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

Indicadores biológicos y de estrés oxidativo en la evolución de pacientes con artritis reumatoide

Introduction: rheumatoid arthritis is an autoimmune and inflammatory disease of unknown cause. In the Rheumatology services, the evolution of the patients is valued by means of erythrocyte sedimentation rate and C-reactive protein. It has been suggested that the oxidative stress contributes to the joint tissue damage.Objective: to analyze differential leukocyte count and oxidative damage in patients with Rheumatoid Arthritis in crisis and remission periods.Methods: prospective study in which global and differential  leukocytes count, thiobarbituric acid reactive substances as a marker of lipid peroxidation, the  superoxide dismutase, as well as  the catalase activities were measured in 23 patients during their crisis and remission periods. C-reactive protein, erythrocyte sedimentation rate and rheumatoid factor were measured, too.Results: rheumatoid factor was over 15 U/ml in the 82.61 % of the patients. A minor neutrophils count was observed   in the remission period   in relation to the active period of the disease (5.03±1.51 vs. 4.21±1.24 ×10-9/L, p=0.003), as well as  the global leukocytes count, the erythrocyte sedimentation rate and  the C-reactive protein. It was verified   that the catalase activity decreased in remission state in relation to  the crisis period (445.31±281.87 vs. 1046.08±659.77 U×L-1min-1).Conclusions: in the evolution of the rheumatoid arthritis, the neutrophils count is in correspondence with the inflammatory state of the patients. Catalase activity is consistent with the regulation of this enzyme to protect against oxidative stress.Introducción: La artritis reumatoide  es una enfermedad autoinmune e inflamatoria crónica.  En los servicios de Reumatología se valora la evolución de los pacientes mediante eritrosedimentación y Proteína C reactiva. Se ha propuesto que el estrés oxidativo contribuye al daño tisular en las articulaciones.Objetivo:  Analizar el leucograma y el daño oxidativo en pacientes con artritis reumatoide en períodos de crisis y remisión.Métodos: Estudio prospectivo en el que se realizó el conteo global y diferencial de leucocitos, la cuantificación de productos reactivos al ácido tiobarbitúrico, y la actividad de las enzimas superóxido dismutasa y catalasa en 23 pacientes con diagnóstico de artritis reumatoide en periodos de crisis y remisión. Se determinaron además proteína C reactiva, eritrosedimentación y factor reumatoide.Resultados: El factor reumatoide fue mayor de 15 U/mL en el  82.61% de los pacientes. El conteo de neutrófilos fue menor en la etapa de remisión en relación con la etapa activa de la enfermedad (4.21±1.24 vs 5.03±1.51 x10-9/L; p=0.003), comportamiento similar al conteo global de leucocitos, la velocidad de sedimentación globular y la proteína C reactiva. Resultó relevante la menor actividad catalasa en los pacientes en remisión en relación con el periodo de crisis (445.31±281.87 vs 1046.08±659.77 UxL-1min-1).Conclusiones: El comportamiento de los neutrófilos en la evolución hacia la remisión del paciente reumatoideo está en correspondencia con la velocidad de sedimentación globular, la proteína C reactiva y la disminución del estado inflamatorio. La actividad catalasa  contribuye al desbalance redox y su actividad es consistente con una regulación adaptativa de la enzima para la protección contra el estrés oxidativ

Cuantificación de la inmunoglobulina G y la albúmina en el líquido cefalorraquídeo mediante las modificaciones de las técnicas para otros fluidos biológicos

To evaluate the results of estimating the functional status of blood–cerebrospinal fluid barrier (B–CSFB) and intrathecal immunoglobulin synthesis (ITS) of IgG for central nervous system by modified commercial techniques designed for other biological fluids. Methods: Disc polyacrylamide gel electrophoresis and quantification of CSF total protein in CSF and serum of 61 patients were conducted at the Institute of Neurology and Neurosurgery (INN) between April and September 2014. The concentration of albumin and IgG was determined by commercial standardized techniques and by modifications of commercial techniques. Albumin ratio and IgG index were calculated and employed to evaluate B–CSFB permeability and ITS, respectively. Results: Total protein and protein electrophoresis patterns were correlated with the quantifications performed by modified commercial techniques. There was no significant difference between validated commercial techniques and modified techniques for quantifications of CSF albumin (Z=0,41; p=0,6791), serum albumin (Z=0,08; p=0,9382), Qalb (Z=0,21; p=0,8361), CSF IgG (Z=1,65; p=0,0995) and IgG index (Z=1,10; p=0,2721). Conclusions: The immunological studies in CSF obtained from modifying commercial techniques designed for other biological fluids are useful to estimate the functionality of B–CSFB and intrathecal immunoglobulin synthesis. The modifications carried out for the turbidimetric technique and for the UMELISA kit should be standardized for the validation of BCSF–B permeability and IgG ITS by the nervous system.OBJETIVO: Evaluar los resultados de la estimación del estado funcional de la barrera sangre–líquido cefalorraquídeo (LCR) y la síntesis intratecal de inmunoglobulina G (IgG) por el sistema nervioso central mediante las modificaciones de las técnicas comerciales diseñadas para otros fluidos biológicos.MÉTODOS: A muestras de LCR y suero de 61 pacientes se les realizaron electroforesis de disco en geles de poliacrilamida y cuantificación de proteínas totales (PT) en el Instituto de Neurología y Neurocirugía, Habana, Cuba (INN), entre los meses de abril y diciembre de 2014. Se determino las concentraciones de albúmina e IgG empleando paralelamente técnicas comerciales modificadas en el laboratorio y métodos validados para estos estudios. Se calculó el cociente albúmina (Qalb) y el índice IgG, como indicadores del estado funcional de la barrera sangre–LCR y de la síntesis intratecal (SIT), respectivamente.RESULTADOS: Las PT y los patrones de electroforesis se correlacionaron con el Qalb y albúmina, realizado por las técnicas modificadas. No se encontraron diferencias significativas entre las cuantificaciones de las técnicas validadas y modificadas para los valores de albúmina en LCR (Z=0,41; p=0,6791), albúmina en suero (Z=0,08; p=0,9382), el Qalb (Z=0,21; p=0,8361), IgG en LCR (Z=1,65; p=0,0995) e índice IgG (Z=1,10; p=0,2721).CONCLUSIONES: Se demuestra que estas modificaciones en técnicas comerciales diseñadas para otros fluidos bilógicos resultan útiles para estimar la funcionalidad de la BS–LCR y calcular la SIT de inmunoglobulinas. Las modificaciones introducidas a la técnica turbidimétrica y al UMELISA pueden ser estandarizadas para su validación en el diagnóstico de daño de la BS–LCR y de síntesis intratecal de IgG por el sistema nervioso

Association of inflammatory markers and endothelial dysfunction with depression in patients with ischemic cerebrovascular disease

Foundation: depression in ischemic cerebrovascular disease is one of the most frequent non-neurological complications.Objective: to determine the association of inflammatory markers and endothelial dysfunction with depression in patients with ischemic cerebrovascular disease.Methods: an analytical, prospective, cross-sectional study was carried out in patients with acute (N=22) and non-acute (N=37) ischemic cerebrovascular disease; treated at the Institute of Neurology and Neurosurgery; and the Manuel Fajardo Hospital, in Havana, Cuba. Demographic variables, risk factors, etiology and location of the infarction, neurological deficiency, disability for activities of daily living (Barthel index), neuropsychological (depression by Beck inventory and Hamilton test) were collected. C-reactive protein, alpha-1-antitrypsin, C3 and C4 complements, and microalbuminuria were determined.Results: the scores of the neuropsychological tests did not have significant differences between the acute and non-acute phase, but there was a statistical increase in the frequency of patients without depression and with slight depression in the non-acute phase. In the acute phase, C4, and in the non-acute phase, C3, C-reactive protein and alpha-1-antitrypsin were directly correlated with the Beck inventory score. C-reactive protein and C3 were statistically correlated with the Hamilton test score. In the multivariate analysis, C-reactive protein showed an independent association with the degree of depression by the Hamilton test.Conclusions: C-reactive protein could be related to the severity of depression, perhaps by association with the disability for activities of daily living.</p

Tecnología e innovación en educación superior: escenarios pospandemia

: ilustraciones, tablas, gráficos ; 28 cm.En este libro, titulado Tecnología e innovación en educación superior: escenarios pospandemia, se continúa el diálogo con expertos, específicamente en los temas de mayor debate que surgieron a partir del primer confinamiento provocado por el COVID-19, frente al aporte de la tecnología en los proceso de la calidad educativa. Se han identificado los investigadores que trabajan las temáticas de la obra y se les ha invitado a escribir para este libro, por lo que se convierte en aporte de indudable valor para el sector universitario, y se espera que continúe contribuyendo a los debates sobre la educación superior

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Biodiversity recovery of Neotropical secondary forests.

Old-growth tropical forests harbor an immense diversity of tree species but are rapidly being cleared, while secondary forests that regrow on abandoned agricultural lands increase in extent. We assess how tree species richness and composition recover during secondary succession across gradients in environmental conditions and anthropogenic disturbance in an unprecedented multisite analysis for the Neotropics. Secondary forests recover remarkably fast in species richness but slowly in species composition. Secondary forests take a median time of five decades to recover the species richness of old-growth forest (80% recovery after 20 years) based on rarefaction analysis. Full recovery of species composition takes centuries (only 34% recovery after 20 years). A dual strategy that maintains both old-growth forests and species-rich secondary forests is therefore crucial for biodiversity conservation in human-modified tropical landscapes

TRATAMIENTO SINDROMICO DE FLUJO VAGINAL EN GESTANTES ATENDIDAS EN EL CENTRO DE SALUD CHACAPUNCO ENERO A JUNIO 2017

TesisObjetivo: Determinar las características del tratamiento sindrómico de flujo vaginal. Metodología: El tipo de investigación es sustantiva, nivel descriptivo y diseño descriptivo simple. Se trabajó con una muestra censal de 30 gestantes que desarrollaron síndrome de flujo vaginal resultados: Las características encontradas en la edad fue edad mínima 17 años y la máxima 40 años, la mayoría presentó 23 años., el 53% son convivientes. Según el grado de instrucción, el 60% de las gestantes tienen primaria, el 47% son amas de casa, el 87% procede del área rural. Dentro de las características clínicas el 67% de las gestantes tienen abundante secreción, las características de las secreciones vaginales son el 67% presentan aspecto leche cortada, el 33% mal olor. Y los síntomas identificados fueron 60% disuria y prurito vulvar. Se encontró que el 60% de las gestantes atendidas tienen como diagnostico presuntivo trichomona y cándida. Las complicaciones encontradas fueron: amenaza de parto prematuro 60%, amenaza de aborto 27%. La respuesta al tratamiento sindrómico de flujo vaginal en gestantes el 73% de las gestantes se suministró el Metronidazol y al 87% con Clotrimazol. Conclusión: El tratamiento sindrómico de flujo vaginal con medicamentos resulto que el 83% de las gestantes fue efectivo y el 17% de las gestantes no fue efectivo. Palabras claves: Síndrome de flujo vaginal, tratamiento y gestantes