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

Entre retratos e cadáveres: a fotografia na Guerra do Paraguai

O registro fotográfico da guerra do Paraguai contra a Tríplice Aliança (1864-1870) foi, em termos gerais, uma continuidade do tipo de fotografia que se fazia na época. Mas foi, também, mais do que isso. A cobertura in loco e a força do assunto trouxeram maneiras inovadoras de se representar o conflito, o que colaborou para a constituição de uma linguagem fotográfica com características próprias em relação à pintura ou gravura do período dedicadas à guerra

Oral health in children with acute lymphoblastic leukaemia: before and after chemotherapy treatment

© 2019, European Academy of Paediatric Dentistry. Aim: To evaluate changes in the oral health status of children under the age of 14 years with acute lymphoblastic leukaemia (ALL) attending a cancer centre before and after chemotherapy treatment. Materials and methods: A total of 32 children with ALL without distinction of gender were selected for study. The oral cavity of the patients was evaluated before the induction stage and 17 days later. Clinical evaluation of the submandibular, submental, and cervical lymph nodes was performed. Saliva samples were collected during the early morning hours. Bacterial plaque was assessed by using the Silness and Löe plaque index (SLPI) and gingiva status was evaluated with the gingival Löe and Silness index (GLSI). The WHO toxicity oral scale was used to record the degree of oral mucositis. The resulting data were analysed with McNemar’s test, t test (for related samples), and Wilcoxon test. Results: There were statistically significant differences for palpable lymph nodes, paleness of oral mucosa, and ecchymoseis, respectively, P ≤ 0.000, P = 0.03, and P = 0.01, with these manifestations decreasing significantly after treatment. Incipient gingivitis had frequencies of 71.9% and 75% before and after treatment, respectively. The mean SLPI score declined significantly from 1.16 ± 0.52 (before treatment) to 0.56 ± 0.36 (after treatment) (P < 0.000); salivary flow increased significantly from 0.54 ± 0.34 to 1.22 ± 1.07 after chemotherapy treatment (P < 0.00). Oral mucositis was present in 24 children (75%) with a 1–2 severity level. Conclusions: After chemotherapy treatment, there were changes in the oral conditions of children with ALL. Some manifestations decreased after treatment, whereas in others increased.© 2019, European Academy of Paediatric Dentistry. Aim: To evaluate changes in the oral health status of children under the age of 14 years with acute lymphoblastic leukaemia (ALL) attending a cancer centre before and after chemotherapy treatment. Materials and methods: A total of 32 children with ALL without distinction of gender were selected for study. The oral cavity of the patients was evaluated before the induction stage and 17 days later. Clinical evaluation of the submandibular, submental, and cervical lymph nodes was performed. Saliva samples were collected during the early morning hours. Bacterial plaque was assessed by using the Silness and Löe plaque index (SLPI) and gingiva status was evaluated with the gingival Löe and Silness index (GLSI). The WHO toxicity oral scale was used to record the degree of oral mucositis. The resulting data were analysed with McNemar’s test, t test (for related samples), and Wilcoxon test. Results: There were statistically significant differences for palpable lymph nodes, paleness of oral mucosa, and ecchymoseis, respectively, P ≤ 0.000, P = 0.03, and P = 0.01, with these manifestations decreasing significantly after treatment. Incipient gingivitis had frequencies of 71.9% and 75% before and after treatment, respectively. The mean SLPI score declined significantly from 1.16 ± 0.52 (before treatment) to 0.56 ± 0.36 (after treatment) (P < 0.000); salivary flow increased significantly from 0.54 ± 0.34 to 1.22 ± 1.07 after chemotherapy treatment (P < 0.00). Oral mucositis was present in 24 children (75%) with a 1–2 severity level. Conclusions: After chemotherapy treatment, there were changes in the oral conditions of children with ALL. Some manifestations decreased after treatment, whereas in others increased

Desempenho de novilhas leiteiras sob manejo para crescimento compensatório recebendo suplementação com ionóforo

Objetivou-se avaliar a influência do manejo para crescimento compensatório e da suplementação com ionóforo sobre o desempenho de novilhas leiteiras. Foram utilizadas 20 novilhas Pardo-Suíças puras, com peso inicial de 200 kg e cinco meses de idade. Os tratamentos foram arranjados em um esquema fatorial (2 x 2) e os animais foram alocados aleatoriamente em cada uma das combinações. O fator 1 consistiu dos sistemas de alimentação (convencional e crescimento compensatório) e o fator 2, da utilização ou não de ionóforo (200 mg de monensina/animal/dia). Os animais do sistema convencional receberam alimentação ad libitum, enquanto os do sistema de crescimento compensatório foram submetidos a um manejo nutricional com dois períodos distintos: período de restrição energética (90 dias, P1) e período de realimentação (60 dias, P2). A eficiência de conversão de MS e EM consumida em ganho de peso diário foi menor durante o período de realimentação. Não houve diferença para as variáveis relacionadas ao balanço de nitrogênio dos animais do sistema convencional e daqueles submetidos ao manejo para crescimento compensatório. A inclusão de ionóforo na dieta das novilhas resultou em menor excreção de nitrogênio (N) urinário e, conseqüentemente, a retenção de N foi maior no período de restrição e menor no período de realimentação, o que refletiu na eficiência de utilização do N consumido. Não houve efeito dos sistemas, da utilização de ionóforo ou do período sobre os parâmetros morfo-estruturais estudados e sobre o peso ao final do período experimental. Novilhas em crescimento compensatório apresentaram maior ganho de peso diário ao 135º e 150º dias do período experimental, em comparação às do sistema convencional

Low-Resource Unsupervised NMT: Diagnosing the Problem and Providing a Linguistically Motivated Solution

Unsupervised Machine Translation hasbeen advancing our ability to translatewithout parallel data, but state-of-the-artmethods assume an abundance of mono-lingual data. This paper investigates thescenario where monolingual data is lim-ited as well, finding that current unsuper-vised methods suffer in performance un-der this stricter setting. We find that theperformance loss originates from the poorquality of the pretrained monolingual em-beddings, and we propose using linguis-tic information in the embedding train-ing scheme. To support this, we look attwo linguistic features that may help im-prove alignment quality: dependency in-formation and sub-word information. Us-ing dependency-based embeddings resultsin a complementary word representationwhich offers a boost in performance ofaround 1.5 BLEU points compared to stan-dardWORD2VECwhen monolingual datais limited to 1 million sentences per lan-guage. We also find that the inclusion ofsub-word information is crucial to improv-ing the quality of the embedding