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

Diversity and Inclusion: Key to Improve Productivity - A Case Study on WIPRO

Diversity is an essential consideration which all employees have to deal with throughout their careers at one stage today. Diversity of the workforce means differences and similarities between people working in an organization. This diversity can be in terms of age, ethnicity, types of cognition, employment, appearance, education, ethnic groups, family background, social status, community, and more. Therefore, people who work in an organization with different demographic backgrounds make a diverse workforce. Diversity and inclusion are the mission, policies, and procedures of an organization to facilitate a diverse workforce and leverage the benefits of diversity to achieve a competitive business advantage. The notion of diversity and inclusion of the workforce gained tremendous popularity with globalization and the need for companies to expand their business internationally to reach consumers worldwide. A diverse workforce is reflecting a changing world and market place. A diverse work environment is the utmost priority at Wipro. Diversity and inclusion play a vital role in organizational sustainability. This study focuses on the analysis of diversity and inclusion practices followed by Wipro to improve productivity

More Optimism about Real-Time Distributed Commit Processing

In [6], we proposed a new commit protocol, OPT, spe-cially designed for use in distributedfirm-deadline real-time database systems. OPT allows transactions to “optimisti-cally ” borrow uncommitted prepared data in a controlled manner: This controlled borrowing reduces the data inac-cessibility and the priority inversion that is inherent in real-rime commit processing. Experimental evaluations showed the new OPTprotocol to be highly successful, as compared to the classical distributed commit protocols, in minimizing the number of missed transaction deadlines. In this paper; we extend and improve upon this prior work in the following ways: First, we consider parallel distributed transactions whereas the previous study was re-stricted to sequential transactions. Second, we evaluate the extent to which OPT’S real-time performance is adversely affected by those cases where its optimism turns out to be misplaced. This is achieved by comparing OPTS perfor-mance with that of Shadow-OPT a protocol that augments OPT with the “shadow transaction ” approach of [3] and ensures that the right decision about access to uncommitted data is always eventually made. In all of our experiments, which considered a wide range of workloads and system configurations, the difference between OPT and Shadow-OPT never exceeded ten percent. Moreover; the difference was reduced to less than two percent when OPT was en-hanced with a simple “healthy lenders ” heuristic. Finally, we compare the pevormance of OPT to that of an alter-native priority inheritance-based approach to addressing priority inversion during commit processing. Our results show that the benefits that prioriv inheritance provides are much smaller than those obtained with the OPT approach. 1

The PROMPT Real-Time Commit Protocol

We investigate the performance implications of providing transaction atomicity for firm-deadline real-time applications operating on distributed data. Using a detailed simulation model, the real-time performance of a representative set of classical transaction commit protocols is evaluated. The experimental results show that data distribution has a significant influence on real-time performance and that the choice of commit protocol clearly affects the magnitude of this influence. We also propose and evaluate a new commit protocol, PROMPT (Permits Reading Of Modified Prepared-data for Timeliness), that is specifically designed for the real-time domain. PROMPT allows transactions to &quot;optimistically&quot; borrow, in a controlled manner, the updated data of transactions currently in their commit phase. This controlled borrowing reduces the data inaccessibility and the priority inversion that is inherent in distributed real-time commit processing. A simulation-based evaluation shows PROMPT to ..

Commit Processing in Distributed Real-Time Database Systems

We investigate here the performance implications of supporting transaction atomicity in a distributed realtime database system. Using a detailed simulation model of a firm-deadline distributed real-time database system, we profile the real-time performance of a representative set of commit protocols. A new commit protocol that is designed for the real-time domain and allows transactions to &quot;optimistically&quot; read uncommitted data is also proposed and evaluated. The experimental results show that data distribution has a significant influence on the real-time performance and that the choice of commit protocol clearly affects the magnitude of this influence. Among the protocols evaluated, the new optimistic commit protocol provides the best performance for a variety of workloads and system configurations. 1. Introduction Many real-time database applications, especially in the areas of communication systems and military systems, are inherently distributed in nature [15]. Incorporating distr..

Darier-White disease in siblings responding to isotretinoin

Darier-White disease (keratosis follicularis) is a rare disorder of keratinization involving the epidermis, mucous membranes, and nails. It is said to occur as a result of mutation in the ATP2A2 gene located on chromosome 12q23-24.1. In this article we present the case of two brothers with exacerbations of Darier-White disease who responded very well to systemic retinoids without any side effects within 2 weeks of commencing treatment

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lower large arterial elasticity index were identified as independent predictors of CVD events. Conclusion: Homocysteine, waist circumference, coronary artery calcification and the large artery elasticity index appear to be the major independent predictors of CVD events in individuals on statins with no pre-existing CVD. In addition to emphasizing weight loss, alternative approaches beyond lipid reduction may need to be explored to better characterize and attenuate the residual risk in subjects on statin therapy for primary prevention