Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

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 middle-income 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 low-income 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 low-income, 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

Riesgo cardiovascular en estudiantes de medicina del municipio Puerto Padre de Las Tunas

Introduction: cardiovascular diseases are the first cause of death in Cuba; as a result, the identification of cardiovascular risks from early ages allows the implementation of health promotion and prevention strategies to reduce their impact in the futureObjective: to identify the cardiovascular risk in medical students in Puerto Padre Municipality, Las Tunas province.Methods: an observational, descriptive and cross-sectional study was conducted. The target group included 545 medical students, 237 of whom were selected by means of a simple random sample. The body mass index and waist-hip ratio were studied. Descriptive statistics was applied.Results: the predominant age group was 18-21 years old (50,2 %). The 51,47 % of the students presented a high waist-hip ratio, 54,02 % a high abdominal circumference, 52,74 % a high body mass index, and in all groups 35,44 % presented blood pressure figures lower than 120/80 mmHg; 39 % had a cardiovascular risk.Conclusions: low percentages of cardiovascular risk were identified in medical students from Puerto Padre Municipality, Las Tunas province, determined by high values of waist-hip index, body mass index and abdominal circumference.Introducción: las enfermedades cardiovasculares constituyen la primera causa de mortalidad en Cuba; por lo cual la identificación de riesgos cardiovasculares desde edades tempranas permite implementar estrategias de promoción y prevención de salud para disminuir su impacto en el futuroObjetivo: identificar el riesgo cardiovascular en estudiantes de medicina del municipio Puerto Padre de Las Tunas.Método: se realizó un estudio observacional, descriptivo y transversal. El universo estuvo constituido por 545 estudiantes de medicina, seleccionándose 237 mediante un muestreo aleatorio simple. Se estudió el índice de masa corporal, la circunferencia abdominal y la índice cintura cadera. Se empleó estadística descriptiva.Resultados: se encontró predominio del grupo etario de 18 a 21 años (50,2 %). El 51,47 % de los estudiantes presentó un índice cintura-cadera alto, el 54,02 % una circunferencia abdominal alta, el 52,74 % un índice de masa corporal alta, así como en todos los grupos el 35,44 % presentó cifras de tensión arterial inferiores a 120/80 mmHg. El 39 % presentó riesgo cardiovascular.Conclusiones: se identificaron bajos porcientos de riesgo cardiovascular en los estudiantes de medicina del municipio Puerto Padre de Las Tunas, determinado por altos valores los índice cintura-cadera, índice de masa corporal y circunferencia abdominal

Large Supralevator Puerperal Haematoma Following a Normal Delivery

BACKGROUND: Puerperal Haematomas are not very common and Supralevator haematomas following normal vaginal deliveries are quite rare.METHOD: We report a case of  supralevator haematoma following a normal spontaneous vertex delivery, necessitating laparotomy.RESULTS: A 29 year old multiparous woman who had a normal pregnancy and normal labour, developed a large supralevetor haematoma . She had a laparotomy and her  recovery was uneventful.CONCLUSION: Supralevator haematomas  should be considered  in  patients presenting with lower abdominal pains and absence of  vaginal bleeding following normal delivery. Ultrasound scan is helpful, but not conclusive in the diagnosis of supralevator  haematomas.KEY WORDS: Puerperal, Haematoma, Supralevator, Infralevator

A Review of Gynaecological Hysterectomies in a Private Specialist Hospital in Nigeria

Background: Hysterectomy, the removal of the uterus, is practised worldwide. It is a major surgery, which may lead to significant morbidity or even mortality, hence, there must be a justifiable indication before the procedure is undertaken. Symptomatic fibroids and utero-vaginal prolapse are common indications in this environment.Objective: To audit the 30 consecutive gynaecological hysterectomies done in our centre from January 2003 to July 2009, with a view to determining the demographic factors, indications, types of hysterectomies done, and morbidity/mortality associated with the procedures.Methodology: This is a retrospective descriptive study. Data concerning these 30 patients were retrieved from the theatre records and their case notes. The analysis was done using simple tables and percentages.Results: Hysterectomies accounted for 30(28.0%) of 107 major gynaecological operations done during the period under review. Of the 30 hysterectomies 11(36.7%) were vaginal hysterectomies, while total and subtotal abdominal hysterectomies accounted for 13(43.3%) and 6(20%), respectively. Bilateral salpingo-oophorectomy was done in 4(13.3%) patients. The most common indication was uterine fibroids 16(53.3%) followed by utero-vaginal prolapse 8(26.7%). The most common age range of the patients was 40-49year group 16(53.3%), mean age was 45.5&#177;6.7. The most common parity group was para 5-8(53.3%). On the average, the vaginal hysterectomy patients needed less diclofenac injections for pain relief. One bladder injury was encountered. There was no mortality.Conclusion: The indications for, and surgical outcome following gynaecological hysterectomy in a private specialist hospital, is comparable to that from public hospitals. The private hospitals should be considered in manpower development to help improve gynaecological practice

Evaluation of hydrochemical characteristics and flow directions of groundwater quality in Udi Local Government Area Enugu State, Nigeria

A hydrogeological study was conducted at the Udi Local Government Area in south-eastern region of Nigeria to examine the hydrochemical constituent of groundwater and determine the quality for drinking and agricultural purposes. Results show that groundwater in the area is slightly acidic to slightly basic, soft and potable, when compared with the World Health Organisation standards for drinking water, and is suitable for agricultural purposes. The groundwater flow direction was determined to establish the implications of pollution from any water contamination. Twenty-one groundwater samples from existing boreholes were collected and analysed for various physicochemical parameters using standard field and laboratory techniques. Distribution of major ions was plotted on a Trilinear Piper diagram. Ajali Sandstone, known as major aquiferous layer in the area, outcrops predominately in sandy bed with medium to coarse-grained sediments. The aquifers are unconfined, semi-confined and with hydraulic conductivity values ranging from 9.0 x 10(-2) to 8.5 x 10(-2) m/day indicating medium transmissivity of groundwater in some areas and a flow net south to northward groundwater flow towards the coast. This explains why the aquifer does not appear to be very permeable and only provides a medium yield of good quality water in some regions of the study area