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

Chromosome comparison between two species of Phyllostomus (Chiroptera - Phyllostomidae) from Eastern Amazonia, with some phylogenetic insights

The karyotypes of Phyllostomus discolor and P. hastatus from Eastern Amazonia were studied by G-, C-, G/C sequential and Ag-NOR techniques. Both species presented 2n = 32, with the autosome complement composed of 30 bi-armed in P. discolor and 28 bi-armed plus 1 acrocentric in P. hastatus. In both species, the X chromosome is medium submetacentric while the Y is minute acrocentric. The present study found only one difference between the karyotypes of P. discolor and P. hastatus: the smallest autosome (pair 15) is bi-armed in discolor and acrocentric in hastatus, a result best explained by pericentric inversion. The C-banding revealed constitutive heterochromatin only at the centromeric regions of all chromosomes, with the NOR site located at the distal region of short arm of pair 15, in both species. The taxon P. discolor is considered primitive for genus Phyllostomus and the bi-armed form of pair 15 is the assumed primitive condition which, rearranged by a pericentric inversion originated the acrocentric from found in P. hastatus.<br>Os cariótipos de Phyllostomus discolor e P. hastatus da Amazônia oriental são estudados por bandeamentos G, C, G/C sequencial e coloração Ag-NOR. Ambas as espécies apresentaram 2n = 32, sendo o complemento autossômico composto por 15 pares bi-armed em P. discolor e 14 bi-armed mais 1 par acrocêntrico em P. hastatus. O cromossomo X é um submetacêntrico médio e o Y é um pequeno acrocêntrico em ambas as espécies. O presente estudo encontrou apenas uma diferença entre os cariótipos de P. discolor e P. hastatus: o menor autossomo (par 15) é metacêntrico em discolor e acrocêntrico em hastatus. Este resultado é melhor explicado por uma inversão pericêntrica. O bandeamento C revelou heterocromatina constitutiva na região centromérica de todos os cromossomos, e os sítios NOR foram localizados na região distal do par 15, em ambas as espécies. O táxon P. discolor é considerado primitivo para o gênero Phyllostomus e supõe-se que a forma metacêntrica do par 15 seja a condição primitiva, que foi rearranjada por uma inversão pericêntrica, originando a forma acrocêntrica encontrada em P. hastatus

Comparative cytogenetic analysis in the species Uroderma magnirostrum and U. bilobatum (cytotype 2n = 42) (Phyllostomidae, Stenodermatinae) in the Brazilian Amazon

The genus Uroderma includes two species: U. magnirostrum and U. bilobatum. These species are characterized by their high degree of karyotypic evolution, diverging from most other species of the subfamily Stenodermatinae, which have a lower degree of chromosomic evolution. The present study reports the first banding patterns of U. magnirostrum (G-, C-banding and Ag-NOR) and U. bilobatum (C-banding and Ag-NOR). The chromosomic data in conventional staining of U. magnirostrum (2n = 36, NF = 62) and U. bilobatum (cytotype 2n = 42, NF = 50) are equivalent to that described in the literature. When compared, chromosomal homeologies are found in both karyotypes, as well as differences, confirming that karyotypic evolution in the Uroderma genus is intense. Fission, fusion, inversion or translocation events are required to explain the karyotypic evolution of this genus. The comparison of karyotype, described here, to one of the species of the genus Artibeus (2n = 30/31), suggests that some chromosomic forms are apomorphic and shared between the two species of Uroderma. This confirms the monophyly of the genus, and that U. magnirostrum presents a more primitive karyotype when compared to U. bilobatum