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

Taking stock of 10 years of published research on the ASHA programme: Examining India’s national community health worker programme from a health systems perspective

Background: As India’s accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale. Methods: We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW–health systems interface framework. Results: A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results. Conclusion: Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight

Matrix method for eigenvalue assignment: The single input case

The eigenvalue assignment/pole placement procedure has found application in a wide variety of control problems. The associated literature is rather extensive with a number of techniques discussed to that end. In this paper a method for assigning eigenvalues to a Linear Time Invariant (LTI) single input system is proposed. The algorithm determines a matrix, which has eigenvalues at the desired locations. It is obtained from the knowledge of the open-loop system and the desired eigenvalues. Solution of the matrix equation, involving unknown controller gains, open-loop system matrices and desired eigenvalues, results in the state feedback controller. The proposed algorithm requires the closed-loop eigenvalues to be different from those of the open-loop case. This apparent constraint is easily overcome by a negligible shift in the values. Two examples are considered to verify the proposed algorithm. The first one pertains to the in-plane libration of a Tethered Satellite System (TSS) while the second is concerned with control of the short period dynamics of a flexible airplane. Finally, the method is extended to determine the Controllability Grammian, corresponding to the specified closed-loop eigenvalues, without computing the controller gains

Matrix method for eigenvalue assignment: The single input case

The eigenvalue assignment/pole placement procedure has found application in a wide variety of control problems. The associated literature is rather extensive with a number of techniques discussed to that end. In this paper a method for assigning eigenvalues to a Linear Time Invariant (LTI) single input system is proposed. The algorithm determines a matrix, which has eigenvalues at the desired locations. It is obtained from the knowledge of the open-loop system and the desired eigenvalues. Solution of the matrix equation, involving unknown controller gains, open-loop system matrices and desired eigenvalues, results in the state feedback controller. The proposed algorithm requires the closed-loop eigenvalues to be different from those of the open-loop case. This apparent constraint is easily overcome by a negligible shift in the values. Two examples are considered to verify the proposed algorithm. The first one pertains to the in-plane libration of a Tethered Satellite System (TSS) while the second is concerned with control of the short period dynamics of a flexible airplane. Finally, the method is extended to determine the Controllability Grammian, corresponding to the specified closed-loop eigenvalues, without computing the controller gains

Relationship between the controllability grammian and closed-loop eigenvalues: the single input case

The controllability grammian is important in many control applications. Given a set of closed-loop eigenvalues the corresponding controllability grammian can be obtained by computing the controller which assigns the eigenvalues and then by solving the Lyapunov equation that defines the grammian. The relationship between the controllability grammian, resulting from state feedback, and the closed-loop eigenvalues of a single input linear time invariant (LTI) system is obtained. The proposed methodology does not require the computation of the controller that assigns the specified eigenvalues. The closed-loop system matrix is obtained from the knowledge of the open-loop system matrix, control influence matrix and the specified closed-loop eigenvalues. Knowing the closed-loop system matrix, the grammian is then obtained from the solution of the Lyapunov equation that defines it. Finally the proposed idea is extended to find the state covariance matrix for a specified set of closed-loop eigenvalues (without computing the controller), due to impulsive input in the disturbance channel and to solve the eigenvalue assignment problem for the single input case

Matrix method for eigenstructure assignment - The multi-input case with application

The eigenvalue and eigenstructure assignment procedure has found application in a wide variety of control problems. In this paper a method for assigning eigenstructure to a linear time invariant multi-input system is proposed. The algorithm determines a matrix that has eigenvalues and eigenvectors at the desired locations. It is obtained from the knowledge of the open-loop system and the desired eigenstructure. Solution of the matrix equation, involving unknown controller gams, open-loop system matrices, and desired eigenvalues and eigenvectors, results hi the state feedback controller. The proposed algorithm requires the closed-loop eigenvalues to be different from those of the open-loop case. This apparent constraint can easily be overcome by a negligible shift in the values. Application of the procedure is illustrated through the offset control of a satellite supported, from an orbiting platform, by a flexible tether