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

Environmental education and participant action research: record an analytical educational praxis.

O universo de estudo desta pesquisa configura-se em torno dos processos de elaboração e construção da Agenda 21 Escolar de Embu das Artes, cujo percurso pautou-se pela adoção de técnicas e estratégias da pesquisa-ação integral e sistêmica de André Morin, buscando o envolvimento dos participantes do processo como co-autores de conhecimentos e prática engajadas, numa abordagem interativa, colaborativa. Nutriu-se do diálogo com uma diversidade de autores aliados ao pensamento crítico-transformador numa perspectiva emancipatória, entre eles Paulo Freire, Henry Giroux, Michael Apple, Jürgen Habermas, e dos aportes da psicologia sócio-histórica de Vygotsky, enfatizando-se nessa linha as contribuições de González Rey sobre a subjetividade e processos de subjetivação. Este trabalho pretende contribuir com a práxis da Educação Ambiental crítica na escola, por meio da investigação de processos colaborativos de construção de agendas 21 escolares, que como a pesquisa indicou, revelaram-se de grande potencial sensibilizador, indutor de participação, mobilizador de sujeitos comprometidos com propostas de transformação da escola e do bairro. Procurou-se verificar em que medida e se a escola pública, como instituição formal, portanto, instituída e burocratizada, pode se tornar mediadora e fomentadora de espaços horizontalizados de diálogos, do exercício da escuta e reconhecimento do outro. Um espaço de vivência democrática, de reflexão e ações coletivas, capaz de impulsionar e capilarizar processos educativos-formativos em educação ambiental, para além de seus limites institucionais, atingindo o contexto de relações e sujeitos que se inserem dentro e fora de seus contornos, na construção de comunidades socioambientalmente conscientes, educativas e co-responsáveis.The universe of this research is configured around the processes of design and construction of School Agenda 21 of Embu das Artes, whose route was marked by the adoption of techniques and strategies of André Morin\'s integral and systematic research-action, seeking involvement of participants in the process as co-authors of engaged knowledge and practice in an interactive approach, collaborative. Nourished from the dialogue with a diversity of authors allied to critical-transformer thinking in an emancipatory perspective, including Paulo Freire, Henry Giroux, Michael Apple, Jürgen Habermas, and the contributions of social-historical psychology of Vygotsky, emphasizing in that line the contributions of González Rey on subjectivity and subjective processes. This work aims to contribute to the practice of critical Environmental Education in school, through the investigation of collaborative processes for the construction of school Agenda 21, which as the research indicated, proved to be of great potential sensitizer, inducing participation, mobilizing of individuals committed with proposals to transform the school and neighborhood. It was sought to ascertain to what extent and if the public school, as a formal institution, therefore, established and bureaucratized, can become a mediator and fomenter of horizontalized spaces of dialogue, the practice of listening and recognition of each other. An area of democratic experience, reflection and collective action, able to boost and disseminate educational-formative processes in environmental education, beyond their institutional boundaries, reaching the context of relations and subjects that fall within and outside its boundaries, in building of social-environmentally conscious, educational and co-responsible communities

Educação ambiental e pesquisa-ação participante: registro analítico-crítico de uma práxis educativa

O universo de estudo desta pesquisa configura-se em torno dos processos de elaboração e construção da Agenda 21 Escolar de Embu das Artes, cujo percurso pautou-se pela adoção de técnicas e estratégias da pesquisa-ação integral e sistêmica de André Morin, buscando o envolvimento dos participantes do processo como co-autores de conhecimentos e prática engajadas, numa abordagem interativa, colaborativa. Nutriu-se do diálogo com uma diversidade de autores aliados ao pensamento crítico-transformador numa perspectiva emancipatória, entre eles Paulo Freire, Henry Giroux, Michael Apple, Jürgen Habermas, e dos aportes da psicologia sócio-histórica de Vygotsky, enfatizando-se nessa linha as contribuições de González Rey sobre a subjetividade e processos de subjetivação. Este trabalho pretende contribuir com a práxis da Educação Ambiental crítica na escola, por meio da investigação de processos colaborativos de construção de agendas 21 escolares, que como a pesquisa indicou, revelaram-se de grande potencial sensibilizador, indutor de participação, mobilizador de sujeitos comprometidos com propostas de transformação da escola e do bairro. Procurou-se verificar em que medida e se a escola pública, como instituição formal, portanto, instituída e burocratizada, pode se tornar mediadora e fomentadora de espaços horizontalizados de diálogos, do exercício da escuta e reconhecimento do outro. Um espaço de vivência democrática, de reflexão e ações coletivas, capaz de impulsionar e capilarizar processos educativos-formativos em educação ambiental, para além de seus limites institucionais, atingindo o contexto de relações e sujeitos que se inserem dentro e fora de seus contornos, na construção de comunidades socioambientalmente conscientes, educativas e co-responsáveis. ===ABSTRACT=== The universe of this research is configured around the processes of design and construction of School Agenda 21 of Embu das Artes, whose route was marked by the adoption of techniques and strategies of André Morin's integral and systematic research-action, seeking involvement of participants in the process as co-authors of engaged knowledge and practice in an interactive approach, collaborative. Nourished from the dialogue with a diversity of authors allied to critical-transformer thinking in an emancipatory perspective, including Paulo Freire, Henry Giroux, Michael Apple, Jürgen Habermas, and the contributions of social-historical psychology of Vygotsky, emphasizing in that line the contributions of González Rey on subjectivity and subjective processes. This work aims to contribute to the practice of critical Environmental Education in school, through the investigation of collaborative processes for the construction of school Agenda 21, which as the research indicated, proved to be of great potential sensitizer, inducing participation, mobilizing of individuals committed with proposals to transform the school and neighborhood. It was sought to ascertain to what extent and if the public school, as a formal institution, therefore, established and bureaucratized, can become a mediator and fomenter of horizontalized spaces of dialogue, the practice of listening and recognition of each other. An area of democratic experience, reflection and collective action, able to boost and disseminate educational-formative processes in environmental education, beyond their institutional boundaries, reaching the context of relations and subjects that fall within and outside its boundaries, in building of social-environmentally conscious, educational and co-responsible communities

A função social da educação ambiental nas práticas colaborativas: participação e engajamento

A participação como eixo norteador das práticas sociais de educação ambiental coloca como necessidade a articulação de saberes e fazeres para responder às complexas questões socioambientais. Este artigo desenvolve uma reflexão crítica sobre as práticas socioambientais educativas de caráter coletivo e colaborativo, com dinâmicas abertas e vivenciais, que têm se revelado como processos importantes na produção de uma cultura de diálogo, de participação, de mobilização e de potência de ação. Enfatizam-se as abordagens integradoras das relações entre as dimensões subjetivas e intersubjetivas e a possibilidade de estimularem a constituição de identidades coletivas e de comunidades em espaços de convivência. Isso abre caminhos para incrementar o potencial educativo de espaços dentro e fora da escola que podem se tornar contextos possíveis de diálogos democráticos, mediando experiências de diferentes sujeitos, protagonistas locais na construção de projetos de intervenção coletivos

Núcleos de Ensino da Unesp: artigos 2008

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research