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

Propuesta de intervención para trastornos específicos del aprendizaje

Objetivo: Optimizar el proceso de enseñanza-aprendizaje en los niños con trastorno específico del aprendizaje de la fundación Colombo Alemana Volver A Sonreír de la ciudad de Bucaramanga. Método: 250 Maestros de las distintas sedes de la fundación colombo alemana volver a sonreír. Diseño: Evaluación experimental, con un solo grupo pretest- postest (grupo intervención). Instrumento: Cuestionario de evaluación acerca de los conocimientos de los trastornos específicos de aprendizaje (Elaboración propia). El programa de intervención psicoeducativa fue desarrollado durante cuatro sesiones a través de plataformas virtuales debido a la contingencia por Covid-19, mediante técnicas psicoeducativas y ejercicios prácticos. Resultados: Existe un porcentaje estadísticamente significativo de la población docente, que exhiben el incremento de sus nociones teóricas y prácticas para reconocer cuándo se encontraban frente a un posible caso de trastorno especifico de aprendizaje, con un 97% de la población con conocimiento frente a trastorno específicos de aprendizaje y un 3% que informó de su no conocimiento persistente sobre los mismos. Conclusiones: Se logró durante la ejecución del programa psicoeducativo un incremento total de los niveles de conocimiento en los docentes, correspondiente a un 37%, considerando que algunas de las variables analizadas estuvieron sujetas a falsos positivos (6,2%).Objective: Optimize the teaching-learning process in children with a specific learning disorder from the Colombo Aleman Foundation Volver a Sonreír in the city of Bucaramanga. Method: 250 Teachers from the different headquarters of the German-Colombian Foundation to smile again. Design: Experimental evaluation, with a single pretest-posttest group (intervention group). Instrument: Assessment questionnaire about knowledge of specific learning disorders (Own elaboration). The psychoeducational intervention program was developed during four sessions through virtual platforms due to the Covid-19 contingency, using psychoeducational techniques and practical exercises. Results: There is a statistically significant percentage of the teaching population, which show an increase in their theoretical and practical notions to recognize when they were faced with a possible case of specific learning disorder, with 97% of the population with knowledge of the disorder. specific learning and 3% who reported their persistent non-knowledge about them. Conclusions: During the execution of the psychoeducational program, a total increase in the levels of knowledge in the teachers was achieved, corresponding to 37%, considering that some of the variables analyzed were subject to false positives (6.2%).Introducción. -- Objetivos. -- General. -- Específicos. -- Justificación. -- Fundamentación. -- Marco teórico. -- Teoría de Piaget. -- Marco legal. -- Marco investigativo. -- Investigaciones Internacionales Investigaciones nacionales. -- Propuesta metodológica. -- Participantes. -- Instrumento. -- Diseño y procedimiento. -- Propuesta destinataria. -- Actividades. -- Cronograma de Actividades. -- Análisis de Resultados. -- Preguntas tipo Likert Pos-Test. -- Conclusiones. -- Recomendaciones. -- Referencias. -- [email protected]@[email protected]

Taller de comercialización de los excedentes producidos por los centros de producción de la universidad cooperativa de Colombia seccional Bucaramanga

El taller de comercialización de los excedentes de los centros de producción y formación de la Universidad Cooperativa de Colombia ha hecho posible la participación del esfuerzo colectivo de un equipo de profesionales en las áreas de ingeniería de mercados y medicina veterinaria y zootecnia, mediante la investigación descriptiva y exploratoria aplicada en el campo practico para una mejor toma de decisiones. Luego del redireccionamiento proporcionado al taller de grado inicialmente denominado mejoramiento de productos y procesos productivos de los centros de producción de la Universidad Cooperativa de Colombia se iniciaron actividades de recolección y selección de información de los centros de producción, así como de los temas a tratar en el proyecto a partir de libros, folletos, revistas, paginas electrónicas, medios magnéticos y el aporte profesional de los docentes de dichas facultades. Habiendo comprendido y analizado la fundamentación teórica correspondiente a los centros de producción y formación de la fortuna y Guatiguará se continuo con la elaboración de los proyectos pertinentes a los mismos. En el centro de producción la fortuna se realizaron visitas que permitieron conocer la situación real de los sistemas productivos en el manejo de pastos tanto de corte como de pradera, forrajes y en semovientes el análisis de los costos que intervienen en el manejo del ganado bovino lechero de la raza Holstein Friesan. En el centro de producción Guatiguará los forrajes constituyen la fuente de materia prima mas importante para la alimentación del ganado, el cual es vulnerable y abundante en épocas de lluvias y de escasez en tiempos de sequía, aspecto que conduce al sobre pastoreo, a la disminución de la producción de leche, a la perdida de peso, al retraso del crecimiento, incremento del costo de producción y a un menor ingreso percibido. Por lo tanto para superar estas limitantes de almacenamiento y conservación de forraje que se presenta en el centro de producción pecuario de Guatiguará, se optará por la técnica de ensilaje la cual requiere de estrategias que conduzcan a la disponibilidad de forraje abundante y de buena calidad en forma permanente y a bajo costo para el consumo de los animales. Respecto a la producción avícola se propone un proyecto para poner en marcha iniciativas de desarrollo de producción orgánica y semiorganica con un seguimiento de estrategias de desarrollo rural, en busca de un producto de calidad y seguridad alimentaría. Ante la necesidad de ofertar los bienes producidos por los centros de producción y formación de la Universidad Cooperativa de Colombia y con el objetivo de aplicar conocimientos, habilidades, destrezas y experiencias se plantea un proyecto que condense dicha información en un portafolio de productos y servicios que incluye el diseño de marca, logotipo, logosimbolo, imagen corporativa y tipografía del color, proyectados en la imagen visual y el material impreso se determina la viabilidad en el diseño de una pagina web, todo ello haciendo uso de instrumentos de investigación como la observación, análisis y deducción, matriz DOFA y demás herramientas básicas parra el desarrollo del proyecto, acompañado de una serie de actividades de mercadeo que permiten mejorar la producción e investigación existente y a su vez aprovechar el recurso humano, técnico, financiero y de infraestructura hacia el beneficio de los propietarios y la comunidad local, regional y nacional.Introducción. -- 1. Producción y evaluación de pastos y forraje (gramíneas y leguminosas) y semovientes Centro de producción pecuario la fortuna. – 1.1 Antecedentes históricos. -- 1.1.1 Historia productiva de la finca la fortuna. -- 1.2 Marco teórico. -- 1.3 Marco legal. -- 1.4 Situación actual del centro de producción. -- 1.4.1 Pastos de pradera para pastoreo. -- 1.4.2 Oferta de forraje en pradera. -- 1.4.3 Selección de la especie. -- 1.4.4 Aforo. -- 1.4.5 Control de malezas. -- 1.4.6 Método de aplicación de los fertilizantes. -- 1.4.7 Riego. -- 1.4.8 Tipo de pastoreo. -- 1.4.9 Provisión de agua y sales minerales a los animales. -- 1.4.10 Henolaje. -- 1.5 Pasto de corte. -- 1.5.1 Procedimiento para el manejo de pasto de corte. -- 1.5.2 Consumo diario. -- 1.5.3 Compostage. -- 1.5.4 Procedimiento de preparación de compostaje. -- 1.6 Producción pecuaria. -- 1.6.1 Lote de producción. -- 1.6.2 Lote de terneras. -- 1.6.3 Lote de levante. -- 1.6.4 Lote de horras. -- 1.6.5 Reproductor. -- 1.7 Sistema de ordeño. -- 1.7.1 Procedimiento para el ordeño mecánico. -- 1.7.2 Elementos utilizados en el sistema de ordeño. -- 1.7.3 Producción de leche. -- 1.7.4 Ordeñadora transportable cerezo. -- 1.8 Costos de producción. -- 1.8.1 Costos de producción mensual año 2004. -- 1.8.2 Relación de costos de producción del hato lechero. -- 1.9 Propuestas. -- 1.9.1 Pastos y forrajes. -- 1.9.2 Zona de pastos de corte (demanda y oferta). -- 1.9.3 Señalética de espacios externos. -- 1.9.4 Proceso de ordeño y sala para este fin. -- 1.9.5 Área de fármacos e insumos veterinarios y zootécnicos. -- 1.9.6 Mejoramiento de intervalos de corte y oferta de forrajes. -- 1.10 Impacto ambiental. -- 2. Almacenamiento y conservación de forrajes. -- Centro de producción pecuario guatiguara. -- 2.1 Generalidades del ensilaje. -- 2.2 Etapas del ensilaje. -- 2.2.1 Respiración. -- 2.2.2 Acidificación. --2.3 Calidad del ensilaje. -- 2.4 Ventajas y desventajas del ensilaje. -- 2.5 Principios del ensilaje. -- 2.6 Forrajes para ensilar. -- 2.7 El silo. -- 2.7.1 Silo de montón. -- 2.8 El ensilaje como alimento. -- 2.9 Perdidas en el ensilaje. -- 2.10 Plantas que se pueden ensilar. -- 2.11 Manejo agronómico del cultivo del maíz. -- 2.11.1 Ecología. -- 2.11.2 Semilla. -- 2.11.3 Semilla a utilizar para el estudio. -- 2.11.4 Rendimiento del maíz. -- 2.12 Prácticas de manejo. -- 2.12.1 Preparación del suelo. -- 2.12.2 Siembra. -- 2.12.3 Fertilización. -- 2.12.4 Manejo de malezas. -- 2.12.5 Plagas y su manejo. -- 2.13 Manejo alelopatico de los cultivos. -- 2.13.1 Tipo de control alelopatico. -- 2.14 Lombricultura o vermicultura. -- 2.14.1 Siembra. -- 2.15 Diseño, metodológico. -- 2.15.1 Diseño. -- 2.15.2 Procedimiento. -- 2.16 Costos de producción. -- 2.16.1 Costos directos. --2.16.2 Costos indirectos. -- 3. Propuesta avicola. -- 3.1 Marco teorico. -- 3.2 Marco referencial. -- 3.2.1 Marco contextual. -- 3.3 Requerimientos nutricionales de las aves. -- 3.3.1 Alimentación. -- 3.4 Sanidad animal. -- 3.5 Alternativas organicas para la alimentación de las aves. -- 3.5.1 Mataratón (gliricida sepium). -- 3.5.2 El bledo (amaranthus retroflexus ) . -- 3.5.3 El aro (trichantera gigantea). -- 3.6 Horticultura y plantas aromaticas. -- 3.6.1 La sábila (aloe vera o burman). -- 3.6.2 La albahaca (ocinum basilicum). -- 3.6.3 La limonaria (lemon grass). -- 3.6.4 La calédula (caléndula officinalis). -- 3.7 Alternativa de suplementacion en avicultura. -- 3.7.1 Lombricultura. -- 3.7.2 Compost. -- 3.7.3 Lombriz roja californiana (eisenia foetida). -- 3.7.4 La lombriz aliada del hombre. -- 3.7.5 alimentación. -- 3.7.6 Un cultivo naciente. -- 3.7.7¿De que se alimenta la lombriz? -- 3.7.8 ¿Cómo se cosecha la lombriz en el lombricultor? . -- 3.7.9 ¿Cómo se cultiva el lombricompuesto? -- 3.7.10 Características de la lombriz roja californiana. -- 3.7.11 Lombricultura como actividad rentable. -- 3.7.12 Recomendaciones para el cultivo. -- 3.8 Produccion de lombriz roja californiana con Bovinaza (estiercol de vaca o boñiga). -- 3.8.1 Método de producción. -- 3.8.2 Aspectos a tener en cuenta en la lombricultura. -- 3.9 Análisis de costos directos, indirectos y de Inversión de los centros de producción pecuarios en la producción orgánica de aves. -- 3.9.1 Costos variables. – 3.9.2 Costos fijos. -- 3.9.3 Costos de inversión. -- 3.10 Costos del proyecto. -- 3.10.1 Costos de producción. -- 3.10.2 Costos totales del proyecto. -- 3.11 Ventas al público. -- 3.12 Utilidad esperada. -- 4. Portafolio de productos y servicios. -- 4.1 Antecedentes históricos. -- 4.2 Antecedentes contextuales. -- 4.2.1 La inseminación artificial. -- 4.2.2 Porcinos. -- 4.3 Antecedentes teórico. -- 4.3.1 ¿Qué es una marca? -- 4.3.2 Imagen de marca. -- 4.3.3 Identidad corporativa. -- 4.3.4 La imagen corporativa. -- 4.3.5 Elementos básicos del diseño. -- 4.3.6 Teoría del color. -- 4.3.7 Tipografía. -- 4.3.8 Edición de revistas. -- 4.4 Antecedentes legales. -- 5. Diagnostico. -- 5.1 Competitividad. -- 5.2 Matriz dofa. -- 5.3 Marketing mix. -- 6. Desarrollo. -- 6.1 Portafolio de productos y servicios. -- 6.1.1 Objetivo general. -- 6.1.2 Objetivos específicos. -- 6.1.3 Justificación. -- 6.1.4 Propuesta. -- 6.2 Imagen corporativa. -- 6.2.1 Objetivo general. -- 6.2.2 Objetivo específico. -- 6.2.3 justificación. -- 6.2.4 propuesta. -- 6.3 diseño página web. -- 6.3.1 Objetivo general. -- 6.3.2 Objetivo específico. -- 6.3.3 Justificación. -- 6.4 Mercadeo de lechones. -- 6.4.1 Objetivo general. -- 6.4.2 Objetivo específico. -- 6.4.3 Justificación. -- 6.4.4 Propuesta. -- 6.5 Desarrollo de estrategias. -- 6.5.1 Objetivo general. -- 6.5.2 Objetivo específico. -- 6.5.3 Justificación. -- 6.5.4 Propuesta. -- 7. Impacto. -- 7.1 Social. -- 7.2 Ambiental. -- 7.3 cultural. – Conclusiones. -- Recomendaciones. -- Glosario veterinario. -- Glosario de mercadeo. -- Anexos. -- Bibliografía. [email protected]@[email protected]@[email protected]@[email protected]@[email protected]é[email protected]@[email protected]@[email protected]ñó[email protected]@[email protected]@[email protected]

Memorias VIII Coloquio Perspectivas Metodológicas y Pedagógicas de la Investigación en Lengua Materna

La investigación como campo de actuación profesional requiere que las dimensiones del ser y del hacer del profesor se expliciten mediante actitudes y aptitudes desde las cuales se incida en procesos de innovación y transformación educativa y cultural, coherentes con el contexto histórico-social del momento. "Perspectivas de la Investigación en Pedagogía de la Lengua Materna y la Literatura" presenta el trabajo de discusión académica desarrollado en el VIII Coloquio en Pedagogía de la Lengua Materna, a propósito de los estatutos metódicos, teóricos y pedagógicos involucrados en el devenir de las investigaciones sobre la enseñanza -aprendizaje de la lengua materna y de la literatura, como también sobre el proceso de formación del docente - investigador en este campo.Research as a field of professional action requires that the dimensions of the being and of the teacher be made explicit through attitudes and skills from which the processes of innovation and educational and cultural transformation are based, coherent with the historical-social context of the moment. "Perspectives of Research in Pedagogy of the Mother Tongue and Literature" presents the academic discussion work developed in the VIII Colloquium in Pedagogy of the Mother Tongue, with regard to the methodical, theoretical and pedagogical statutes involved in the evolution of research on teaching - learning the mother tongue and literature, as well as the process of teacher training - researcher in this field.Bogotá-Colombi

NEOTROPICAL CARNIVORES: a data set on carnivore distribution in the Neotropics

Mammalian carnivores are considered a key group in maintaining ecological health and can indicate potential ecological integrity in landscapes where they occur. Carnivores also hold high conservation value and their habitat requirements can guide management and conservation plans. The order Carnivora has 84 species from 8 families in the Neotropical region: Canidae; Felidae; Mephitidae; Mustelidae; Otariidae; Phocidae; Procyonidae; and Ursidae. Herein, we include published and unpublished data on native terrestrial Neotropical carnivores (Canidae; Felidae; Mephitidae; Mustelidae; Procyonidae; and Ursidae). NEOTROPICAL CARNIVORES is a publicly available data set that includes 99,605 data entries from 35,511 unique georeferenced coordinates. Detection/non-detection and quantitative data were obtained from 1818 to 2018 by researchers, governmental agencies, non-governmental organizations, and private consultants. Data were collected using several methods including camera trapping, museum collections, roadkill, line transect, and opportunistic records. Literature (peer-reviewed and grey literature) from Portuguese, Spanish and English were incorporated in this compilation. Most of the data set consists of detection data entries (n = 79,343; 79.7%) but also includes non-detection data (n = 20,262; 20.3%). Of those, 43.3% also include count data (n = 43,151). The information available in NEOTROPICAL CARNIVORES will contribute to macroecological, ecological, and conservation questions in multiple spatio-temporal perspectives. As carnivores play key roles in trophic interactions, a better understanding of their distribution and habitat requirements are essential to establish conservation management plans and safeguard the future ecological health of Neotropical ecosystems. Our data paper, combined with other large-scale data sets, has great potential to clarify species distribution and related ecological processes within the Neotropics. There are no copyright restrictions and no restriction for using data from this data paper, as long as the data paper is cited as the source of the information used. We also request that users inform us of how they intend to use the data

Reproducibility of fluorescent expression from engineered biological constructs in E. coli

We present results of the first large-scale interlaboratory study carried out in synthetic biology, as part of the 2014 and 2015 International Genetically Engineered Machine (iGEM) competitions. Participants at 88 institutions around the world measured fluorescence from three engineered constitutive constructs in E. coli. Few participants were able to measure absolute fluorescence, so data was analyzed in terms of ratios. Precision was strongly related to fluorescent strength, ranging from 1.54-fold standard deviation for the ratio between strong promoters to 5.75-fold for the ratio between the strongest and weakest promoter, and while host strain did not affect expression ratios, choice of instrument did. This result shows that high quantitative precision and reproducibility of results is possible, while at the same time indicating areas needing improved laboratory practices.Peer reviewe

Risk of COVID-19 after natural infection or vaccinationResearch in context

Summary: Background: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection. Methods: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection status at enrolment and treatment: no previous infection/placebo; previous infection/placebo; no previous infection/vaccine; and previous infection/vaccine. The main outcome was RT-PCR-confirmed COVID-19 >7–15 days (per original protocols) after final study injection. We calculated crude and adjusted efficacy measures. Findings: Previous infection/placebo participants had a 92% decreased risk of future COVID-19 compared to no previous infection/placebo participants (overall hazard ratio [HR] ratio: 0.08; 95% CI: 0.05–0.13). Among single-dose Janssen participants, hybrid immunity conferred greater protection than vaccine alone (HR: 0.03; 95% CI: 0.01–0.10). Too few infections were observed to draw statistical inferences comparing hybrid immunity to vaccine alone for other trials. Vaccination, previous infection, and hybrid immunity all provided near-complete protection against severe disease. Interpretation: Previous infection, any hybrid immunity, and two-dose vaccination all provided substantial protection against symptomatic and severe COVID-19 through the early Delta period. Thus, as a surrogate for natural infection, vaccination remains the safest approach to protection. Funding: National Institutes of Health

Risk of COVID-19 after natural infection or vaccinationResearch in context

Background: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection. Methods: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection status at enrolment and treatment: no previous infection/placebo; previous infection/placebo; no previous infection/vaccine; and previous infection/vaccine. The main outcome was RT-PCR-confirmed COVID-19 >7–15 days (per original protocols) after final study injection. We calculated crude and adjusted efficacy measures. Findings: Previous infection/placebo participants had a 92% decreased risk of future COVID-19 compared to no previous infection/placebo participants (overall hazard ratio [HR] ratio: 0.08; 95% CI: 0.05–0.13). Among single-dose Janssen participants, hybrid immunity conferred greater protection than vaccine alone (HR: 0.03; 95% CI: 0.01–0.10). Too few infections were observed to draw statistical inferences comparing hybrid immunity to vaccine alone for other trials. Vaccination, previous infection, and hybrid immunity all provided near-complete protection against severe disease. Interpretation: Previous infection, any hybrid immunity, and two-dose vaccination all provided substantial protection against symptomatic and severe COVID-19 through the early Delta period. Thus, as a surrogate for natural infection, vaccination remains the safest approach to protection. Funding: National Institutes of Health

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)