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

Stability analysis based on birfurcation theory of the DSTATCOM operating in current control mode

This paper presents the stability analysis for a distribution static compensator (DSTATCOM) that operates in current control mode based on bifurcation theory. Bifurcations delimit the operating zones of nonlinear circuits and, hence, the capability to compute these bifurcations is of important interest for practical design. A control design for the DSTATCOM is proposed. Along with this control, a suitable mathematical representation of the DSTATCOM is proposed to carry out the bifurcation analysis efficiently. The stability regions in the Thevenin equivalent plane are computed for different power factors at the point of common coupling. In addition, the stability regions in the control gain space, as well as the contour lines for different Floquet multipliers are computed. It is demonstrated through bifurcation analysis that the loss of stability in the DSTATCOM is due to the emergence of a Neimark bifurcation. The observations are verified through simulation studies

Non-linear oscillations assessment of the distribution static compensator operating in voltage control mode

This article deals with the non-linear oscillations assessment of a distribution static comensator ooperating in voltage control mode using the bifurcation theory. A mathematical model of the distribution static compensator in the voltage control mode to carry out the bifurcation analysis is derived. The stabiity regions in the Thevein equivalent plane are computed. In addition, the stability regions in the control gains space, as well as the contour lines for different Floquet multipliers are computed. The AC and DC capacitor impacts on the stability are analyzed through the bifurcation theory. The observations are verified through simulaation studies. The computation of the stability region allows the assessment of the stable operating zones for a power system that includes a distribution static compensator operating in the voltage mode

Stability analysis of STATCOM in distribution networks

This chapter presents the stability analysis based on bifurcation theory of the distribution static compensator (DSTATCOM) operating both in current control mode as in voltage control mode. The bifurcation analysis allows delimiting the operating zones of nonlinear power systems and hence the computation of these boundaries is of interest for practical design and planning purposes. Suitable mathematical representations of the DSTATCOM are proposed to carry out the bifurcation analyses efficiently. The stability regions in the Thevenin equivalent plane are computed for different power factors at the Point of Common Coupling (PCC). In addition, the stability regions in the control gain space are computed, and the DC capacitor and AC capacitor impact on the stability are analyzed in detail. It is shown through bifurcation analysis that the loss of stability in the DSTATCOM is in general due to the emergence of oscillatory dynamics. The observations are verified through detailed simulation studies

Hydrodynamic Cavitation as Pretreatment for Removal of Hardness From Reverse Osmosis Reject Water

In the present investigation, the treatment of reverse osmosis reject water hardness by hydrodynamic cavitation with the addition of sodium bicarbonate was studied. Hydrodynamic cavitation (HC), which is formed as a result of fluid pressure and velocity variation, has attracted great attention in industrial wastewater treatment due to its simple design and ease of operation. The influence of wastewater recirculation flow rate and the number of holes in the metal plate on the percentage removal of calcium hardness was studied. The study used a two-factor factorial design with three levels, plates with( 3, 5 and 9 holes)and a recirculation flow rate of (0.6, 1 and 1.5 L/min) with a treatment time of 60 minutes. Calcium hardness, total dissolved solids, pH and liquid temperature were evaluated as a function of time. The results show that as the flow rate and the number of orifices increase, the percentage of hardness removal increases. A linear correlation of hardness removal with respect to flow rate and number of orifices in the metal plate is also observed. For the recirculation flow rate of 1.5 L/min and a plate with 9 holes, a maximum removal rate of 66.76 % was achieved. It was also observed that the temperature increases as a function of time, reaching up to 75°C, while pH and total dissolved solids decrease during the treatment time. Hydrodynamic cavitation represents an environmentally friendly mechanical treatment technology and, considering that the removal efficiency is higher than 60%, it is an alternative as a pretreatment for the removal of water hardness