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

Tomada de decisão de controle da traça-do-tomateiro através de armadilhas com feromônio sexual Decision making for integrated pest management of the South American tomato pinworm based on sexual pheromone traps

Visou-se estabelecer a relação entre a infestação da traça-do-tomateiro, Tuta absoluta, na planta e adultos capturados em armadilhas com feromônio sexual e a produtividade, para avaliar a influência da infestação na produção da cultura do tomate e aperfeiçoar a tomada de decisão de controle pela densidade de adultos. Armadilhas com feromônio sexual foram instaladas e avaliadas duas vezes por semana, em três áreas de cultivo comercial de tomateiro em São Paulo (Mogi-Guaçu, Tambaú e Sorocaba), em sistema estaqueado, divididas em áreas experimentais com cerca de 18.000 plantas cada (1,5 ha). Nas mesmas datas foi avaliada a infestação de pragas nas plantas, estendendo-se até o término da colheita. A produtividade foi definida pelo total de caixas (24 kg) comercializadas/1.000 plantas. A relação entre a produção da cultura do tomate e a infestação de T. absoluta na planta ou nas armadilhas com feromônio foi expressa por uma equação linear e negativa. A ocorrência de adultos nas armadilhas e a infestação da praga em plantas foram relacionados significativamente com a redução da produtividade. O nível de controle de T. absoluta através do monitoramento com feromônio sexual foi de 45 &plusmn; 19,50 insetos/dia na armadilha.<br>The relationship between the productivity and the infestation of Tuta absoluta on tomato plants and adults caught in sexual pheromone traps was established to evaluate the effect of pest infestation on yield losses as well as on adults' density for decision-making improvement. Sexual pheromone traps were installed in three commercial fields of tomato in São Paulo State, Brazil (Mogi Guaçu, Tambaú and Sorocaba counties) with experimental plots of 18,000 plants each (1.5 ha). The presence of insects in the traps as well as the infestation on plants were evaluated twice a week on the same dates. The evaluations took place until harvesting. The productivity was expressed as marketable boxes of 24 kg/1000 plants. The relationship between tomato production and pest infestation on plants or pheromone traps was linear and negative. The adults' occurrence on traps and plant infestation showed an influence on yield losses. The action level of T. absoluta with sexual pheromone traps was 45 &plusmn; 19.50 insects daily

Estimated GFR and the Effect of Intensive Blood Pressure Lowering after Acute Intracerebral Hemorrhage

Background: The kidney-brain interaction has been a topic of growing interest. Past studies of the effect of kidney function on intracerebral hemorrhage (ICH) outcomes have yielded inconsistent findings. Although the second, main phase of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) suggests the effectiveness of early intensive blood pressure (BP) lowering in improving functional recovery after ICH, the balance of potential benefits and harms of this treatment in those with decreased kidney function remains uncertain. Study Design: Secondary analysis of INTERACT2, which randomly assigned patients with ICH with elevated systolic BP (SBP) to intensive (target SBP &lt; 140 mm Hg) or contemporaneous guideline-based (target SBP &lt; 180 mm Hg) BP management. Setting &amp; Participants: 2,823 patients from 144 clinical hospitals in 21 countries. Predictors Admission estimated glomerular filtration rates (eGFRs) of patients were categorized into 3 groups based on the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine equation: normal or high, mildly decreased, and moderately to severely decreased (&gt;90, 60-90, and &lt;60 mL/min/1.73 m2, respectively). Outcomes: The effect of admission eGFR on the primary outcome of death or major disability at 90 days (defined as modified Rankin Scale scores of 3-6) was analyzed using a multivariable logistic regression model. Potential effect modification of intensive BP lowering treatment by admission eGFR was assessed by interaction terms. Results: Of 2,623 included participants, 912 (35%) and 280 (11%) had mildly and moderately/severely decreased eGFRs, respectively. Patients with moderately/severely decreased eGFRs had the greatest risk for death or major disability at 90 days (adjusted OR, 1.82; 95% CI, 1.28-2.61). Effects of early intensive BP lowering were consistent across different eGFRs (P = 0.5 for homogeneity). Limitations: Generalizability issues arising from a clinical trial population. Conclusions: Decreased eGFR predicts poor outcome in acute ICH. Early intensive BP lowering provides similar treatment effects in patients with ICH with decreased eGFRs