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

Immediate post-discectomy percutaneous facet nerve continuous and nerve root pulsed radiofrequency and intraluminal injection of steroid with hyaluronidase improved outcome of surgery for lumbar disk herniation

Objectives: Evaluation of effects of postoperative (PO) facet nerve continuous thermal radiofrequency neurotomy (CTRFN), nerve root pulsed RF (PRF) and triamcinolone with hyaluronidase injection on outcome of patients undergoing open lumber discectomy. Patients & methods: Seventy patients were allocated into the following groups: Group S underwent open discectomy alone and Group M underwent open discectomy followed by the three adjuvant procedures. Low back pain (LBP) severity was assessed using numeric rating scale (NRS) and disability was assessed using the Oswestry Disability Index (ODI). Primary outcome measure was at least 50% improvement of NRS and ODI. Secondary outcome involved scoring of pain medication requirements, Odom's criteria for improvement of preoperative abnormal findings and patients' satisfaction. Results: Throughout 12-m follow-up, mean NRS and ODI scores of all patients were significantly lower than preoperative scores with significantly lower scores in group M than in group S. Frequency of patients had ⩾50% improvement which was significantly higher in group M than in group S. Patients of both groups showed significant reduction of scoring of consumed analgesics with significantly less consumption of PO analgesics in group M than in group S. Odom's scoring, resumption of activity and overall satisfaction scoring were significantly higher in group M than in group S. Conclusion: Open discectomy provided significant improvement of LBP and disability secondary to LDH. Discectomy with adjuvant therapy including PRF, CTRFN and triamcinolone and hyaluronidase intraluminar injection significantly improved outcome compared to discectomy alone

Impact of direct acting antiviral agents on kidney function in hepatitis C virus infected patients with chronic kidney disease

Introduction: Hepatitis C virus (HCV) infection is strongly associated with chronic kidney disease (CKD). It is an independent risk factor for developing CKD and significantly increases morbidity and mortality in CKD patients. Treatment with newer direct-acting antiviral (DAA) regimens in patients with CKD is showing conflicting results as regards safety and efficacy. Objectives: To evaluate the safety and efficacy of DAAs and their impact on kidney function in CKD patients. Patients and Methods: We conducted a prospective observational study on 100 CKD patients stages 3-4, receiving treatment for HCV at MASRI (Faculty of Medicine Ain Shams University Research Institute), with two different DAAs regimens (sofosbuvir/daclatasvir with or without ribavirin and ombitasvir/paritaprevir/ritonavir [OMV/PTV/RTV] with ribavirin), completed over six months follow up. Serum creatinine, estimated glomerular filtration rate (eGFR), and proteinuria were followed during and after treatment. Results: Sustained virological response (SVR) was achieved in all patients. Improvement of eGFR (8-15 mL/min/1.73 m2) and proteinuria was found in both study groups. Acute kidney injury (AKI) was uncommon; it occurred in three (3%) patients, out of them, two patients showed complete recovery. Adverse events were common (43%), but serious adverse events were uncommon (2%). Conclusion: DAA regimens were effective and well-tolerated for HCV infected patients with stage 3-4 CKD, where viral clearance caused improvement in eGFR and proteinuria

Sofosbuvir Plus Daclatasvir in Treatment of Chronic Hepatitis C Genotype 4 Infection in a Cohort of Egyptian Patients: An Experiment the Size of Egyptian Village

Background and Aims. As indicated by the World Health Organization (WHO), Egypt is positioned as the country with the world’s highest prevalence of Hepatitis C virus (HCV). HCV is transmitted through unexamined blood transfusions, different employments of syringes, and poor cleansing, as per the WHO. Our study aimed at screening and management of chronic hepatitis C genotype 4 infected patients in Bardeen village, Sharkeya Governorate, Egypt, with Sofosbuvir plus Daclatasvir, as well as estimating the safety and efficacy of that regimen. Methods. Screening of adult patients in Bardeen village was done from March 2016 till November 2016 using hepatitis C virus antibodies by third-generation ELISA testing. Positive results were confirmed by PCR. Patients eligible for treatment received Sofosbuvir 400 mg and Daclatasvir 60 mg daily for 12 weeks and were assessed for sustained virologic response at 12 weeks following the end of treatment (SVR 12). Results. Out of 2047 subjects screened for hepatitis C virus, 249 (12.2%) showed positive results. 221 out of those 249 subjects (88.7%) had detectable RNA by PCR. Treatment of eligible patients (183 patients) with Sofosbuvir plus Daclatasvir for 12 weeks resulted in 96% achievement of sustained virologic response at week 12. Adverse events were tolerable. Conclusion. Sofosbuvir plus Daclatasvir regimen is safe and effective for treatment of chronic hepatitis C Genotype 4 infected patients with minimal adverse events. HCV eradication program implemented in Egypt can be a model for other countries with HCV and limited resources. The availability of generic drugs in Egypt will help much in eradication of the virus

Data on photo-nanofiller models for self-cleaning foul release coating of ship hulls

The data presented in this article are related to the research article entitled “Smart photo-induced silicone/TiO2 nanocomposites with dominant [110] exposed surfaces for self-cleaning foul-release coatings of ship hulls” (Selimet al., 2016) [1]. This article reports on successfully designing and controlling TiO2 spherical single crystal photo-nanofillers and indicating evidence of fouling resistance after stimulation through UV radiation exposure. These data also reveal that the influence of well-dispersed spherical TiO2 nanoparticles (NPs) into the polymer matrix surface features on the prepared fouling release (FR) coating. Single crystal TiO2 nanospheres have played a large role in the scenario of photocatalysis due to its cost effectiveness, inert nature and photo stability. The model output and the surface and mechanical behavior data of the fabricated UV-irradiated silicone-based FR nanocoatings are made publicly available through analyzing nanocomposite topology, superhydrophilicity and self-cleaning efficiency in order to enable critical analysis of the tailored model. It also investigates the photo-bactericidal effect confirmed through biofilm coverage data disability. The modeled nanocomposites were subjected to comparable studies with other published models so as to understand how different UV-irradiated nano-scale parameters propagate and affect bulk film response. Keywords: Nanofillers, Fouling release, Self-cleaning, Photo-bactericida

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population