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

O direito à terra como um direito humano: a luta pela reforma agrária e o movimento de direitos humanos no Brasil

O objetivo deste texto é analisar, por meio da história recente dos movimentos sociais que lutam pela reforma agrária no Brasil, a construção do direito à terra como um direito humano. A partir dos anos de 1970, a interação de movimentos camponeses da Igreja Católica progressista e da rede transnacional de direitos humanos confluiu na produção dessa ideia da posse da terra como um direito humano, que marcou não apenas a luta pela terra no Brasil, como também influenciou a forma como o próprio movimento de direitos humanos foi construído no país e na maneira como ele se inseriu nessa rede transnacional de ativistas.<br>This article seeks to analyze, within the recent history of social movements that struggle for agrarian reform in Brazil today, the build of the land rights as a human right. Since the 1970s, the interaction between peasant movements, the progressive church and the transnational network of human rights has converged into this idea that the land rights are a human right, which not only has marked the character of the struggle for land in Brazil, but has also influenced the way in which the human rights movement has been constructed in the country and how it has taken its place within the transnational network of human rights activism

Regime internacional para refugiados: mudanças e desafios

O objetivo deste artigo é discutir as dificuldades e os dilemas envolvidos na gestão da questão dos refugiados na ordem global contemporânea. Com essa finalidade, apresentaremos a evolução institucional das normas e das organizações que compõem o regime internacional para refugiados, elaborado no âmbito da Organização das Nações Unidas (ONU), desde o final da II Guerra Mundial até os dias de hoje. Ao longo dessa apresentação, acreditamos ser possível identificar as origens de alguns dos problemas que ainda hoje afetam o tratamento dado ao problema dos refugiados, assim como destacar os fatores mais recentes que acrescentam novas dificuldades ao funcionamento do regime. Finalmente, concluímos que os principais desafios a serem enfrentados relacionam-se ao desenho institucional da organização internacional, sobretudo seu mandato e suas fontes de financiamento. Além disso, entendemos que o regime deveria ser fortalecido para solucionar de maneira mais eficaz os problemas vivenciados pelos refugiados na atualidade. Todavia, reconhecemos que há entraves políticos para que seja reaberto o debate sobre a revisão desse regime internacional. O processo de reformulação deveria ocorrer de forma compartilhada entre diversos atores no cenário internacional, sendo de responsabilidade não só da agência da ONU que atua em prol dos refugiados, mas também dos Estados e da sociedade civil global

A "securitização da imigração": mapa do debate The "securitization of migration": a map of the debate and some critical considerations

Baseado em duas questões centrais - "está ocorrendo, ou deve ocorrer, a securitização da imigração?" e "o conceito de segurança societal é útil para a compreensão dos dilemas das sociedades nacionais contemporâneas?" - o artigo propõe um mapa do recente debate acadêmico sobre o assunto, com enfoque no caso europeu. Depois de analisar as ideias de diversos e conhecidos autores, este texto desenvolve três contra-argumentos ao conceito de "segurança societal", defendido por membros da Escola de Copenhague, que estimula o perigoso processo de securitização da imigração.<br>Based on two central questions - "is there a process of securitization of migration taking place?" and "is the concept of societal security useful for understanding some of the dilemmas faced by modern society?" - this article proposes a map of the recent academic debate, focusing on the European case. After analyzing the ideas of several and well-known authors, the article develops three critical arguments to the concept of "societal security", advanced mainly by the members of the Copenhagen School, which stimulates the dangerous process of securitization of migration