Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

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 middle-income 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 low-income 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 low-income, 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

Guidelines for the use and interpretation of assays for monitoring autophagy (4th edition)1.

In 2008, we published the first set of guidelines for standardizing research in autophagy. Since then, this topic has received increasing attention, and many scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Thus, it is important to formulate on a regular basis updated guidelines for monitoring autophagy in different organisms. Despite numerous reviews, there continues to be confusion regarding acceptable methods to evaluate autophagy, especially in multicellular eukaryotes. Here, we present a set of guidelines for investigators to select and interpret methods to examine autophagy and related processes, and for reviewers to provide realistic and reasonable critiques of reports that are focused on these processes. These guidelines are not meant to be a dogmatic set of rules, because the appropriateness of any assay largely depends on the question being asked and the system being used. Moreover, no individual assay is perfect for every situation, calling for the use of multiple techniques to properly monitor autophagy in each experimental setting. Finally, several core components of the autophagy machinery have been implicated in distinct autophagic processes (canonical and noncanonical autophagy), implying that genetic approaches to block autophagy should rely on targeting two or more autophagy-related genes that ideally participate in distinct steps of the pathway. Along similar lines, because multiple proteins involved in autophagy also regulate other cellular pathways including apoptosis, not all of them can be used as a specific marker for bona fide autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field

Global variation in diabetes diagnosis and prevalence based on fasting glucose and hemoglobin A1c

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29–39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance

Benefícios de um programa de educação postural para alunos de uma escola municipal de Garibaldi, RS Benefits of a posture education program for schoolchildren in the city of Garibaldi, RS

A fisioterapia tem importante papel no meio escolar, pois estudantes desenvolvem maus hábitos e alteraç��es posturais que, a longo prazo, podem gerar restrição funcional. O objetivo deste estudo foi analisar os efeitos de um programa de educação postural em estudantes do ensino fundamental da cidade de Garibaldi, RS. Participaram 48 alunos com idade entre 8 e 10 anos, que responderam um questionário sobre hábitos posturais e foram submetidos à avaliação de peso, modelo e modo de transporte da mochila antes e após uma sessão educativa; quatro semanas mais tarde foi feita uma reavaliação. Os pais participaram do estudo respondendo um questionário sobre a postura dos filhos. Quanto aos hábitos escolares, constatou-se mudança positiva na adoção de postura adequada dos pés na posição sentada (p=0,001); e, nas atividades de vida diária, mudanças na posição ao ver televisão (p<0,0001), dormir (p=0,019), pegar objetos no chão (p<0,0001) e costume de ler e/ou escrever na cama (p=0,002). Em relação ao peso da mochila obteve-se redução significativa após a intervenção (p=0,002), enquanto no modelo e modo de transporte não houve diferença. Segundo os pais, os filhos têm bons hábitos de postura e costumam utilizá-los no dia-a-dia. Concluiu-se que a realização de uma sessão de educação postural para alunos promoveu o conhecimento de hábitos posturais saudáveis e modificação de algumas posturas, mas não se pode afirmar que provocou mudanças nos hábitos posturais.<br>Physical therapy plays an important role in school, as students develop bad habits and postural dysfunctions which may generate long-term functional restrictions. The aim of this study was to analyse the effects of an educational program on students' posture in Garibaldi, RS. Forty-eight 8-to-10 year-old schoolchildren filled up a questionnaire about postural habits and had their knapsacks assessed as to weight, type and carrying mode, before and after an educational session; a further assessment was made four weeks later. Parents participated by answering a questionnaire on children's posture. Results showed positive changes in feet posture in the sitting position (p=0.001); in daily living activities, better postures or habits were found while watching television (p<0.0001), sleeping (p=0.019), getting objects from the ground (p<0.0001), and reading and/or writing in bed (p=0.002). As to knapsack weight, a significant decrease (p=0,002) was noticed after the session, while neither the model or mode of transport changed. Parents answered that their children have good postural habits and keep them on a regular basis. It may thus be said that one session of postural educational program for schoolchildren resulted in better knowledge on healthy postural behaviour and modified some postures, but one can't say it brought about changes in postural habits

O peso do baço em chagásicos crônicos Weight of the spleen in chronic chagasic patients

O baço pode aumentar de tamanho nas inflamações com repercussões sistêmicas e na congestão venosa crônica, denominando-se respectivamente, hiperplasia reacional e esplenomegalia congestiva. Sendo a doença de Chagas uma doença infecciosa com repercussões hemodinâmicas, possivelmente o baço responda não só ao envolvimento cardíaco, como também ao processo inflamatório. O objetivo deste trabalho é avaliar comparativamente o peso do baço em chagásicos ou não-chagásicos, com ou sem insuficiência cardíaca congestiva (ICC). Em estudo retrospectivo foram coletados nos protocolos de necropsias de adultos, a idade, o sexo, a cor e o peso do baço. Os 88 casos selecionados foram divididos em quatro grupos: 1) chagásicos com ICC, 2) chagásicos sem ICC, 3) não-chagásicos com ICC e 4) não-chagásicos sem ICC. A idade média foi 44,9 ± 15,4 anos, sendo 53,4% brancos e 70,5% do sexo masculino, não havendo diferença significante destas variáveis entre os grupos. O peso do baço nos grupos com ICC foi de 183,7 ± 85,9g para os chagásicos e de 206,3 ± 101,0g para os não-chagásicos. Nos grupos sem ICC o peso foi de 173,7 ± 118,9g para os chagásicos e de 117,2 ± 52,0g para os não-chagásicos. O peso foi significantemente maior nos chagásicos sem ICC quando comparados aos não-chagásicos sem ICC. Estes resultados sugerem que o componente inflamatório na doença de Chagas desempenharia papel importante no aumento do peso do baço, associado às alterações hemodinâmicas decorrentes da ICC.<br>During the course of systemic inflammatory reactions and chronic venous congestion, the documented phenomenon of increased spleen size is respectively called reactional hyperplasia and congestive splenomegaly. In Chagas' disease, the inflammatory process observed in the heart of chronically infected patients can result in heart failure and ultimately in congestive failure. In order to evaluate the spleen response to both inflammatory and cardiac processes, in this retrospective study we compare the weight of spleens from normal and chagasic patients, with or without congestive failure. Information about patient age, sex, race and spleen weight was collected from autopsy reports. Eighty-eight selected cases were divided into four groups: 1) chagasic patients with congestive failure, 2) chagasic patients without congestive failure, 3) non-chagasic patients with congestive failure, 4) non-chagasic patients without congestive failure. The average age was 44.9 ± 15.4 years, 53.4% were Caucasians and 70.5% were males, and no significant difference in these parameters was observed between the four groups. The spleen weight for the groups presenting congestive failure was 183.7 ± 85.9g for chagasic and 206.3 ± 101.0g for non-chagasic patients; for the groups without congestive failure the average spleen weight was 173.7 ± 118.9g for the chagasic and 117.2 ± 52.0g for non-chagasic patients. The spleen weight was significantly higher for the chagasic patients without congestive failure when compared to the non-chagasic group without congestive failure. These results suggest that the inflammatory component in Chagas' disease plays an important role in the increase of spleen weight together with hemodynamic alterations arising from congestive heart failure