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

Endogenous neuropeptides in patients with acute traumatic head injury .1. Cerebrospinal fluid beta-endorphin levels are increased within 24 hours following the trauma

The changes in the cerebrospinal fluid (CSF) beta-endorphin (beta-end) levels within 24 h following the trauma were examined in 45 patients with head injuries. CSF samples obtained from 25 healthy subjects who had minor surgical operations under spinal anaesthesia were included as the controls. Patients with head injuries were evaluated according to their Glasgow Coma Scale (GCS) scores on admission to the neurosurgery clinic and four subgroups were formed as follows: Group I: minor head trauma (GCS: 13-15) without skull fracture; Group II: mild head injury (GCS: 13-15) with skull fracture; Group III: moderate head injury (GCS: 8-12) and Group IV: severe head injury (GCS: < 8)

EFFECTS OF TRH AND HIGH-DOSE CORTICOSTEROID-THERAPY ON EVOKED-POTENTIALS, AND TISSUE NA+, K+ AND WATER-CONTENT IN EXPERIMENTAL SPINAL-INJURY

The therapeutic effects of continuous infusion of thyrotropin-releasing hormone (TRH) and methylprednisolone (MP) in experimental spinal cord injury were studied in Swiss albino rats. Thirty rats received a 53-g clip-compression injury on the cord at T1, then were allocated randomly and blindly to one of three treatment groups (ten animals in each): (1) control; received equal volumes of saline solution; (2) MP; received 30 mg/kg methylprednisolone i.v. 1 h after trauma, followed by infusion of 5.4 mg/kg/per hour i.v. for 3 h. (3) TRH: received 2 mg/kg TRH i.v. 1 h after trauma, followed by infusion of 1 mg/kg/per hour i.v. for 3h. MP and TRH treatments significantly improved somatosensory-evoked potentials (SEPs; P < 0.001). Both treatments significantly reduced water content, decreased Na+ content and increased the K+ content of the cord segment that included the centre of the impact (P < 0.01). Our data provide evidence for the beneficial effects of high-dose corticosteroid and TRH in promoting electrophysiological recovery and preserving spinal cord tissue following experimental injury

SERUM OSTEOCALCIN LEVELS IN TYPE-I DIABETES-MELLITUS

Serum osteocalcin levels are a marker of bone formation. In this study, bone and mineral metabolism in type I diabetes mellitus (DM) were investigated, and the changes related to diabetic microvascular complications were examined. Serum calcium (Ca), inorganic phosphate (P), osteocalcin (OC) and parathyroid hormone (PM) levels were measured in 42 type I diabetic subjects. Diabetics were subdivided into those with or without complications. Age and sex-matched control subjects were used for comparisons with the diabetic groups. Serum P and PTH levels were not different from those of controls. Serum Ca levels were significantly increased (p < 0.001) although the values were within the normal range. CC levels were significantly lower in the complicated (retinopathy and/or protenuria) diabetic group (p < 0.005). In Type I diabetes mellitus, the serum OC level is influenced by the presence of microvascular complications

Does tuberculosis really cause hypercalcemia?

Hypercalcemia has been known to be associated with tuberculosis. In some studies it has been reported to occur commonly. It seems that the studies in which tuberculosis was complicated by hypercalcemia were retrospective and therefore the other causes of hypercalcemia could not be excluded. We have a great deal of experience concerning tuberculosis and have not seen a patient with hypercalcemia due to tuberculosis itself. Therefore we aimed to investigate whether tuberculosis really cause hypercalcemia in a prospective study. We evaluated 104 patients with tuberculosis aged between 14-85 (mean +/- SD 38.5 +/- 15) years, 73 males and 31 females, and 50 age-matched healthy subjects aged between 19-70 (mean +/- SD 39 +/- 13) years, 33 males and 17 females. No significant differences between the patients and healthy subjects were detected in terms of 250HD(3), calcium and phosphate levels. Albumin levels were significantly higher in the control group than in the tuberculous group (p < 0.02). No significant difference was found between the calcium levels measured before the therapy (2.4 +/- 0.1 nmol/L) and after the therapy (2.4 +/- 0.2). We think that patients with tuberculosis are not at risk for hypercalcemia either before or during treatment and the development of hypercalcemia as a result of tuberculosis is rather doubtful and needs to be clarified. (C) 1996, Editrice Kurti

The role of the oxidative state of glutathione and glutathione-related enzymes in anemia of hemodialysis patients

Objective: To investigate the oxidative state of glutathione and glutathione peroxidase (GSH-Px), glutathione reductase (GSSG-R), and glucose-6-phosphate dehydrogenase (G-6-PD) revels in patients with chronic renal failure (CRF) and controls

LIPID-PEROXIDATION IN EXPERIMENTAL SPINAL-CORD INJURY - COMPARISON OF TREATMENT WITH GINKGO-BILOBA, TRH AND METHYLPREDNISOLONE

Ischaemia-induced lipid peroxidation is one of the most important factors producing tissue damage in spinal cord injury. In our study, the protective effects of Ginkgo biloba, thyroid releasing hormone (TRH) and methylprednisolone (MP) on compression injury of the rat spinal cord were investigated. For this study 45 rats in four groups, including control, MP, TRH and Gingko biloba, were used to determine the formation of malondialdehyde (MDA). All the animals were made paraplegic by the application clip method of Rivlin and Tator. Rats were divided randomly and blindly to one of four treatment groups (ten animals in each). MP and Ginkgo biloba treatments significantly decreased MDA levels (F=54.138, P<0.01). These results suggest that MP and Ginkgo biloba may have a protective effect against ischaemic spinal cord injury by the antioxidant effect

Agenesis of the dorsal pancreas

Developmental anomalies of the pancreas have been reported but dorsal pancreatic agenesis is an extremely rare entity. We report an asymptomatic 62-year-old woman with complete agenesis of the dorsal pancreas. Abdominal computed tomography (CT) revealed a normal pancreatic head, but pancreatic body and tail were not visualized. Magnetic resonance imaging (MRI) findings were similar to CT. At magnetic resonance cholangiopancreatography (MRCP), the major pancreatic duct was short and the dorsal pancreatic duct was not visualized. The final diagnosis was dorsal pancreatic agenesis