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

Diagnóstico del proceso artesanal de producción de hilo de fibra de alpaca en Puno, Perú

Esta investigación buscaba conocer el estado actual del proceso artesanal de producción de hilo de fibra de alpaca, de la región de Puno en el Perú. Por tal motivo, se realizó un estudio con una perspectiva de alcance descriptivo y exploratorio, teniendo como unidad de análisis a los alpaqueros, artesanos, productores medianos y algunos directivos del sector textil. Se diseñó una investigación documental para obtener datos cualitativos y cuantitativos sobre la producción del hilado de alpaca. En el 2019 se hizo la investigación de campo para recolectar los datos directamente de las comunidades alpaqueras, obteniendo información sobre los métodos del proceso de producción de hilos de fibra de alpaca. Se concluyó que la fabricación artesanal de hilo de alpaca mantiene, principalmente, un proceso manual, sin embargo, se han incorporado pequeñas máquinas como la abridora y la de hilatura, compuestas de dispositivos mecá- nicos simples, con la finalidad de reducir el tiempo de producción de la fibra y mejorar la calidad del hilo obtenido

Características textiles de la fibra de alpaca Huacaya, segúnzonas agroecológicas, sexo y edad en la Región Puno (Perú)

El objetivo del estudio fue evaluar el efecto de la zona agroecológica en las características textiles de la fibra de alpaca (Vicugna pacos), procedente de rebaños de unidades productivas de la Puna seca y Puna húmeda en la región Puno, según sexo y edad. Las muestras fueron obtenidas de 5530 alpacas Huacaya. El Diámetro de fibra (DF), Desviación estándar del diámetro de fibra (DEDF), Coeficiente de variación de diámetro de fibra (CVDF), Finura al hilado (FH), Índice de curvatura (IC) y Desviación estándar del índice de curvatura (DEIC) fueron registrados utilizando el equipo OFDA 2000. Los efectos de la zona agroecológica con relación al sexo y edad (Diente de leche [DL], 2 dientes [2D], 4 dientes [4D] y Boca llena [BLL]) se estimaron mediante un diseño al azar con arreglo factorial y prueba de rango múltiple de Duncan. Los valores de DF se encuentran en el rango de 13.3 a 34.5 µm con un valor promedio de 20.32 µm. Las alpacas de la Puna húmeda presentaron menor DF (13.3-34.5 µm) en comparación con las de la Puna seca (13.6-37.9 µm). La edad y el sexo inciden en el DF, pues las alpacas BLL registraron mayor DF frente a las alpacas DL (p<0.05). Asimismo, se observó un menor DF en alpacas macho en comparación con las hembras (p<0.05). La correlación entre zonas agroecológicas, sexo y edad se demostró al obtener menor diámetro en las alpacas macho DL de Puna húmeda. Además, se identificó una correlación significativa entre la calidad de fibra evaluada a partir de sus características textiles con la zona agroecológica

Candida bloodstream infections in intensive care units: analysis of the extended prevalence of infection in intensive care unit study

To provide a global, up-to-date picture of the prevalence, treatment, and outcomes of Candida bloodstream infections in intensive care unit patients and compare Candida with bacterial bloodstream infection. DESIGN: A retrospective analysis of the Extended Prevalence of Infection in the ICU Study (EPIC II). Demographic, physiological, infection-related and therapeutic data were collected. Patients were grouped as having Candida, Gram-positive, Gram-negative, and combined Candida/bacterial bloodstream infection. Outcome data were assessed at intensive care unit and hospital discharge. SETTING: EPIC II included 1265 intensive care units in 76 countries. PATIENTS: Patients in participating intensive care units on study day. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of the 14,414 patients in EPIC II, 99 patients had Candida bloodstream infections for a prevalence of 6.9 per 1000 patients. Sixty-one patients had candidemia alone and 38 patients had combined bloodstream infections. Candida albicans (n = 70) was the predominant species. Primary therapy included monotherapy with fluconazole (n = 39), caspofungin (n = 16), and a polyene-based product (n = 12). Combination therapy was infrequently used (n = 10). Compared with patients with Gram-positive (n = 420) and Gram-negative (n = 264) bloodstream infections, patients with candidemia were more likely to have solid tumors (p < .05) and appeared to have been in an intensive care unit longer (14 days [range, 5-25 days], 8 days [range, 3-20 days], and 10 days [range, 2-23 days], respectively), but this difference was not statistically significant. Severity of illness and organ dysfunction scores were similar between groups. Patients with Candida bloodstream infections, compared with patients with Gram-positive and Gram-negative bloodstream infections, had the greatest crude intensive care unit mortality rates (42.6%, 25.3%, and 29.1%, respectively) and longer intensive care unit lengths of stay (median [interquartile range]) (33 days [18-44], 20 days [9-43], and 21 days [8-46], respectively); however, these differences were not statistically significant. CONCLUSION: Candidemia remains a significant problem in intensive care units patients. In the EPIC II population, Candida albicans was the most common organism and fluconazole remained the predominant antifungal agent used. Candida bloodstream infections are associated with high intensive care unit and hospital mortality rates and resource use