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

Could Targeted Exercise Programmes Prevent Lower Limb Injury in Community Australian Football?

Background Australian football is a popular sport in Australia, at both the community and elite levels. It is a high-speed contact sport with a higher incidence of medically treated injuries when compared with most other organized sports. Hamstring injuries, ligament injuries to the knee or ankle, hip/groin injuries and tendinopathies are particularly common and often result in considerable time lost from sport. Consequently, the prevention of lower limb injuries is a priority for both community and elite Australian football organizations. There is considerable literature available on exercise programmes aimed at reducing lower limb injuries in Australian football and other running-related sports. The quality and outcomes of these studies have varied considerably, but indicate that exercise protocols may be an effective means of preventing lower limb injuries. Despite this, there has been limited high-quality and systematic evaluation of these data. Objective The aim of this literature review is to systematically evaluate the evidence about the benefits of lower limb injury prevention exercise protocols aimed at reducing the most common severe lower limb injuries in Australian football. Methods The Cochrane Central Register of Controlled Trials, the Cochrane Bone Joint and Muscle Trauma Group Specialized Register, MEDLINE and other electronic databases were searched, from January 1990 to December 2010. Papers reporting the results of randomized controlled trials (RCTs), quasi-RCTs, cohort and case-control studies were extracted. Primary outcomes were injury reduction or risk factor identification and/or modification. Secondary outcomes were adherence to any trialled interventions, injury severity and adverse effects such as secondary injuries and muscle soreness. The methodological quality of extracted manuscripts was assessed and results were collated. Results Forty-seven papers were identified and reviewed of which 18 related to hamstring injury, eight related to knee or ankle ligament injury, five related to tendon injury and four were hip or groin injury related. Another 12 papers targeted general lower limb injuries. Most (n = 27 [57 %]) were observational studies, investigating injury risk factors. Twenty reported the results of intervention trials. Of these, 15 were efficacy trials reporting the effects of an intervention in reducing injury rates, four were biomechanical interventions in which the impact of the intervention on a known injury risk factor was assessed and one reported changes in injury risk factors as well as injury rates. The strength of the evidence base for exercise programmes for lower limb injury prevention was found to be limited, primarily due to the research methods employed, low adherence to interventions by the study participants and a lack of statistical power. Limited evidence obtained from a small number of RCTs suggests that balance and control exercises might be efficacious in preventing ankle ligament injuries and a programme involving a combination of balance and control exercises, eccentric hamstring, plyometrics and strength exercises could be efficacious in preventing all lower limb injuries. Conclusions Overall, the evidence for exercise programmes as an efficacious lower limb injury prevention strategy is predominantly restricted to studies addressing injury aetiology and mechanisms. The findings of this review highlight the need to develop and test interventions in well designed population-based trials with an emphasis on promoting intervention uptake and adherence and, hence, intervention effectiveness. The results of this review can inform the development of the components of a future lower limb injury prevention exercise protocol for community-level Australian football.No Full Tex

Dominance style is a key predictor of vocal use and evolution across nonhuman primates

Animal communication has long been thought to be subject to pressures and constraints associated with social relationships. However, our understanding of how the nature and quality of social relationships relates to the use and evolution of communication is limited by a lack of directly comparable methods across multiple levels of analysis. Here, we analysed observational data from 111 wild groups belonging to 26 non-human primate species, to test how vocal communication relates to dominance style (the strictness with which a dominance hierarchy is enforced, ranging from ‘despotic’ to ‘tolerant’). At the individual-level, we found that dominant individuals who were more tolerant vocalized at a higher rate than their despotic counterparts. This indicates that tolerance within a relationship may place pressure on the dominant partner to communicate more during social interactions. At the species-level, however, despotic species exhibited a larger repertoire of hierarchyrelated vocalizations than their tolerant counterparts. Findings suggest primate signals are used and evolve in tandem with the nature of interactions that characterize individuals’ social relationships.https://royalsocietypublishing.org/journal/rsosMammal Research Institut

Dominance style is a key predictor of vocal use and evolution across nonhuman primates

Animal communication has long been thought to be subject to pressures and constraints associated with social relationships. However, our understanding of how the nature and quality of social relationships relates to the use and evolution of communication is limited by a lack of directly comparable methods across multiple levels of analysis. Here, we analysed observational data from 111 wild groups belonging to 26 non-human primate species, to test how vocal communication relates to dominance style (the strictness with which a dominance hierarchy is enforced, ranging from ‘despotic’ to ‘tolerant’). At the individual-level, we found that dominant individuals who were more tolerant vocalized at a higher rate than their despotic counterparts. This indicates that tolerance within a relationship may place pressure on the dominant partner to communicate more during social interactions. At the species-level, however, despotic species exhibited a larger repertoire of hierarchy-related vocalizations than their tolerant counterparts. Findings suggest primate signals are used and evolve in tandem with the nature of interactions that characterize individuals' social relationships

Evolution of Multilevel Social Systems in Nonhuman Primates and Humans

Multilevel (or modular) societies are a distinct type of primate social system whose key features are single-male–multifemale, core units nested within larger social bands. They are not equivalent to fission–fusion societies, with the latter referring to routine variability in associations, either on an individual or subunit level. The purpose of this review is to characterize and operationalize multilevel societies and to outline their putative evolutionary origins. Multilevel societies are prevalent in three primate clades: papionins, Asian colobines, and hominins. For each clade, we portray the most parsimonious phylogenetic pathway leading to a modular system and then review and discuss likely socioecological conditions promoting the establishment and maintenance of these societies. The multilevel system in colobines (most notably Rhinopithecus and Nasalis) has likely evolved as single-male harem systems coalesced, whereas the multilevel system of papionins (Papio hamadryas, Theropithecus gelada) and hominins most likely arose as multimale–multifemale groups split into smaller units. We hypothesize that, although ecological conditions acted as preconditions for the origin of multilevel systems in all three clades, a potentially important catalyst was intraspecific social threat, predominantly bachelor threat in colobines and female coercion/infanticide in papionins and humans. We emphasize that female transfers within bands or genetic relationships among leader males help to maintain modular societies by facilitating interunit tolerance. We still lack a good or even basic understanding of many facets of multilevel sociality. Key remaining questions are how the genetic structure of a multilevel society matches the observed social effort of its members, to what degree cooperation of males of different units is manifest and contributes to band cohesion, and how group coordination, communication, and decision making are achieved. Affiliative and cooperative interunit relations are a hallmark of human societies, and studying the precursors of intergroup pacification in other multilevel primates may provide insights into the evolution of human uniqueness