rhythm of activity and social organization for the species in the wild. In addition, post-release movements revealed three patterns: during the first few days after release, small daily movements (average 2.78 km) close to the fence, followed by long-distance exploratory movements (up to 50 km) until establish territories; and finally, daily movements between established territories (average 8.39 km). Exceptional long distances (>50 km/day) were traveled after a poaching event. The study has also revealed the ability of the species to select and settle territories in favorable areas, after being kept for generations under captive or semi-captive conditions. However, their inability to recognize predators was demonstrated in an unexpected attack by dogs, resulting in the death of seven released gazelles. This mortality following the dog attack was favored, in part, because the released gazelle remained close to the fence, and therefore suggests that the release procedure should be revised, especially when there are predators in the release site. This study has confirmed that dogs as predators and poaching continue to be the main threat to reintroduction projects in Southern Morocco.This project has been funded by UNESCO/MaB (no 4500261532), HCEFLCD and the National Spanish Research Council (CSIC OTT 2005X0269). Emilio Rodriguez Caballero would like to acknowledge the Spanish Ministry for Economy and Competitiveness for the Juan de la Cierva-Incorporación grant (IJCI-2016-29274) and the University of Almeria for the Hipatia-UAL postdoctoral fellowshi

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe