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

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

Security and Privacy in Wireless and Mobile Networks

Currently, at the dawn of 5G networks, and the era of the Internet-of-Things, wireless and mobile networking is becoming increasingly ubiquitous [...

TRIS: A Three-Rings IoT Sentinel to Protect Against Cyber-Threats

The Internet of Things (IoT) is considered as an emerging technology with considerable potentialities. Its paradigm of everything connected together invaded the real world, with smart objects located in several daily appliances able to communicate autonomously through already existing network infrastructures. On the downside, the great advance carried by IoT in our life brings at the same time serious security issues, since the information flow among the objects remains mainly unprotected from malicious attackers. The paper at hand proposes TRIS, a novel sentinel to protect smart environments from cyber threats. Our sentinel shields the IoT devices using three defense rings, resulting in a more accurate protection. Additionally, we discuss the actual deployment of the sentinel using open-source tools. Exhaustive experiments are conducted on the sentinel, showing that the deployed sentinel performs meticulously even in heavily stressing conditions, thus demonstrating the applicability of TRIS in a distributed and dynamic scenario such as IoT.El Internet de las cosas (IoT) se considera una tecnología emergente con potencialidades considerables. Su paradigma de todo conectado entre sí invadió el mundo real, con objetos inteligentes ubicados en varios aparatos cotidianos capaces de comunicarse de forma autónoma a través de infraestructuras de red ya existentes. Como contrapartida, el gran avance que ha supuesto el IoT en nuestra vida trae consigo al mismo tiempo graves problemas de seguridad, ya que el flujo de información entre los objetos queda mayoritariamente desprotegido frente a atacantes malintencionados. El artículo que nos ocupa propone TRIS, un novedoso centinela para proteger los entornos inteligentes de las ciberamenazas. Nuestro centinela protege los dispositivos IoT mediante tres anillos de defensa, lo que da como resultado una protección más precisa. Además, analizamos la implementación real del centinela utilizando herramientas de código abierto. Se llevan a cabo experimentos exhaustivos en el centinela, lo que demuestra que el centinela desplegado funciona meticulosamente incluso en condiciones de mucho estrés, lo que demuestra la aplicabilidad de TRIS en un escenario distribuido y dinámico como IoT

TRIS: A Three-Rings IoT Sentinel to Protect Against Cyber-Threats

The Internet of Things (IoT) is considered as an emerging technology with considerable potentialities. Its paradigm of everything connected together invaded the real world, with smart objects located in several daily appliances able to communicate autonomously through already existing network infrastructures. On the downside, the great advance carried by IoT in our life brings at the same time serious security issues, since the information flow among the objects remains mainly unprotected from malicious attackers. The paper at hand proposes TRIS, a novel sentinel to protect smart environments from cyber threats. Our sentinel shields the IoT devices using three defense rings, resulting in a more accurate protection. Additionally, we discuss the actual deployment of the sentinel using open-source tools. Exhaustive experiments are conducted on the sentinel, showing that the deployed sentinel performs meticulously even in heavily stressing conditions, thus demonstrating the applicability of TRIS in a distributed and dynamic scenario such as IoT.El Internet de las cosas (IoT) se considera una tecnología emergente con potencialidades considerables. Su paradigma de todo conectado entre sí invadió el mundo real, con objetos inteligentes ubicados en varios aparatos cotidianos capaces de comunicarse de forma autónoma a través de infraestructuras de red ya existentes. Como contrapartida, el gran avance que ha supuesto el IoT en nuestra vida trae consigo al mismo tiempo graves problemas de seguridad, ya que el flujo de información entre los objetos queda mayoritariamente desprotegido frente a atacantes malintencionados. El artículo que nos ocupa propone TRIS, un novedoso centinela para proteger los entornos inteligentes de las ciberamenazas. Nuestro centinela protege los dispositivos IoT mediante tres anillos de defensa, lo que da como resultado una protección más precisa. Además, analizamos la implementación real del centinela utilizando herramientas de código abierto. Se llevan a cabo experimentos exhaustivos en el centinela, lo que demuestra que el centinela desplegado funciona meticulosamente incluso en condiciones de mucho estrés, lo que demuestra la aplicabilidad de TRIS en un escenario distribuido y dinámico como IoT