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

Dictatorship Across Borders: How Brazil Influenced the Chilean \u3ci\u3eCoup d’état\u3c/i\u3e of 1973

Based on the testimony of Brazilian exiles who lived in Chile during the coup d’état of 1973, on documents recently declassified by the Brazilian Truth Commission and the Chilean Ministry of Foreign Relations, and on broad archival research in United States and South American collections, this dissertation investigates the political, economic, and diplomatic relations between Brazil and Chile from Salvador Allende’s candidacy to presidency and the first days of the Chilean military dictatorship. Despite the the widely held notion that the United States was the one and only supporter of the Chilean September 11 coup, this theis shows that Brazilian influence was also instrumental to the overthrow of the democratically elected socialist president and to the solidification of the Augusto Pinochet regime. The Brazilian government sent expertise, torturers, weapons, and medicines, and installed a network to monitor the activities of Brazilian exiles in the country, which would serve as a model for Operation Condor. The Brazilian Ministry of Planning, Roberto Campos, one of the most influential Brazilian economists, disagreed with the state-based policies that characterized the Brazilian civilian-military regime. Instead of nationalization and price controls, Campos believed in the strength of the free market and private institutions, a perspective similar to the one implemented by the Chicago Boys in Chile, and which he took to Chile during trips to that country in the early 1970s. The Brazilian Ambassador in Santiago, Antônio Cândido da Câmara Canto, was also an important ally of the Chilean dictatorship. He helped organize the opposition to Allende and provided information about the activities of leftist groups and the government through the Centro de Informações do Exterior do Itamaraty (CIEX), the Brazilian Foreign Office’s Intelligence Center. Investigating the role of diplomats, businessmen, and politicians, as well as the connections between the United States and Brazil which shared the common objective of preventing the socialist government from developing its “Chilean Path to Socialism,” this dissertation aims to open a new avenue of research at the local and transnational levels, pointing to the significance of relations among South American countries in shaping historical trajectories, instead of limiting the Cold War framework to the question of West-East tensions