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

Determinant Factors of Green Marketing Adoption in the Hospitality Sector

Green marketing is falling into the category of answers provided by the business world to the requirement to combine the economic development with the preservation of natural resources which represents a pressing concern of the modern times. In this context, the hospitality sector is facing as well an increasing pressure to pay attention to environmental issues, hotel organizations are increasingly tending to use environmentally friendly products and services, and to implement programs to manage energy and water consumption and waste. The adoption of green marketing in hospitality industry is significantly facilitated by internal and external factors. The paper focuses on the analysis of determinant internal factors: first and foremost on the pro-environmental behavior of the hotel managers and employees, and also on the already implemented green practices in the daily hotel activity. The implementation of green marketing strategies further examined being taken into account the organizational change theory, discloses a third determinant factor, namely, to what extent the process of changing is prepared. This paper is advancing an integrated model of determinant internal factors of green marketing implementation in the hospitality sector. The proposed research model has been tested and validated after analyzing the data collected in a quantitative research conducted on 330 managers and employees from the hospitality industry in Romania. The results show that the three predictors - pro-environmental behavior, current green practices and the change readiness - are having a significant influence on the implementation of green marketing

Neural Networks for Assessment of Flight Deck Human-Automation Interaction Dataset

The files contained in this folder are the basis for the human-automation relationship taxonomy (HART), which has been developed to predict human-automation interaction (HAI). HART attempts to model the human-automation relationship using a multi-dimensional description of the automation itself, the task for which the automation is used, the context in which the automation is used, and the operator. For a more thorough discussion of this approach, please see the two publications listed below.Related publication: K.B. Sullivan, K.M. Feigh, R. Mappus IV, F.T. Durso, U. Fischer, V. Pop, K.L. Mosier, D.G. Morrow, Using neural networks to assess flight deck human–automation interaction, Reliability Engineering & System Safety, Volume 114, December 2012, Pages 26-35, doi:10.1016/j.ress.2012.12.005Related publication: K.L. Mosier, U. Fischer, D.G. Morrow, K.M. Feigh, F.T. Durso, K.B. Sullivan, V. Pop. Automation, Task, and Context Features: Impacts on Pilots’ Judgments of Human–Automation Interaction. Journal of Cognitive Engineering and Decision Making, May 2013 doi:10.1177/1555343413487178The files comprising the simulation are packaged in a zipped file, and they must be extracted before they can be used. Matlab software is required to run some parts of the simulation.United States. Federal Aviation Administratio

Oxime-Bridged Mn₆ Clusters Inserted in One-Dimensional Coordination Polymer

The reaction of MnCl₂·4H₂O with salicylaldoxime (H₂salox) and the sodium salt of 1,3-bis­(carboxy­propyl)­tetramethyl­disiloxane (H₂L) in a 1:1:1 molar ratio led to the self-assembly of {[Mn₆O₂(salox)₆­(H₂salox)­(H₂O)₃(μ-L)]­H₂salox·1.2H₂O}_<i>n</i>, a 1D coordination polymer consisting of hexamanganese­(III) salicylaldoximate cluster as secondary building unit (SBU) and tetramethyl­disiloxane-based dicarboxylate linker, namely, 1,3-bis­(carboxy­propyl)­tetramethyl­disiloxane. The structure of the compound was established by single crystal X-ray diffraction. The Mn­(III) clusters consist of two staggered μ₃-oxo-bridged Mn₃ triangles held together by the oxygen atoms of the oxime groups. Because of Jahn–Teller distortion, the Mn–O distances reach 2.5 Å for the oxygen atoms located above and below the triangles mean planes. The compound showed a glass transition peak at around 14 °C in the differential scanning calorimetry (DSC) curve. The magnetic susceptibility data were fitted with a set of three intracluster antiferromagnetic exchange interaction coupling constants: <i>J</i>₁ = −0.65 cm^–1, <i>J</i>₂ = −1.5 cm^–1, and <i>J</i>₃ = −0.9 cm^–1. The ac magnetic susceptibility measurements in the 2–5 K temperature range reveal a frequency-dependent behavior indicative of a slow relaxation of magnetization at low temperature. The coexistence of the lypophilic 1,3-bis­(propyl)­tetramethyl­disiloxane moieties and hydrophilic polar SBUs confers to the structure an amphiphilic character. Dynamic light scattering (DLS), small-angle X-ray scattering (SAXS), and transmission (TEM) and scanning (SEM) electron microscopies demonstrate that in dimethyl­formamide (DMF) the coordination polymer organizes as micelles, whereas in chloroform it tends to form inverse micelles and vesicles

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London