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

Whole genome characterization of methicillin resistant Staphylococcus aureus in an Egyptian Tertiary Care Hospital

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a significant healthcare-associated (HA-MRSA) pathogen due to its increased morbidity and mortality rates. There is a paucity of data regarding MRSA clones circulating in the Middle East in the literature, especially from Egypt. We aimed to identify the pattern of resistance and virulence in the propagating clones using NGS technologies for the whole genome sequence. Methods: From an 18-month surveillance program for MRSA-positive patients, 18 MRSA isolates from surgical healthcare associated infections were selected. The Vitek2 system was used to assess antimicrobial susceptibility. The whole genome sequencing was performed using the NovaSeq6000. The reads were mapped to the reference genome (Staphylococcus_aureus_ATCC_BAA_1680), used for variant calling, screened for virulence/resistance genes, and typed using multi-locus sequence typing and spa typing. Correlation between demographic and clinical data and molecular findings were performed. Results: All the MRSA isolates were highly resistant to tetracycline followed by gentamicin (61%) and highly susceptible to trimethoprim/sulfamethoxazole. Most of the isolates showed a high virulence profile. ST239 was the predominant sequence type (6/18), while t037 was the predominant spa type (7/18). Five isolates shared the same ST239 and spa t037. ST1535, an emerging MRSA strain, was the second most prevalent in our study. One isolate showed a unique pattern of a high abundance of resistance and virulence genes. Conclusion: WGS elucidated the resistance and virulence profiles of MRSA isolated from clinical samples of HAI patients with high-resolution tracking of clones predominant in our healthcare facility

Antibiotics and Phage Sensitivity as Interventions for Controlling Escherichia coli Isolated from Clinical Specimens

Escherichia coli is considered one of the most frequent causative agents of common bacterial infections worldwide. In addition, effective treatment and prevention measures are still in demand due to the rise of antibiotic resistance and the emergence of new virulent strains. In this work, we evaluated antibiotics and bacteriophages as interventions for controlling pathogenic E. coli. A total of 15 E. coli isolates were included in this study. The automated identification system, namely Vitek 2, has been utilized for the identification. Antibiotics susceptibility profiles of all isolates were confirmed by disc diffusion method. All strains exhibited resistance at least to one antibiotic (ampicillin) while 13 strains were resistant to Ampicillin/Sulbactam, Cefazolin, and Ceftriaxone. Except for two strains, no resistance to Amikacin was observed. On the other hand, bacteriophages designated øEU-3 and øEU-4 were isolated by single plaque isolation and investigated as antimicrobial agents against pathogenic E. coli. Phages morphology, determined by transmission electron microscopy, revealed a structure comprised of a head diameter (71.42 nm) and a tail length (214.28 nm). These features placed the øEU-3 phage in the family Siphoviridae while øEU-4 belonged to family Myoviridae with a head diameter (66.6 nm) and a contractile tail length (108.3nm). Phages susceptibilities were determined by spot test to fifteen E. coli isolates. Coliphage øEU-3 and øEU-4 had narrow host range. This work described the efficacy of antibiotics and bacteriophages as intervention strategies to control pathogenic E. coli and paved the way for depth studies to broaden the antimicrobial spectrum of øEU-3 and øEU-4 phages

Development of Sedative Dexmedetomidine Sublingual In Situ Gels: In Vitro and In Vivo Evaluations

Intravenous dexmedetomidine (DEX) is currently approved by the FDA for the sedation of intubated patients in intensive care units to reduce anxiety and to augment postoperative analgesia. Bradycardia and hypotension are limitations associated with the intravenous administration of DEX. In this study, DEX sublingual in situ gels were developed and assessed for their pH, gelling capacity, viscosity, mucoadhesion and in vitro drug release. The optimized gelling system demonstrated enhanced mucoadhesion, superior gelling capacity, reasonable pH and optimal rheological profile. In vivo, compared to the oral solution, the optimal sublingual gel resulted in a significant higher rate and extent of bioavailability. Although the in situ gel had comparable plasma levels to those observed following intravenous administration, significant amelioration of the systemic adverse reactions were attained. As demonstrated by the hot plate method, a sustained duration of analgesia in rats was observed after sublingual administration of DEX gel compared to the intravenously administered DEX solution. Furthermore, no changes in systolic blood pressure and heart rate were recorded in rats and rabbits, respectively, after sublingual administration of DEX. Sublingual administration of DEX in situ gel provides a promising approach for analgesia and sedation, while circumventing the reported adverse reactions associated with intravenous administration of DEX

Biofilm Inhibitory Activity of Actinomycete-Synthesized AgNPs with Low Cytotoxic Effect: Experimental and In Silico Study

The emergence of resistance by biofilm-forming bacteria has reached alarming and dangerous levels that threaten human civilization. The current study sought to investigate the antibiofilm potential of green-synthesized silver nanoparticles, mediated by a new Streptomyces strain. Zeta potential, transmission electron microscopy (TEM), and UV-Vis spectroscopy were used to analyze the biosynthesized AgNPs. Results revealed that silver nanoparticles had a size of (5.55 and 45.00 nm) nm and a spherical shape, with surface plasmon resonance (SPR) absorption at 400–460 nm in the UV-vis spectra establishing the formation of Streptomyces-Ag-NPs. The biosynthesized AgNPs showed a pronounced antibacterial efficacy against Escherichia coli, Pseudomonas aeruginosa, Bacillus subtilis, and Staphylococcus aureus. Moreover, the obtained Streptomyces-AgNPs exerted biofilm inhibition activity against nosocomial hospital-resistant bacteria, including Bacillus subtilis, Staphylococcus aureus, and Escherichia coli. The mechanism of biogenic AgNPs antibacterial action was visualized using TEM, which indicated the AgNPs accumulation and disruption of bacterial cell membrane function. Additionally, a molecular docking study was conducted to evaluate the binding mode of AgNPs with an Escherichia coli outer membrane. Furthermore, the cytotoxic profile of the AgNPs was evaluated toward three cell lines (MCF-7, HepG2 & HCT 116), and the low cytotoxic effects of the obtained nanoparticles indicated their possible medical application with low risks to human health

Anatomical and Physiological Performance of Jojoba Treated with Proline under Salinity Stress Condition

A field trial study was conducted for two consecutive seasons 2020 and 2021 in approximately 8-month-old jojoba plants to evaluate the physiological responses following salt treatment and the role of proline as a foliar application to enhance jojoba tolerance to salinity stress. Jojoba plants were irrigated once a week for four months with diluted seawater in concentrations of 5000, 10,000, and 15,000 ppm and tap water (control). Anti-stress proline was applied four times throughout the experiment, the first at the beginning of the experiment and another three times at 30-day intervals, at concentrations of 0, 300, and 450 ppm. The effect of proline treatments on jojoba plant behavior includes growth vegetative characteristics, namely plant height increase percentage (PHIP), shoot number increase percentage (NSIP), stem diameter increase percentage (SDIP), number of leaves, leaf thickness, leaf area, and fresh and dry weights of leaves, and chemical characteristics, namely chlorophyll a and b, total chlorophyll, carotenoids, leaf mineral contents (N, P, K, Na, and Cl), total phenolic content (TPC), and proline concentration. Moreover, the impacts of proline on hydrogen peroxide (H2O2), superoxide anion (O2&bull;&minus;), malondialdehyde (MDA), and ion leakage (IL) under salinity stress were investigated. Briefly, proline at 450 ppm enhanced all studied growth and physiological characteristics and promoted the antioxidant system of jojoba plants compared with the control and other treatments. The anatomical structure of leaves was also examined, and favorable variations in the anatomical structure were detected in the stressed and proline-treated plants. Exogenous application of proline enhanced most of this anatomical characteristic of jojoba leaf under saline stress. In conclusion, proline as a foliar application at 450 ppm under salinity stress of 10,000 ppm enhances jojoba tolerance to salinity stress by modifying the physicochemical and morphological characteristics of jojoba plants