Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

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 middle-income 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 low-income 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 low-income, 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

Experts, theories, and electric mobility transitions: toward an integrated conceptual framework for the adoption of electric vehicles

I expand and integrate a theory of mobility (Automobility) with one of science and technology (Actor Network Theory) and one about social acceptance and user adoption (UTAUT). I apply this integrative framework to the diffusion (and non-diffusion) of electric vehicles and the process of electric mobility. I begin by presenting my methods, namely semi-structured qualitative research interviews with social theorists. Then, I present the three theories deemed most relevant by respondents. Automobility holds that, on a cultural or social level, automobiles exist as part of a complex, one that involves hardware and infrastructure—a hybridity between drivers and machines—along with patterns of identity and attitudes about driving pleasure. Actor Network Theory (ANT) involves the concepts of network assemblage, translation, enrollment, and actants and lieutenants. The Unified Theory of Acceptance and Use of Technology, or UTAUT, states that on an individual level, the adoption of new technologies will be predicated on interconnected factors such as performance expectancy, effort expectancy, and other facilitating conditions. Based largely on the original interview data supplemented with peer-reviewed studies, I propose a conceptual framework of user acceptance consisting of motile pleasure, sociality, sociotechnical commensurability, and habitual momentum. I conclude with implications for research and policy

Correlation of Intraocular Pressure Between Both Eyes After Bilateral Selective Laser Trabeculoplasty in Open-Angle Glaucoma

PURPOSE: To investigate the correlation of intraocular pressure (IOP)-lowering effects of selective laser trabeculoplasty (SLT) between the 2 eyes treated with SLT in open-angle glaucoma (OAG). METHODS: This prospective cohort study sequentially recruited subjects with bilateral OAG. All subjects received a single session of 360-degree SLT treatment. Success was defined as IOP reduction of ≥20%. Spearman correlation was used to compare the following parameters between the 2 eyes following SLT: IOP at day 1, 1 week, and 1 month; percentage of success; and IOP reduction. RESULTS: In 84 eyes of 42 subjects that received bilateral SLT treatment, both eyes had statistically comparable baseline characteristics. There were significant correlations between the IOP in both eyes at all time intervals following SLT as well as for the percentage of IOP reduction and the success rate at 1 month after SLT (all r≥0.7, P0.6, P<0.02). Nineteen percent had success in 1 eye and nonsuccess in the fellow eye with an inverse correlation between the 2 eyes (Spearman r=-0.7, P=0.03). CONCLUSION: There is a strong and significant correlation in the IOP-lowering response to SLT between both eyes in near 80% of treated OAG subjects, whereas near 20% had an asymmetrical and inverse response to SLT between both the eyes

Meta-analysis on the efficacy of selective laser trabeculoplasty in open-angle glaucoma

Poster Session 10: Other: POAG, ACGPurpose: To compare the efficacy of selective laser trabeculoplasty(SLT) with argon laser trabeculoplasty(ALT) and medication in the treatment of open-angle glaucoma(OAG) Method: We identified randomized controlled trials from databases including Pubmed, EMBASE, CENTRAL, thesis and dissertation databases as well as hand searching. Two authors independently assessed the quality of eligible trials. Outcome measures included absolute mean IOP reduction and odds ratio(OR) for treatment success. Heterogeneity was assessed through I2 statistics. Sensitivity analyses were performed to assess pooled estimates after excluding studies with outlying results. Result: 244 relevant records were identified. After qualitative assessment, 4 trials were included for comparison between SLT and ALT, involving a pooled total of 150 and 140 eyes in the SLT and ALT group respectively. There was no significant difference in the pooled mean IOP reduction (pooled estimate -0.5 mmHg, 95% confidence interval (C.I.) -1.5 to 0.4 mmHg). SLT was also non-inferior to ALT in achieving treatment success (OR 1.2, 95% C.I.: 0.7 to 1.8). Another 4 trials were included for comparison between SLT and medication. There was a pooled total of 166 eyes involved in SLT and 107 eyes in medication. The difference in pooled mean IOP reduction was not significant (pooled estimate 0.85 mmHg, 95% C.I. -0.2 to 1.9). SLT was also comparable to medication in achieving treatment success (OR 0.8, 95% C.I. 0.33 to 2.0). Conclusion: This meta-analysis provides evidence that SLT has comparable efficacy to ALT and medication in IOP lowering and achieving treatment success. For newly diagnosed OAG patients, SLT may be offered as a primary treatment apart from medication. In those having uncontrolled IOP with maximally tolerated medication, SLT can be offered as an alternative to ALT before considering invasive surgery

Hypertensive retinopathy

10.1056/NEJMra032865New England Journal of Medicine351222310-2317NEJM