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

Open Fractures in patients from the Teodoro Maldonado Carbo Hospital in Guayaquil city

Objetivo: Caracterizar epidemiológicamente las fracturas expuestas y las complicaciones infecciosas en pacientes atendidos en el servicio de emergencia de Traumatología del Hospital Teodoro Maldonado Carbo de la ciudad de Guayaquil, Ecuador. Método: Se realizó un estudio descriptivo, retrospectivo, mediante un análisis del sistema de registro del Teodoro Maldonado Carbo incluyéndose pacientes con diagnóstico de fracturas expuestas durante el período 2015-2017. Resultados: Se incluyeron 438 pacientes, con predominio en hombres (75,1%; n=329) y jóvenes <35 años 61% (n=267), la región tibial fue la zona corporal más afectada (62,3%; n=273). En cuanto a la severidad del grado de exposición, la fractura tipo IIIB fue la más frecuente 36,1% (n=158), siendo la fijación externa el procedimiento más empleado (57,8%; n=253). El 39,7% (n=174) de las fracturas se infectó y el staphylococcus aureus fue el agente más común con 40,8% (n=71). Conclusiones: La frecuencia de casos de fracturas expuestas en el Hospital Teodoro Maldonado Carbo de la ciudad de Guayaquil es alta en comparación con otros estudios, con un predominio en hombres, en sujetos jóvenes y con afectación tibial. Asimismo, se observa una alta frecuencia de infección en la fracturas, siendo el staphylococcus aureus el principal microorganismos aislado.© 2019, Sociedad Venezolana de Farmacologia y de Farmacologia Clinica y Terapeutica. All rights reserved. Objective: To characterize epidemiologically the open fractures and their infectious complications in patients attended in the orthopedic emergency service of the Teodoro Maldonado Carbo Hospital in Guayaquil city, Ecuador. Method: A descriptive, retrospective study was carried out through a record analysis of this hospital, including patients with open fractures diagnosis during the 2015-2017 period. Results: 438 patients were included, predominantly men (75.1%, n=329) and young people <35 years 61% (n=267), the tibial region was the most affected area (62.3%; n=273). Regarding the degree of exposure, type IIIB fracture was the most frequent one 36.1% (n=158), with external fixation being the most used procedure (57.8%, n=253). Likewise, 39.7% (n=174) of the fractures were infected and staphylococcus aureus was the most common agent with 40.8% (n=71). Conclusions: The frequency of open fractures cases in the Teodoro Maldonado Carbo Hospital in Guayaquil city is high in comparison to other studies, especially in men, young subjects and tibial affectation. Also, a high frequency of infection in the fractures is observed, staphylococcus aureus being the main isolated microorganism