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

Cytotoxicity in vitro of two non-commercial samples of chrysotile and fibrous erionite

Exposure to naturally occurring asbestos and fibrous erionite can have severe impacts for the human health and cause malignant mesothelioma. The disease burden associated with this exposure is difficult to quantify and is not properly investigated. A characterization of the crystal-chemical-physical properties and toxicity/carcinogenicity of naturally occurring fibres with attention to asbestos and erionite is therefore highly recommended. The present study deals with the in vitro biological effects in MeT5A and A549 human cell lines of two non-commercial asbestos fibres: Valmalenco chrysotile from Central Alps Italy and fibrous erionite from Jersey Nevada, USA, including the standards UICC Chrysotile and UICC crocidolite. Light and scanning electron microscopy (SEM) observations showed morphological cell perturbation of treated cells. SEM-EDAX investigations revealed that the release of chemical components in the culture media affect cell viability. ROS levels increased in accordance with glutathione depletion, witnessing a remarkable cellular stress. Free radical release on pristine fibres was investigated by means of electron paramagnetic resonance (EPR) spin trapping technique and FTIR spectroscopy to characterize the molecular structures of fibres. Results reflect the cytotoxic effects and evidence the different toxicity pathways prompted by these fibre species due to their different crystal assemblages and physical properties

Paddy rice methane emissions across Monsoon Asia

Although rice cultivation is one of the most important agricultural sources of methane (CH4) and contributes ∼8% of total global anthropogenic emissions, large discrepancies remain among estimates of global CH4 emissions from rice cultivation (ranging from 18 to 115 Tg CH4 yr−1) due to a lack of observational constraints. The spatial distribution of paddy-rice emissions has been assessed at regional-to-global scales by bottom-up inventories and land surface models over coarse spatial resolution (e.g., > 0.5°) or spatial units (e.g., agro-ecological zones). However, high-resolution CH4 flux estimates capable of capturing the effects of local climate and management practices on emissions, as well as replicating in situ data, remain challenging to produce because of the scarcity of high-resolution maps of paddy-rice and insufficient understanding of CH4 predictors. Here, we combine paddy-rice methane-flux data from 23 global eddy covariance sites and MODIS remote sensing data with machine learning to 1) evaluate data-driven model performance and variable importance for predicting rice CH4 fluxes; and 2) produce gridded up-scaling estimates of rice CH4 emissions at 5000-m resolution across Monsoon Asia, where ∼87% of global rice area is cultivated and ∼ 90% of global rice production occurs. Our random-forest model achieved Nash-Sutcliffe Efficiency values of 0.59 and 0.69 for 8-day CH4 fluxes and site mean CH4 fluxes respectively, with land surface temperature, biomass and water-availability-related indices as the most important predictors. We estimate the average annual (winter fallow season excluded) paddy rice CH4 emissions throughout Monsoon Asia to be 20.6 ± 1.1 Tg yr−1 for 2001–2015, which is at the lower range of previous inventory-based estimates (20–32 CH4 Tg yr−1). Our estimates also suggest that CH4 emissions from paddy rice in this region have been declining from 2007 through 2015 following declines in both paddy-rice growing area and emission rates per unit area, suggesting that CH4 emissions from paddy rice in Monsoon Asia have likely not contributed to the renewed growth of atmospheric CH4 in recent years

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys