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

Obreros y movilidad social en Bahía, Brasil

En anteriores trabajos se señala el hecho de que muchos trabajadores cualificados en la gran industria de Bahía son originarios de la pequeña clase media (hijos de pequeños funcionarios públicos, pequeños comerciantes, etc.) que, apremiados por las circunstancias y la percepción de éstas, cambiaron una trayectoria tradicional de ascenso, que pasaba por una educación universitaria, por una trayectoria obrera que requería una carrera técnica (Guimarães, 1988; Guimarães y Agier, 1990). La trayec..

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Los usos de la historia de vida en las ciencias sociales. I

El seminario internacional «El uso de las historias de vida en ciencias sociales: teorías, metodologías y prácticas» tuvo lugar en la ciudad de Villa de Ley va (Colombia) del 17 al 20 de marzo de 1992. Se reunieron investigadores de distintas disciplinas académicas y de varios países de América latina como de Europa y Norteamérica, reconocidos por su trabajo en el uso de las historias de vida. El evento fue organizado por el Centro de Investigaciones sobre Dinámica Social (CIDS) de la Universidad Externado de Colombia. La mayor parte de las ponencias en él presentadas, son recompiladas en dos tomos. Los temas principales abordados son los siguientes: historia oral e historia social; movilidad social, trayectorias laborales y las transformaciones socio-estructurales (primer tomo); identidad de género, espacio privado, espacio público; identidad cultural, valores y representaciones. sociales; tendencias actuales en el uso de las historias de vida (en el segundo). Ante la multiplicación de trabajos que recurren a las historias de vida, en contextos con experiencias más o menos recientes, se manifestó la necesidad de producir una reflexión crítica en torno a sus implicaciones teóricas y metodológicas, sus aportes y limitaciones, dentro de los debates sobre su validez. Pero, más allá y a través de esas discusiones, son retratos en vivo de muchos de los actores de nuestras sociedades contemporáneas que se destacan y se cruzan: hombres y mujeres, pobladores urbanos, campesinos, obreros, colonizadores, indígenas, líderes negros, patronas y. empleadas domésticas, políticos y sindicalistas, guerrilleros, etc. Esos relatos muestran destinos individuales, colectivos, de familias, de generaciones. Traducen también identidades múltiples, en crisis o en recomposición