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

QUÍMICA APLICADA Y ANALÍTICA

Abstract Vitamin loss during irradiation has been claimed as a critical area in food irradiation technology, especially that of thiamine (B1), which has been considered as the most sensitive to radiation. Although it has been suggested that no vitamin deficiency could result from consuming irradiated food, a long debate on the loss of vitamins and other nutrients during food irradiation has been maintained by the lack of experimental studies monitoring decomposition rates at different concentrations and doses. Since thiamine, riboflavin, and pyridoxine are labile vitamins, this study has focused on their radiolytic decomposition in dilute aqueous solutions in the presence of air. The decomposition process was followed by HPLC and UV-spectroscopy. The results obtained in aqueous solutions showed a dependence of the decomposition as a nonlinear function of the dose. Of these three compounds, the decomposition was higher for thiamine than for riboflavin and even less in pyridoxine. Resumen La pérdida de vitaminas durante procesos de irradiación ha sido considerada como un área crítica en la tecnología de irradiación de alimentos, especialmente la tiamina (B1), que ha sido considerada como la más sensible a la radiación ionizante. La deficiencia de vitaminas en humanos no es producida por el consumo de alimentos irradiados, sin embargo, existen debates sobre la pérdida de vitaminas y otros nutrientes provocada por la irradiación de alimentos, esta discusión sigue latente debido a que hay pocos estudios experimentales de la descomposición de vitaminas a diferentes dosis y concentraciones. Esta investigación se centró en el estudio de la descomposición radiolítica de tiamina, riboflavina y piridoxina en soluciones acuosas y en presencia de aire. El proceso de descomposición fue seguido por cromatografía líquida con detección UV. Los resultados obtenidos en soluciones acuosas mostraron una dependencia no lineal entre la descomposición en función de la dosis. De estos tres compuestos, la descomposición fue mayor en tiamina que en riboflavina y menor en la piridoxina. Resumo A perda de vitaminas durante processos de irradiação tem sido considerada uma área crítica na tecnologia de irradiação de alimentos, especialmente no caso da tiamina (B1), que tem sido considerada como a mais sensível à radiação ionizante. Embora a deficiência de vitaminas em seres humanos não seja produzida pelo consumo de alimentos irradiados, longos debates sobre as perdas de vitaminas e outros nutrientes causadas pela irradiação de alimentos tem sido mantidos devido aos estudos experimentais limitados monitorando a proporção da decomposição em diferentes concentrações de vitaminas e doses de radiação aplicadas. Considerando que a tiamina, riboflavina e piridoxina são vitaminas instáveis, o presente estudo focalizou a decomposição radiolítica dessas vitaminas em soluções aquosas diluídas e na presença de ar. O processo de decomposição foi analizado por cromatografia líquida com detecção UV. Os resultados obtidos em soluções aquosas mostraram uma dependência da decomposição como função não linear da dose. Destes três compostos, a descomposição foi mais alta para tiamina que na riboflavina e menor para piridoxina