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

Natural Solid Shampoo: Pashoo

Pashoo es una empresa que se creó gracias a la idea de cinco estudiantes que se encuentran cursando el décimo ciclo en la Universidad Peruana de Ciencias Aplicadas (UPC), la cual está orientada a la industria de cuidado de belleza y salud mediante la fabricación y comercialización de shampoo en barra 100% naturales a base de ingredientes seleccionados de acuerdo con sus valores nutricionales que estos le brindan al cabello. Contamos con shampoos de distintos olores y para todo tipo de cabellos como por ejemplo shampoo a base de aceite de jojoba, coco, almendras, argán y palta combinados con esencias naturales que le brindan al cliente una sensación de relajación. Por otro lado, hemos segmentado a nuestros clientes de manera que nuestro producto pueda solucionar sus problemas. Para este proyecto, nos estamos fijando en las mujeres que tienen problemas de caída de cabello e irritación en el cuero cabelludo y que estén buscando productos orgánicos y naturales que tengan conciencia sobre el cuidado del medio ambiente. Vamos a distribuir nuestros productos mediante ferias y por delivery utilizando como canales de comunicación las redes sociales y nuestra página web en donde los clientes podrán encontrar información necesaria sobre nosotros y nuestros productos. De la misma forma, mostrar las validaciones del modelo de negocio, el desarrollo del negocio, el plan financiero y de marketing, así como las operaciones que se realizaron a lo largo de este proyecto dejando por último nuestras conclusiones y recomendaciones por la realización del proyecto de negocio.Pashoo is a company that was created thanks to the idea of five students who are studying the tenth cycle at the Universidad Peruana de Ciencias Aplicadas (UPC), which is oriented to the beauty and health care industry through manufacturing and marketing 100% natural bar shampoo based on selected ingredients according to their nutritional values that they provide to the hair. We have shampoos of different scents and for all types of hair such as jojoba oil, coconut, almond, argan and avocado shampoo combined with natural essences that give the client a feeling of relaxation. On the other hand, we have segmented our customers so that our product can solve their problems. For this project, we are looking at women who have problems with hair loss and irritation on the scalp and who are looking for organic and natural products that are aware of the care of the environment. We will distribute our products through fairs and by delivery using social media and our webpage as communication channels where customers can find necessary information about us and our products. In the same way, show the validations of the business model, the development of the business, the financial and marketing plan, as well as the operations that were carried out throughout this project, finally leaving our conclusions and recommendations for the completion of the project of business.Trabajo de investigació