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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The importance of being chemical affinity. part iv: the first flowers

After the power void caused by the Roman Empire’s decline, Medieval Europe is involved in a combat climate for the power. The new Christian church from Rome expands and includes kings and emperors. The Christian pope seeks to compel all believers to subscribe the closed religious perspective of that time. However it is religious people who recognize the necessity to observe nature and the world in a different way. The discovery, translation and diffusion of the classic Greek philosophers’ texts allow the initiation of independent thinking, which in turn, spurs the Renaissance and Illustration ages. The inductive thinking method begins with the purpose of finding other ways to interpret nature and advance the thought process. Therefore during the XVI century alchemy is questioned and the first treatises on empirical metallurgy appear, considered to be the foundations of modern science. During the XVII century some individuals begin experimenting with residual alchemical concepts. The first hypotheses on key chemical concepts and phenomena appear which frame the logic and rational thought process during the XVIII century. The concept of affinity emerges as a way to describe the relations among substances, observed during the formation of compounds, and as an analogy to human relations. Published works regarding the components of the thinking process consolidate the basic concepts of chemical bonding and related themes

Long-acting contraceptive agents: Norethisterone esters of monoalkenyl and monoalkynyl acids

9 pages, 1 table, 1 scheme.-- Available online 10 January 2003.The synthesis of nine new esters of norethisterone (17α-ethynyl-17β-hydroxyestr-4-en-3-one) is described, with the esterifying acids bearing an acetylenic or olefinic function in a chain of eight or nine carbon atoms, for evaluation as long-acting contraceptive agents.We thank the World Health Organization for financial support of this work

Prevalence and risk factors of Occult Hepatitis C infections in blood donors from Mexico City.

BACKGROUND:The circulatory system is the main mechanism for transmission of the Hepatitis C Virus (HCV). A new class of HCV infections, Occult HCV infection (OCI), is defined as the presence of HCV-RNA in hepatocytes with the absence of HCV in the serum/plasma utilizing current laboratory assays. Different groups have reported the prevalence of OCI; however, its associated risk factors have not been established. In Mexico, there are no reports about OCI, so the objective of our study was to determine the prevalence of OCI in total blood donors in Mexico City, as well as its associated risk factors. METHODS:Blood donors that were considered eligible for donation, according to NOM 253-SSA1-2012, were randomly selected. Demographic data was collected from 1,037 donors. Plasma and peripheral blood mononuclear cells were assessed for HCV-RNA. The presence of HCV-RNA was determined by nested PCR for the 5'-UTR region. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95%CI) to determine the level of association. RESULTS:The prevalence of OCI was 3.4% among blood donors. Homosexual relationships (OR = 5.52, 95%CI: 1.53-19.92, p<0.05) and acupuncture (OR = 3.56, 95%CI: 1.41-8.98, p<0.05) were significantly associated with OCI. CONCLUSION:There is a significant presence of OCI in the blood donor population in Mexico City. The main risk factors for OCI transmission are homosexual relationships and acupuncture. This study supports the increased use of sensitive and specific screening tests for blood bank testing

Cell Patterns Emerge from Coupled Chemical and Physical Fields with Cell Proliferation Dynamics: The <i>Arabidopsis thaliana</i> Root as a Study System

<div><p>A central issue in developmental biology is to uncover the mechanisms by which stem cells maintain their capacity to regenerate, yet at the same time produce daughter cells that differentiate and attain their ultimate fate as a functional part of a tissue or an organ. In this paper we propose that, during development, cells within growing organs obtain positional information from a macroscopic physical field that is produced in space while cells are proliferating. This dynamical interaction triggers and responds to chemical and genetic processes that are specific to each biological system. We chose the root apical meristem of <i>Arabidopsis thaliana</i> to develop our dynamical model because this system is well studied at the molecular, genetic and cellular levels and has the key traits of multicellular stem-cell niches. We built a dynamical model that couples fundamental molecular mechanisms of the cell cycle to a tension physical field and to auxin dynamics, both of which are known to play a role in root development. We perform extensive numerical calculations that allow for quantitative comparison with experimental measurements that consider the cellular patterns at the root tip. Our model recovers, as an emergent pattern, the transition from proliferative to transition and elongation domains, characteristic of stem-cell niches in multicellular organisms. In addition, we successfully predict altered cellular patterns that are expected under various applied auxin treatments or modified physical growth conditions. Our modeling platform may be extended to explicitly consider gene regulatory networks or to treat other developmental systems.</p></div

Log-log plot of the maximum RAM as a function of the parameter .

<p>Numerical results are blue rhombuses, and the red line is the best fit with a function of the form with R.</p

Plots of local potential, auxin concentration and cell cycle, after coupling dynamics.

<p>The normalized local potential (dashed-blue), the auxin concentration (red) and the advance of the cycle clock (dotted-black) as functions of the distance from the tip (), at time steps, corresponding to seven days.</p