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

Pulmonary artery catheter induced pulmonary haemorrhage

Since its introduction three decades ago, the pulmonary artery (PA) catheter has brought insights into pathophysiology of many diseases enabling intensivists to treat critical conditions much more precisely and securely. PA indications are widening, and those working in an intensive care environment feel more secure in handling critical conditions with objective data. However, PA-induced pulmonary haemorrhage is a well-recognised, uncommon, yet potentially lethal, complication of PA catheter. We report a case with PA haemorrhage induced by placement of the PA catheter during coronary artery bypass surgery. A contrast-enhanced CT scan of the chest confirmed spontaneous remission of the haemorrhage after 7 weeks of the injury without the need for any intervention

Secure Cloud-Mediator Architecture for Mobile-Government using RBAC and DUKPT

Smart mobile devices and cloud computing are widely used today. While mobile and portable devices have different capabilities, architectures, operating systems, and communication channels than one another, government data are distributed over heterogeneous systems. This paper proposes a 3-tier mediation framework providing single application to manage all governmental services. The framework is based on private cloud computing for adapting the content of Mobile-Government (M-Government) services using Role-Based Access Control (RBAC) and Derive Unique Key Per Transaction (DUKPT). The 3-layers in the framework are: presence, integration, and homogenization. The presence layer is responsible for adapting the content with regard to four contexts: device, personal, location, and connectivity contexts. The integration layer, which is hosted in a private cloud server, is responsible for integrating heterogeneous data sources. The homogenization layer is responsible for converting data into XML format. The flexibility of the mediation and XML provides an adaptive environment to stream data based on the capabilities of the device that sends the query to the system.</p

Adult multisystem inflammatory syndrome in a patient who recovered from COVID-19 postvaccination

Multisystem inflammatory syndrome in children has become a recognised syndrome, whereas a parallel syndrome in adults, multisystem inflammatory syndrome in adults (MIS-A), has not been well defined. Most cases occur several weeks following confirmed or suspected SARS-CoV-2 infection, but none have been reported in association with SARS-CoV-2 vaccines. Here we describe the case of a 22-year-old man, who received the inactivated SARS-CoV-2 vaccine 6 weeks following a mild COVID-19 infection. He presented after his second dose of the vaccine with a clinical picture of a multisystem inflammatory syndrome-like illness. Additionally, there was laboratory evidence of acute inflammation. The patient’s condition markedly improved after initiation of steroids. Whether the vaccine augmented an already-primed immunity from the infection and contributed to the occurrence of MIS-A is difficult to prove. Understanding the pathogenesis of this condition will shed light on this question and entail major implications on treatment and prevention

Efficacy of the Immobilized Kocuria flava Lipase on Fe3O4/Cellulose Nanocomposite for Biodiesel Production from Cooking Oil Wastes

The increasing global demand for petroleum oils has led to a significant increase in their cost and has led to the search for renewable alternative waste resources for biodiesel synthesis and production using novel environmentally sound and acceptable methods. In the current study, Kocuria flava lipase was immobilized on Fe3O4/cellulose nanocomposite; and used as a biocatalyst for the conversion of cooking oil wastes into biodiesel through the transesterification/esterification process. The characterization of Fe3O4/cellulose nanocomposite revealed several functional groups including carboxyl (C=O) and epoxy (C-O-C) groups that act as multipoint covalent binding sites between the lipase and the Fe3O4/cellulose nanocomposite and consequently increasing lipase immobility and stability. The immobilized lipase showed a high thermo-stability as it retained about 70% of its activity at 80 &deg;C after 30 min. The kinetics of immobilized lipase revealed that the Km and Vmax values were 0.02 mM and 32.47 U/mg protein, respectively. Moreover, the immobilized lipase showed high stability and reusability for transesterification/esterification reactions for up to four cycles with a slight decline in the enzyme activity. Furthermore, the produced biodiesel characteristics were compatible with the standards, indicating that the biodiesel obtained is doable and may be utilized in our daily life as a diesel fuel

Efficacy of the Immobilized <i>Kocuria flava</i> Lipase on Fe₃O₄/Cellulose Nanocomposite for Biodiesel Production from Cooking Oil Wastes

The increasing global demand for petroleum oils has led to a significant increase in their cost and has led to the search for renewable alternative waste resources for biodiesel synthesis and production using novel environmentally sound and acceptable methods. In the current study, Kocuria flava lipase was immobilized on Fe3O4/cellulose nanocomposite; and used as a biocatalyst for the conversion of cooking oil wastes into biodiesel through the transesterification/esterification process. The characterization of Fe3O4/cellulose nanocomposite revealed several functional groups including carboxyl (C=O) and epoxy (C-O-C) groups that act as multipoint covalent binding sites between the lipase and the Fe3O4/cellulose nanocomposite and consequently increasing lipase immobility and stability. The immobilized lipase showed a high thermo-stability as it retained about 70% of its activity at 80 °C after 30 min. The kinetics of immobilized lipase revealed that the Km and Vmax values were 0.02 mM and 32.47 U/mg protein, respectively. Moreover, the immobilized lipase showed high stability and reusability for transesterification/esterification reactions for up to four cycles with a slight decline in the enzyme activity. Furthermore, the produced biodiesel characteristics were compatible with the standards, indicating that the biodiesel obtained is doable and may be utilized in our daily life as a diesel fuel