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

A Dynamic Duopoly Model: When a Firm Shares the Market with Certain Profit

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Local and Global Dynamics of a Constraint Profit Maximization for Bischi–Naimzada Competition Duopoly Game

The Bischi&ndash;Naimzada game is a market competition between two firms with the objective of maximizing profits under limited information. In this article, we study a more generalized and realistic situation that takes into account the sales constraints. we generalize the economic model suggested by Bischi&ndash;Naimzada by introducing and studying the maximization of profits based on sales constraints. Our motivation in this paper is the studying of profit and sales constraints maximization and their influences on the game&rsquo;s dynamics. The local stability of the equilibrium points of the proposed model is discussed. It examines how the dynamics of the proposed two-dimensional competition game model focusing on changes in both the speed of the adjustment and the sales constraint parameters. The map describing the game is proven to be noninvertible and yields many multi-stable, complex dynamics and the coexistence chaotic attractors may arise. The global behavior of the map is achieved by studying the critical curves. The numerical simulations demonstrate the coexistence of two attractors and complex structures of the attraction basins. Several examples are discussed in order to confirm all the analytical results obtained

New Conditions for Testing the Oscillation of Fourth-Order Differential Equations with Several Delays

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A Variety of Nabla Hardy’s Type Inequality on Time Scales

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Diamond Alpha Hilbert-Type Inequalities on Time Scales

In this article, we will prove some new diamond alpha Hilbert-type dynamic inequalities on time scales which are defined as a linear combination of the nabla and delta integrals. These inequalities extend some known dynamic inequalities on time scales, and unify and extend some continuous inequalities and their corresponding discrete analogues. Our results will be proven by using some algebraic inequalities, diamond alpha H&ouml;lder inequality, and diamond alpha Jensen&rsquo;s inequality on time scales

Optimizing the Monotonic Properties of Fourth-Order Neutral Differential Equations and Their Applications

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Kneser-Type Oscillation Criteria for Half-Linear Delay Differential Equations of Third Order

This paper delves into the analysis of oscillation characteristics within third-order quasilinear delay equations, focusing on the canonical case. Novel sufficient conditions are introduced, aimed at discerning the nature of solutions—whether they exhibit oscillatory behavior or converge to zero. By expanding the literature, this study enriches the existing knowledge landscape within this field. One of the foundations on which we rely in proving the results is the symmetry between the positive and negative solutions, so that we can, using this feature, obtain criteria that guarantee the oscillation of all solutions. The paper enhances comprehension through the provision of illustrative examples that effectively showcase the outcomes and implications of the established findings