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

The hydropolitical challenges of domestic water conservation: Palestine and Tunisia case studies

Southern Mediterranean area, particularly the Middle East and North Africa (MENA), has been facing social, economic, environmental and political challenges related to the water scarcity and quality. Within the European SWMED project, a socio-economic survey was conducted in Palestine and Tunisia, in order to explore the water conditions, and the social and economic situations of local families. The article illustrates the research design and implementation, as well as the main results that were used to select the appropriate sustainable water management solutions to respond to the hydropolitical issues. Due to the huge use of water in agriculture and the difficulty of reducing the water consumption in this sector, fostering tools for domestic water saving may be a winning strategy for facing water scarcity in MENA region.Fil: Anzera, Giuseppe. Università degli studi di Roma "La Sapienza"; ItaliaFil: Belotti, Francesca. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Università degli studi di Roma "La Sapienza"; ItaliaFil: Bousselmi, Latifa. Centre des Recherches et des Technologies des Eaux; TúnezFil: Rabi, Ayman. Palestinian Hydrology Group; Palestina (ANP

Adopting Sustainable Water Management Solutions under Social and Climate Change in Med Region: Cases from Palestine and Tunisia

The Southern Mediterranean region and particularly Middle East and North Africa (MENA) region are probably one of those regions that face serious social, economic, environmental and political challenges. Among the most critical challenges are the increasing water scarcity and,thus, demand, resulting mainly from climate change and rapid population growth. Based on United Nations’ estimates in 2006, the population of the region will reach about 255 million inhabitants in 2025, out of which 179 million people will be living in urban centers in this region. The current paper summarizes the main findings of the socioeconomic survey conducted with the aim to collect baseline socio-economic information to be used in selecting the appropriate sustainable water management (SWM) solutions that can be implemented in various settlement typologies in the region, selected in the view of the main results of this survey. Data have shown that both, simple and advanced solutions (such as tools for regulating the water flow, shower diffusers, WC “Water Saving”, wastewater and greywater treatment and reuse systems, rainwater harvesting at household level, etc.), respond sufficiently to the multiple and different needs of the settlement typologies in the region and help them to improve their adaptive capacity toward any potential changes (especially climate and demographic ones)

Article Impact Assessment and Multicriteria Decision Analysis of Alternative Managed Aquifer Recharge Strategies Based on Treated Wastewater in Northern Gaza

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