A rare case of primary midgut volvulus necessitating extensive bowel resection in an adult

A cause of acute intestinal obstruction in adults, midgut volvulus can be categorized into two types: primary type with no identifiable underlying cause, and secondary type that occurs in the presence of a predisposing condition such as, postoperative adhesions. Primary midgut volvulus can lead to bowel ischemia and necrosis, making an extensive bowel resection imminent. A potential consequence of bowel resection is short-bowel syndrome - a failure of digestion and absorption by the intestines, leading to malnutrition and other complications. As such, we report the diagnosis and management of primary midgut volvulus - a rare entity in adults - occurring in an adult patient

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

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Low hepatitis C antibody screening rates among an insured population of Tennessean Baby Boomers.

Chronic Hepatitis C Virus (HCV) infection is common and can cause liver disease and death. Persons born from 1945 through 1965 ("Baby Boomers") have relatively high prevalence of chronic HCV infection, prompting recommendations that all Baby Boomers be screened for HCV. If chronic HCV is confirmed, evaluation for antiviral treatment should be performed. Direct-acting antivirals can cure more than 90% of people with chronic HCV. This sequence of services can be referred to as the HCV "cascade of cure" (CoC). The Tennessee (TN) Department of Health (TDH) and a health insurer with presence in TN aimed to determine the proportion of Baby Boomers who access HCV screening services and appropriately navigate the HCV CoC in TN.TDH surveillance data and insurance claim records were queried to identify the cohort of Baby Boomers eligible for HCV testing. Billing codes and pharmacy records from 2013 through 2015 were used to determine whether HCV screening and other HCV-related services were provided. The proportion of individuals accessing HCV screening and other steps along the HCV CoC was determined. Multivariable analyses were performed to identify factors associated with HCV screening and treatment.Among 501,388 insured Tennessean Baby Boomers, 7% were screened for HCV. Of the 40,019 who received any HCV-related service, 86% were screened with an HCV antibody test, 20% had a confirmatory HCV PCR, 9% were evaluated for treatment, and 4% were prescribed antivirals. Hispanics were more likely to be screened and treated for HCV than non-Hispanic whites. HCV screening was more likely to occur in the Nashville-Davidson region than in other regions of TN, but there were regional variations in HCV treatment.Many insured Tennessean Baby Boomers do not access HCV screening services, despite national recommendations. Demographic and regional differences in uptake along the HCV CoC should inform public health interventions aimed at mitigating the effects of chronic HCV

Chronic hepatitis C cascade.

<p>Frequency and proportions of insured Tennessean Baby Boomers accessing various HCV-related services, among those eligible for HCV screening and among those who received any HCV-related service.</p

Map of Tennessee Department of Health regions.

<p>East Tennessee includes the Chattanooga-Hamilton, East, Knox, Northeast, Southeast, and Sullivan public health regions. Middle Tennessee includes the Mid-Cumberland, Nashville-Davidson, South Central, and Upper Cumberland public health regions. West Tennessee includes the Jackson-Madison, Memphis-Shelby, and West public health regions.</p

Distribution of patient characteristics, stratified by whether screening with an HCV antibody test was performed.

<p>Distribution of patient characteristics, stratified by whether screening with an HCV antibody test was performed.</p

Multivariable logistic regression analyses to determine associations with (A) HCV antibody screening among the entire at-risk population, and (B) HCV treatment among those evaluated for treatment.

<p>Multivariable logistic regression analyses to determine associations with (A) HCV antibody screening among the entire at-risk population, and (B) HCV treatment among those evaluated for treatment.</p

Chronic hepatitis C cascade.

<p>Frequency and proportions of insured Tennessean Baby Boomers accessing various HCV-related services, among those eligible for HCV screening and among those who received any HCV-related service.</p