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

Analysis of Factors Affecting Patients’ Compliance to Topical Antiglaucoma Medications in Egypt as a Developing Country Model

Purpose. To study factors affecting patients’ compliance to antiglaucoma medications in Egypt where there are unique factors as a developing country. Patients and Methods. A cross-sectional descriptive study on 440 Egyptian patients with open angle glaucoma (OAG) recruited for over two years. The patients were thoroughly interviewed about their age, education level, duration of glaucoma, difficulty in instilling the drops, medication regimens, a family history of glaucoma, knowledge of the disease, and the presence of medical insurance. Results. 236 (53.6%) were noncompliant compared to 204 (46.4%) who were compliant. Females had a tendency for higher compliance (p=0.061). Patient age above 50 years and low level of education and negative family history of glaucoma were factors significantly associated with poor compliance (p<0.0001). Polytherapy and lack of medical insurance could be contributing factors. Conclusion. Egyptian patients have a high rate of noncompliance compared to the average in literature. Great effort is needed in educating patients about the importance of medications and the risk and the prognosis of this disease. Economic factors must also be taken into consideration in developing countries with large number of poor patients. We recommend simplifying drug regimens, incorporating electronic dose monitors, and creating reminders for follow-up visits of glaucoma patients

Analysis of Factors Affecting Patients&apos; Compliance to Topical Antiglaucoma Medications in Egypt as a Developing Country Model

properly cited. Purpose. To study factors affecting patients&apos; compliance to antiglaucoma medications in Egypt where there are unique factors as a developing country. Patients and Methods. A cross-sectional descriptive study on 440 Egyptian patients with open angle glaucoma (OAG) recruited for over two years. The patients were thoroughly interviewed about their age, education level, duration of glaucoma, difficulty in instilling the drops, medication regimens, a family history of glaucoma, knowledge of the disease, and the presence of medical insurance. Results. 236 (53.6%) were noncompliant compared to 204 (46.4%) who were compliant. Females had a tendency for higher compliance ( = 0.061). Patient age above 50 years and low level of education and negative family history of glaucoma were factors significantly associated with poor compliance ( &lt; 0.0001). Polytherapy and lack of medical insurance could be contributing factors. Conclusion. Egyptian patients have a high rate of noncompliance compared to the average in literature. Great effort is needed in educating patients about the importance of medications and the risk and the prognosis of this disease. Economic factors must also be taken into consideration in developing countries with large number of poor patients. We recommend simplifying drug regimens, incorporating electronic dose monitors, and creating reminders for follow-up visits of glaucoma patients

Effect of Topical Nepafenac on Central Foveal Thickness following Panretinal Photocoagulation in Diabetic Patients

Purpose. To evaluate effectiveness of topical nepafenac in reducing macular edema following panretinal photocoagulation (PRP). Design. Prospective randomized double-blinded controlled study. Methods. Sixty eyes of 60 patients having proliferative or severe nonproliferative diabetic retinopathy had PRP. Patients were then divided into two groups: nepafenac group (30 eyes) receiving 1% topical nepafenac eye drops for 6 months and control group (30 eyes) receiving carboxymethylcellulose eye drops for 6 months. Best-corrected visual acuity (BCVA) and macular optical coherence tomography were followed up at 1, 2, 4, and 6 months after PRP. Results. BCVA was significantly better in nepafenac group than in control group at all follow-ups (P<0.01). At 6 months post-PRP, logMAR BCVA was 0.11 ± 0.04 (equivalent to 20/26 Snellen acuity) in the nepafenac group and 0.18 ± 0.08 (equivalent to 20/30 Snellen acuity) in the control group (P<0.01). Central foveal thickness (CFT) increased in both groups from the first month after PRP. Increase in CFT was higher in control group than in nepafenac group throughout follow-up, but the difference became statistically significant only after 4 months. No significant ocular adverse events were reported with topical nepafenac. Conclusion. Topical nepafenac can minimize macular edema and stabilize visual acuity following PRP for diabetic patients

Impact of the International Nosocomial Infection Control Consortium (INICC)’s multidimensional approach on rates of ventilator-associated pneumonia in intensive care units in 22 hospitals of 14 cities of the Kingdom of Saudi Arabia

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and use of INICC Surveillance Online System (ISOS) on ventilator-associated pneumonia (VAP) rates in Saudi Arabia from September 2013 to February 2017. A multicenter, prospective, before–after surveillance study on 14,961 patients in 37 intensive care units (ICUs) of 22 hospitals. During baseline, we performed outcome surveillance of VAP applying the definitions of the CDC/NHSN. During intervention, we implemented the IMA and the ISOS, which included: (1) a bundle of infection prevention practice interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on VAP rates and consequences and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using generalized linear mixed models to estimate the effect of intervention. The baseline rate of 7.84 VAPs per 1000 mechanical-ventilator (MV)-days―with 20,927 MV-days and 164 VAPs―, was reduced to 4.74 VAPs per 1000 MV-days―with 118,929 MV-days and 771 VAPs―, accounting for a 39% rate reduction (IDR 0.61; 95% CI 0.5–0.7; P 0.001). Implementing the IMA was associated with significant reductions in VAP rates in ICUs of Saudi Arabia