A new linear genetic programming approach based on straight line programs: Some theoretical and experimental aspects

Tree encodings of programs are well known for their representative power and are used very often in Genetic Programming. In this paper we experiment with a new data structure, named straight line program (slp), to represent computer programs. The main features of this structure are described, new recombination operators for GP related to slp's are introduced and a study of the Vapnik-Chervonenkis dimension of families of slp's is done. Experiments have been performed on symbolic regression problems. Results are encouraging and suggest that the GP approach based on slp's consistently outperforms conventional GP based on tree structured representation

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Anales de Edafología y Agrobiología Tomo 39 Número 1-6

Suelos. Entisoles sobre materiales carbonatados en clima mediterráneo de la provincia de Castellón de la Plana, por R. Jiménez Ballesta y A. Guerra.-- Inceptisoles sobre materiales carbonatados en clima mediterráneo de la provincia de Castellón de la Plana, por R. Jiménez Ballesta y A. Guerra.-- Suelos fersialíticos sobre cenizas volcánicas. III.. Características micromorfológicas. Interpretación y clasificación, por A. Rodríguez Rodríguez, N. Fedoroff, M. L. Tejedor Salguero y E. Fernández Caldas.-- Características micromorfológicas de los suelos de una climatosecuencia de la vertiente meridional de la isla de Tenerife, por J. Benayas, E. Fernández Caldas, M. L. Tejedor Salguero y A. Rodríguez Rodríguez.-- Génesis y micromorfología de los suelos salinos de las marismas del Guadalquivir (sur de España), por Juan de Olmedo Pujol.-- Los suelos halomorfos de la provincia de Granada. l. Características generales y vegetación, por M. Simón, O. Socorro y J. Aguilar.-- Los suelos halomorfos de la provincia de Granada. 11. Características morfológicas, por M. Simón, J. Aguilar y C. Sierra.-- Los suelos halomorfos de la provincia de Granada. III. Sales solubles y conductividad, por M. Simón, J. Aguilar y C. Sierra.-- Estudio de la adsorción e intercambio de cinc por arcillas, por T. Hernández, l. Tovar y A. Lax.-- La humificación en las etapas de sustitución del bosque climácico en La Pedriza del Manzanares (Madrid), por F. Velasco y J. del Río.-- Fertilidad de suelos. Salinity of saline alkaline soils in the romanian plain as influenced by complex reclamatlon and cultivat10n works, por Sandu, Gh., E. Jacob, Elisabeta lspas y María Dracea.-- Enzimas proteolíticos y bacteriológicos extracelulares producidos por mixococus xanthus, por C. Rodríguez y E. Montoya.-- Primeros resultados de unos experimentos de aplicación de lodos de clarificación en un bosque de picea abies y en una plantación de pinus silvestris en Alemania, por L. Aguinagalde y R. Hüser.-- Influencia del tiempo de equilibrio sobre las relaciones Q/I de potasio en suelos y arcillas, por M. C. Bolarin, M. Caro, G. Fernández y M. Romer.-- Infuencia de la concentración de calcio en la disoluciónsobre los parámetros Q/I de potasio, por M. C. Bolarin, F. C. Fernández, M. Caro, y M. Romero.—Nutrición y Fisiología Vegetal.-- Diagnóstico precoz de la r.utrición fosfórica en la remolacha azucarera mediante el análisis de savia, por l. Bonilla, C. Cadahia, O. Carpena yV. Hernando.-- Incidencia del K sobre el rendimiento y calidad de la remolacha azucarera, por J. Bonilla, C. Cadahia, M. T. Piñero y V. Hernando.- Efecto de bacterias productoras de etileno sobre el crecimiento de las plantas y germinación de quistes de "azotobácter", por D. N. Rodríguez Navarro y J. M. Barea Navarro.-- Producción, composición química y valor nutritivo de comunidades típicas de pastizal salmantino, por Alfonso Escudero Berian, Angel Puerto Martín, Balbino García Criado y Luis García Criado.-- Crecimiento y producción primaria en cultivares de los géneros, trifólium, lólium, medicago, dactylis y festuca, por L. García Criado, B. García Criado y J. M. Gómez Gutiérrez.-- Estudio armónico y estadístico de la radiación solar glohal en Salamanca, por M. Egido, J. M. Yuste, J. Garmendia y J. Seco.-- Nota Metodológica.-- Programa de ordenador para automatizar la aplicación de un sistema de evaluación de suelos, por D. de la Rosa y J. Almorza.--Trabajos recapitualtivos.-- La presencia de gibbsita en suelos de climas templados: una revisión de los conocimientos actuales, por F. Macías Vazquez y Guitián Ojea.-- El enzima indolacético-oxidasa de los vegetales, por L. Catalina, V. Valpuesta y R. Sarmiento. Micorrizas V A. I. Características generales, por J. A. Ocampo.-- Notas.-- Bibliografía.-- Suelos. Caracterización de suelos del Sistema Central. I. Paleustals, por A. Hoyos de Castro, J. Hernando Costa, M. J. Cuchi Ruiz y J. A. Egido Rodríguez.-- Suelos fersialíticos sobre materiales volcánicos. Ultisoles, por A. Rodríguez Rodríguez, M. L. Tejedor Salguero y E. Fernández-Caldas.-- Suelos de la zona húmeda española. X. Suelos sobre serpentinas, por F. Guitián Ojea y M. J. López López.-- La fracción arcilla de suelos de alta montaña sobre rocas carbonatadas. I. Entisoles e Histosoles, por L. J. Alías y J. Hernández.-- Los suelos halomorfos de la provincia de Granada. IV. Estudio mineralógico, por M. Simón, J. Aguilar y C. Dorronsoro.-- Los suelos halomorfos de la provincia de Granada. V. Estudio micromorfológico, por M. Simón y J. Aguilar.-- Molisoles sobre materiales carbonatados en clima mediterráneo de la provincia de Castellón de la Plana, por R. Jiménez Ballesta y A. Guerra.-- Alfisoles sobre materiales carbonatados en clima mediterráneo de la provincia de Castellón de la Plana, por R. Jiménez Ballesta y A. Guerra.-- Suelos formados sobre materiales volcánicos (Islas Canarias) intergrado fersialftico-vértico. I. Características morfológicas, físico-químicas y mineralógias. Interpretación y clasificación, por p. Rodríguez Pascual, E. Fernandez-Caldas y C. M. Rodríguez Hernandez.-- Estudio comparativo de la micromorfología y porosidad caracterizada con imágenes óptico-electrónicas en suelos de olivar (provincia de Jaén), por J. Benayas y F. Serrano Comino.-- Discrimination of soil associations using clustering techniques, por J. L. Labrandera y F. Palou.-- Propiedades físicas y químicas en relación con la porosidad de los suelos: influencia del ciclo natural de humectación-desecación. IV. Hinchamiento y contracción, por J. Martín Aranda, J. L. Arrúe Ugarte y F. Moreno.-- Algunas propiedades espectrales del humus en relación a grades grupos de suelos, por Elba Panuska y Ramón A. Rosell.-- Unidades naturales de la provincia de Guadalajara, por J. L. Labrandera. Fertilidad de suelos.-- Caracteres físicos y balance hídrico de suelos de la zona cerealistica de la cuenca del Duero, por S. Cuadrado Sánchez y A. Blanco de Pablos.-- Estudio de las transformaciones en la fracción humificada de una turba sometida a diversos tratamientos químicos. Acción de tratamientos ácidos, por C. Ortega y R. García.-- Relación entre los parámetros Q/I de potasio y otras propiedades del suelo en Aridisoles del Sureste español, por L. J. Alias, M. C. Bolarín, M. Caro y F. G. Fernández.-- Parámetros Q/I de potasio y su relación con otras propiedades del suelo en Entisoles del Sureste español, por L. J. Alias, M. C. Bolarín, F. G. Fernández y M. Caro.-- Relaciones Q/I de potasio en Mollisoles del Sureste español, por L. J. Alias, M. C. Bolarín, M. Caro y F. G. Fernández.-- Relaciones entre los parámetros Q/I de potasio y otras propiedades del suelo en Inceptisoles del Sureste español, por L. J. Alias, M. C. Bolarín, F. G. Fernánaez y M. Caro.-- Variaciones del número de Rhizobium meliloti nativo y de otros microorganismos en un suelo franco arenoso, por M. A. Sagardoy.-- Interacción de pesticidas organofosforados con montmorillonita. III. Dimetoato, por M. Sánchez Camazano y M. J. Sánchez Martín.—Nutrición y Fisiología Vegetal.-- Estudio y uso de los polietilenglicoles en experimentos con plantas, por Mª P. Sánchez Conde y P. Azuara.-- La caida de presión como índice de revisión de lluvia, por J. Seco, A. Calvo, J. Iglesias, M. Guijo, M. Egido y J. Mateos.-- The global solar radiation and the surface-temperature, por J. Seco, A. Calvo, M. Egido, J. Mateos y J.Garmendía.—Notas.—Bibliografía. Suelos. Caracterización de suelos del Sistema Central. II. Umbrepts, por A. Hoyos de Castro, J. Hernando Costa, M. J. Cuchi Ruiz y J. A. Egido Rodríguez.-- Caracterización de suelos del Sistema Central. III. Umbrepts (con carácter espódico), por A. Hoyos de Castro, J. Hernando Costa, M. J. Cuchi Ruiz y J. A. Egido Rodríguez.-- Caracterización de suelos del Sistema Central. IV. Dystrochrepts, por A. Hoyos de Castro, J. Hernando Costa, M. J. Cuchi Ruiz y J. A. Egldo Rodríguez.-- Estudio de materiales caoliníticos de Sierra Morena occidental. IV. Estudio mineralógico y genético de los yacimientos de Almonaster la Real (Huelva), Cazalla de la Sierra (Sevilla) y Conquista (Córdoba), originados por alteración de rocas intrusivas,_por J. Poyato Ferrera, J. L. Pérez Rodríguez, J. M.a Mesa López-Colmenar y F. Gónzalez García-- Análisis digital de datos landsat aplicado al reconocimiento de suelos: método supervisado, por J. L. Labrandera, A. Guerra y F. Palou.-- Análisis digital de datos landsat aplicado al reconocimiento de suelos: método no supervisado, por J. L. Labrandera, A. Guerra y F. Palou. Aspectos morfologicos y mmeralógicos de alteración de rocas en suelos de Sierra de Francia (Salamanca), por C. Espino y G. Paneque.-- Estudio edafológico de la Sierra del Pinar, Grazalema (Cádiz). l. Factores ecológicos (geología, vegetación y clima), por L. Corral, N. Bellinfante y G. Paneque.-- Estudio edafológico de la Sierra del Pinar, Grazalema (Cádiz). 11. Suelos poco evolucionados: datos del medio, descripción de perfiles y datos analíticos, por L. Corral, N. Bellinfante y G. Paneque.-- Características electroquímicas de andosoles. l. Punto cero de carga. Método potenciométrico, por E. Fernandez Caldas, A. González Batista y J.M. Hernández Moreno. Caracterfsticas electroqufmicas de andosoles. II. Punto cero de carga y retención iónica, por A. Gónzalez Batista, J. M. Hernández Moreno y E. Fernández Caldas.-- Complejos organometálicos en microagregados de un dystrochrept úmbrico, por S. Gónzalez Carcedo y M. A. Fuente Marcos.-- Bentonitas para la industria de la fundición. l. Análisis térmico, superficie especffica y espectroscopia de absorción infrarroja, por A. Bilbao, C. Vizcayno y C. Rodríguez Pascual.-- Caracterfsticas micromorfológicas de podsoles y suelos podsólicos de la zona húmeda española, por F. Macías Vázquez.-- Interpretación de una imagen landsat en el sistema Erman-11, por J. L. Labrandera, A. Guerra y F. Palou.—Fertilidad de suelos.-- Estudios de relación suelo planta en los cultivos de plátanos de la isla de La Palma (Islas Canarias), por J. J. Bravo, V. García, A. Díaz y C. E. Alvarez.-- Utilización de diferentes residuos de leguminosas como abono verde. l. Efecto sobre los nutrientes N, P, S, por F. Gallardo-Lara, B. Vitorino, M. Azcón y J. A. Ocampo.-- Capacidad de adsorción de Cu y Zn de suelos desarrollados bajo tres tipos de vegetación. I., por l. Trujillo Jacinto del Castillo, A. Borges Perez y F. Gutiérrez Jerez.-- Estudio de la adsorción de Cu y Zn en andosoles de las Islas Canarias. II, por A. Borges Pérez, l. Trujillo Jacinto del Castillo, J. A. Pérez Méndez y F. Gutiérrez Jerez.-- Estudio de la distribución y dinámica de los micronutrientes .Cu y Zn en andosoles de las Islas Canarias. III por A. Borges Pérez, l. Trujillo, Jacinto del Castillo, F. Gutiérrez Jerez y J. A. Pérez Méndez.—Nutrición y Fisiología Vegetal.-- Cambios estructurales observados en plantas de tomate (lycopersicum escelentum, mili. var. margoble) crecidas en solución nutritiva contemendo PEG-4.000, por M. R. de Felipe Anton y P. Azuara.-- Evaluación de los efectos del medio nutritivo con bajo contenido en calcio sobre la planta de lechuga, por Mª P. Sánchez Conde.-- Estudio de los sfntomas de absorción de PEG en plantas de mafz, por Mª P. Sánchez Conde y P. Azuara.-- Distribución de nutrientes en plantas de lechuga sometidas a diferentes concentraciones de magnesio, por Mª P. Sánchez Conde y P. Azuara.-- Variaciones en el contenido de mcotina en plantas de nicotina rústica L. sometidas a irradiaciones de ultravioleta lejano y cercano, por J. Baztán y J. Barceló.-- Composición mineral de la planta de fresa en diferentes épocas del ciclo, por J. Mª Martín del Molino y J. A. Rosón Riestra.—Nota previa.-- Organo-metallic complexes in atlantic humiferous soils, por M. Carballas, A. Cabaneiro, F. Guitián-Ribera y T. Carballas.—Nota metodologíca. Programa de ordenador ¡ara elaborar tablas de datos analfticos de suelos por D. de la Rosa, Cardona y J. Almorza.—Trabajo recapitulativos.-- Micorrizas V A. II. Efecto sobre el crecimiento de las plantas, por J. A. Ocampo.-- Micorrizas V A. III. Ecología, por J. A. Ocampo.-- Notas.—Bibliografía.Peer reviewed2019-08.- CopyBook.- Libnova.- Biblioteca IC

The database of the PREDICTS (Projecting Responses of Ecological Diversity In Changing Terrestrial Systems) project

The PREDICTS project—Projecting Responses of Ecological Diversity In Changing Terrestrial Systems (www.predicts.org.uk)—has collated from published studies a large, reasonably representative database of comparable samples of biodiversity from multiple sites that differ in the nature or intensity of human impacts relating to land use. We have used this evidence base to develop global and regional statistical models of how local biodiversity responds to these measures. We describe and make freely available this 2016 release of the database, containing more than 3.2 million records sampled at over 26,000 locations and representing over 47,000 species. We outline how the database can help in answering a range of questions in ecology and conservation biology. To our knowledge, this is the largest and most geographically and taxonomically representative database of spatial comparisons of biodiversity that has been collated to date; it will be useful to researchers and international efforts wishing to model and understand the global status of biodiversity

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)