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

Detecting ontogenetic stages of the palm Attalea humilis in fragments of the Brazilian Atlantic forest

A study of the ontogenetic stages of the acaulescent palm Attalea humilis Mart. ex. Spreng was conducted in three fragments (1.6, 6.4, and 9.9 ha) of the Atlantic forest in southeastern Brazil. The fragments were damaged by fire during the study period (1996-1999). External macromorphology and quantitative measures of leaf number and length of the newest leaf's rachis allowed the distinction of five ontogenetic stages. Seedlings were attached to buried fruit remains and presented entire leaves. Juveniles possessed incomplete segmentation of the blade. Pinnatifid-leafed, non-reproducing individuals were morphometrically divided in two groups: immature, with fewer leaves and smaller but highly variable youngest leaf length, and virginile, with more and larger leaves, but more constant youngest leaf length; the critical crown size by which immature and virginile stages could be identified varied according to fragment and year. Reproductive palms bore identifiable reproductive structures. Seedlings, juveniles, and immatures had fewer leaves than virginile and reproductive individuals. Leaf length was similar between seedlings and juveniles but increased in later stages. The characteristics of each stage were fairly constant throughout the study years in the three fragments and were little affected by fire, indicating that the stages we define in this study are important in the developmental program of A. humilis.7891227123

A opção pela enfermagem: estudo retrospectivo em Sergipe

Foi feito um estudo quanti-qualitativo sobre a escolha da profissão de enfermeiro, sua motivação e identificação com a mesma entre graduados e graduandos da Universidade Federal de Sergipe que ingressaram no curso de Enfermagem entre 1992/1 e 1997/1, identificando facilidades ou dificuldades encontradas neste processo. Consta de pesquisa documental nas listas oficiais da Instituição, e entrevistas semi-estruturadas a, pelo menos, 20% da população. Os resultados revelaram um percentual de apenas 31,5% de graduados entre os que ingressaram no período, variando os demais entre 5 a 7 anos de permanência no curso. Verificou-se um percentual de 76,92% de opção preferencial por outros cursos, constatando-se dificuldades de conhecimento ou identificação com a profissão, anteriores ao mesmo, resultantes de estereótipos e tabus culturais