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

Evaluation of Groundwater Sensitivity to Pollution Using GIS-Based Modified DRASTIC-LU Model for Sustainable Development in the Nile Delta Region

The groundwater resources in the Nile Delta region are an important resource for freshwater because of rising water demand due to anthropogenic activities. The goal of this study is to quantify groundwater sensitivity to pollution in the Nile Delta by a modified GIS-based DRASTIC-LU model. In this study, we utilized two types of modified DRASTIC-LU models, generic and pesticide, to determine the groundwater vulnerability rates to contamination. The results of the generic DRASTIC-LU model showed that the research region, except for the northwestern part with moderate vulnerability of 3.38%, is highly and very highly vulnerable to pollution with 42.69 and 53.91%, respectively. Results from the pesticide DRASTIC-LU model, on the other hand, also confirmed that, except for the northwestern and southern parts with a moderate vulnerability of 9.78%, most the Nile Delta is highly and very highly vulnerable with 50.68 and 39.53%, respectively. A validation of the model generated was conducted based on nitrate concentrations in the groundwater and a sensitivity analysis. Based on the nitrate analysis, the final output map showed a strong association with the pesticide vulnerability model. Examining the model sensitivity revealed that the influence of depth to water and net recharge were the most important factors to consider

Evaluation of Groundwater Sensitivity to Pollution Using GIS-Based Modified DRASTIC-LU Model for Sustainable Development in the Nile Delta Region

The groundwater resources in the Nile Delta region are an important resource for freshwater because of rising water demand due to anthropogenic activities. The goal of this study is to quantify groundwater sensitivity to pollution in the Nile Delta by a modified GIS-based DRASTIC-LU model. In this study, we utilized two types of modified DRASTIC-LU models, generic and pesticide, to determine the groundwater vulnerability rates to contamination. The results of the generic DRASTIC-LU model showed that the research region, except for the northwestern part with moderate vulnerability of 3.38%, is highly and very highly vulnerable to pollution with 42.69 and 53.91%, respectively. Results from the pesticide DRASTIC-LU model, on the other hand, also confirmed that, except for the northwestern and southern parts with a moderate vulnerability of 9.78%, most the Nile Delta is highly and very highly vulnerable with 50.68 and 39.53%, respectively. A validation of the model generated was conducted based on nitrate concentrations in the groundwater and a sensitivity analysis. Based on the nitrate analysis, the final output map showed a strong association with the pesticide vulnerability model. Examining the model sensitivity revealed that the influence of depth to water and net recharge were the most important factors to consider

Investigation of Chemical Compositions and Biological Activities of Mentha suaveolens L. from Saudi Arabia

Mentha is an aromatic plant used since antiquity for its pharmaceutical virtues. The climate of Saudi Arabia favors the growth of aromatic plants including Mentha suaveolens L. The aim of this study is to analyze the volatile oils of different parts of fresh and dried Mentha suaveolens L. grown in Saudi Arabia (Aljouf area) using Gas Chromatography/Mass Spectrometry (GC/MS) and Gas Chromatography Flame Ionization Detector (GC/FID) techniques, to recognize the effect of drying on chemical composition, then to evaluate the antioxidant and antifungal activities of different extracts. In total, 118 compounds were identified via GC/MS and GC/FID, in which carvone is the main volatile constituent (stems, leaves, whole plant 45&ndash;64%). This investigation deduces that Mentha belonged to the carvone chemotype. Then, the analysis of non-volatile constituents of fresh and dried Mentha was performed by HPLC. The main phenolic compound of fresh and dried Mentha for different parts was rosmarinic acid (ranging from 28,002.5 to 6558 &micro;g/g). The ethanolic extract of fresh stem showed the highest antifungal activity (53% inhibition) compared with miconazole (60% inhibition) but the ethanoic extract of dry stem showed no activity. Additionally, all ethanolic extracts, whether for fresh or dry Mentha, have antioxidant activity more than 90% while the antioxidant activity of whole plant volatile oil is equal to 53.33%. This research shows that M. suaveolens L. could be applied to manufacture natural antioxidants, antifungal, and flavoring agents