Creating a high-resolution picture of Cygnus with the Cherenkov Telescope Array

The Cygnus region hosts one of the most remarkable star-forming regions in the Milky Way. Indeed, the total mass in molecular gas of the Cygnus X complex exceeds 10 times the total mass of all other nearby star-forming regions. Surveys at all wavelengths, from radio to gamma-rays, reveal that Cygnus contains such a wealth and variety of sources---supernova remnants (SNRs), pulsars, pulsar wind nebulae (PWNe), H II regions, Wolf-Rayet binaries, OB associations, microquasars, dense molecular clouds and superbubbles---as to practically be a galaxy in microcosm. The gamma-ray observations along reveal a wealth of intriguing sources at energies between 1 GeV and tens of TeV. However, a complete understanding of the physical phenomena producing this gamma-ray emission first requires us to disentangle overlapping sources and reconcile discordant pictures at different energies. This task is made more challenging by the limited angular resolution of instruments such as the Fermi Large Area Telescope, ARGO-YBJ, and HAWC and the limited sensitivity and field of view of current imaging atmospheric Cherenkov telescopes (IACTs). The Cherenkov Telescope Array (CTA), with its improved angular resolution, large field of view, and order of magnitude gain in sensitivity over current IACTs, has the potential to finally create a coherent and well-resolved picture of the Cygnus region between a few tens of GeV and a hundred TeV. We describe a proposed strategy to study the Cygnus region using CTA data, which combines a survey of the whole region at $65^{\circ} < l < 85^{\circ}$ and $-3.5^{\circ} < b < 3.5^{\circ}$ with deeper observations of two sub-regions that host rich groups of known gamma-ray sources.Comment: In Proceedings of the 34th International Cosmic Ray Conference (ICRC2015), The Hague, The Netherlands. All CTA contributions at arXiv:1508.0589

Creating a high-resolution picture of Cygnus with the Cherenkov Telescope Array

The Cygnus region hosts one of the most remarkable star-forming regions in the Milky Way. Indeed, the total mass in molecular gas of the Cygnus X complex exceeds 10 times the total mass of all other nearby star-forming regions. Surveys at all wavelengths, from radio to gamma-rays, reveal that Cygnus contains such a wealth and variety of sources---supernova remnants (SNRs), pulsars, pulsar wind nebulae (PWNe), H II regions, Wolf-Rayet binaries, OB associations, microquasars, dense molecular clouds and superbubbles---as to practically be a galaxy in microcosm. The gamma-ray observations along reveal a wealth of intriguing sources at energies between 1 GeV and tens of TeV. However, a complete understanding of the physical phenomena producing this gamma-ray emission first requires us to disentangle overlapping sources and reconcile discordant pictures at different energies. This task is made more challenging by the limited angular resolution of instruments such as the Fermi Large Area Telescope, ARGO-YBJ, and HAWC and the limited sensitivity and field of view of current imaging atmospheric Cherenkov telescopes (IACTs). The Cherenkov Telescope Array (CTA), with its improved angular resolution, large field of view, and order of magnitude gain in sensitivity over current IACTs, has the potential to finally create a coherent and well-resolved picture of the Cygnus region between a few tens of GeV and a hundred TeV. We describe a proposed strategy to study the Cygnus region using CTA data, which combines a survey of the whole region at $65^\circ < l < 85^\circ$ and $-3.5^\circ < b < 3.5^\circ$ with deeper observations of two sub-regions that host rich groups of known gamma-ray sources

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

Empagliflozin in Patients with Chronic Kidney Disease

Background The effects of empagliflozin in patients with chronic kidney disease who are at risk for disease progression are not well understood. The EMPA-KIDNEY trial was designed to assess the effects of treatment with empagliflozin in a broad range of such patients. Methods We enrolled patients with chronic kidney disease who had an estimated glomerular filtration rate (eGFR) of at least 20 but less than 45 ml per minute per 1.73 m(2) of body-surface area, or who had an eGFR of at least 45 but less than 90 ml per minute per 1.73 m(2) with a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 200. Patients were randomly assigned to receive empagliflozin (10 mg once daily) or matching placebo. The primary outcome was a composite of progression of kidney disease (defined as end-stage kidney disease, a sustained decrease in eGFR to &lt; 10 ml per minute per 1.73 m(2), a sustained decrease in eGFR of &amp; GE;40% from baseline, or death from renal causes) or death from cardiovascular causes. Results A total of 6609 patients underwent randomization. During a median of 2.0 years of follow-up, progression of kidney disease or death from cardiovascular causes occurred in 432 of 3304 patients (13.1%) in the empagliflozin group and in 558 of 3305 patients (16.9%) in the placebo group (hazard ratio, 0.72; 95% confidence interval [CI], 0.64 to 0.82; P &lt; 0.001). Results were consistent among patients with or without diabetes and across subgroups defined according to eGFR ranges. The rate of hospitalization from any cause was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.86; 95% CI, 0.78 to 0.95; P=0.003), but there were no significant between-group differences with respect to the composite outcome of hospitalization for heart failure or death from cardiovascular causes (which occurred in 4.0% in the empagliflozin group and 4.6% in the placebo group) or death from any cause (in 4.5% and 5.1%, respectively). The rates of serious adverse events were similar in the two groups. Conclusions Among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes than placebo