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

Genetic Diversity, Analysis of Some Agro-Morphological and Quality Traits and Utilization of Plant Resources of Alfalfa

Alfalfa (Medicago sativa L.) is one of the most important perennial forage crops to build effective diets for livestock producers. Forage crop improvement depends largely on the availability of diverse germplasms and their efficient utilization. The present investigation was conducted at Ismailia Agricultural Research Station to assess twenty-one alfalfa genotypes for yield components, forage yield and quality traits during 2019/2020 and 2020/2021. The genotypes were evaluated in field experiments with three replicates and a randomized complete block design, using analysis of variance, estimate of genetic variability, estimate of broad sense heritability (hb2) and cluster analysis to identify the inter relationships among the studied genotypes as well as principal component analysis (PCA) to explain the majority of the total variation. Significant differences were found among genotypes for all studied traits. The general mean of the studied traits was higher in the second year than the first year. Moreover, the combined analysis showed highly significant differences between the two years, genotypes and the year &times; gen. interaction for the traits studied. The genotype F18 recorded the highest values for plant height, number of tiller/m2, total fresh yield and total dry yield, while, the genotype F49 ranked first for leaf/stem ratio. The results showed highly significant variation among the studied genotypes for crude protein %, crude fiber % and ash %. Data revealed that the genotypes P13 and P5 showed the highest values for crude protein %, whereas, the genotype F18 recorded the highest values for crude fiber % and ash content. The results revealed high estimates of genotypic coefficient and phenotypic coefficient of variation (GCV% and PCV%) with high hb2, indicating the presence of genetic variability and effective potential selection for these traits. The cluster analysis exhibited considerable genetic diversity among the genotypes, which classified the twenty one genotypes of alfalfa into five sub-clusters. The genotypes F18, F49, K75, S35, P20, P5 and P13 recorded the highest values for all studied traits compared with other clusters. Furthermore, the PC analysis grouped the studied genotypes into groups and remained scattered in all four quadrants based on all studied traits. Ultimately, superior genotypes were identified can be utilized for crop improvement in future breeding schemes