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

Adherencia terapéutica en pacientes hipertensos ambulatorios de un hospital de primer nivel de atención de Antioquia, Colombia

Determinar la adherencia terap&eacute;utica enpacientes hipertensos ambulatorios, enun primer nivel de atenci&oacute;n en Colombia.M&eacute;todos: estudio descriptivo observacional, en pacientescon diagn&oacute;stico de hipertensi&oacute;n arterial y terapia 3meses antes. Se aplic&oacute; un formulario que incluyo el testde Morisky-Green para valorar adherencia terap&eacute;utica. Elan&aacute;lisis se realiz&oacute; con el programa SPSS&reg; v. 21, se aplic&oacute;estad&iacute;stica descriptiva con frecuencias absolutas y proporciones.Resultados: participaron 75 pacientes hipertensos,edad promedio 61.7&plusmn;11 a&ntilde;os y participan del programade Promoci&oacute;n y Prevenci&oacute;n 86.7%. Respecto a los resultadosdel test de Morisky-Green un 30.7% de los pacienteshipertensos ha olvidado tomar la medicaci&oacute;n, 13.3%cuando se encontraba bien dej&oacute; alguna vez de tomar lamedicaci&oacute;n. Conclusi&oacute;n: La adherencia terap&eacute;utica encontradaes superior a lo reportado en la literatura, sinembargo, es moderada; es necesario que la instituci&oacute;n estudiela posibilidad de implementar o mejorar estrategiassobre adherencia terap&eacute;utica

Caracterización clínica y epidemiológica de pacientes con enfermedad de von Willebrand que consultan por sangrado uterino anormal atendidas en una institución de alto nivel de complejidad

Caracterizar cl&iacute;nica y epidemiol&oacute;gicamente las pacientes con enfermedad de von Willebrand y sangrado uterino anormal. M&eacute;todos: Estudio observacional descriptivo transversal, en mujeres con diagn&oacute;stico de enfermedad de von Willebrand que consultaron en una instituci&oacute;n de alta complejidad de la ciudad de Medell&iacute;n. El an&aacute;lisis se llev&oacute; a cabo a trav&eacute;s del programa SPSS V 24. Resultados: Se incluyeron 70 pacientes, 50 de estas fueron descartadas por no presentar hemorragia uterina anormal otener otros diagn&oacute;sticos que pod&iacute;an intervenir en la caracterizaci&oacute;n como s&iacute;ndrome antifosfol&iacute;pido. La mediana de la edad de las pacientes incluidas fue de 19,5 a&ntilde;os (m&iacute;n: 11, m&aacute;x: 52), 9 pacientes (60%) planificaban, los m&eacute;todos reportados fueron anticonceptivos orales combinados (26,7%), dispositivos intrauterinos (20%) y m&eacute;todos quir&uacute;rgicos (13,3 %). En cuanto a la caracterizaci&oacute;n cl&iacute;nica realizada, se encontr&oacute; que la presencia de hematomas 40% (8) y epistaxis 40% (8) fueron las manifestaciones m&aacute;s frecuentes. La mayor&iacute;a de las pacientes, 65% (13) no hab&iacute;a recibido tratamiento previo ala consulta para la hemorragia uterina anormal. Respecto a la evaluaci&oacute;n de los paracl&iacute;nicos se encontr&oacute;: hemoglobina 13 g/dL (6,6 &ndash; 15,7), hematocrito 37,5 % (20,3 &ndash; 46,1), plaquetas 279 000 c&eacute;lulas/mm3 (106 000 &ndash; 393 000), ant&iacute;genoplasm&aacute;tico factor de von Willebrand 68,5 UI (19,7 &ndash; 205), actividad plasm&aacute;tica del factor de von Willebrand 44 UI (23 &ndash; 126). Conclusi&oacute;n: El sangrado uterino anormal es una manifestaci&oacute;n frecuente en mujeres con enfermedad de von Willebrandy puede llegar a presentarse en distintas etapas de la vida, pese a su diagn&oacute;stico, las mujeres no reciben manejo de estamanifestaci&oacute;n cl&iacute;nica sino hasta su consulta con ginecolog&iacute;a.Characterize clinically and epidemiologically patients with von Willebrand disease and abnormal uterine bleeding.Methods: A cross-sectional descriptive observational study was carried out. The study population was women with adiagnosis of von Willebrand&rsquo;s disease who consulted in a highly complex institution in the city of Medell&iacute;n. The analysis wascarried out through the SPSS V 24 program.Results: 70 patients were included, 50 of these were discarded because they did not present abnormal uterine bleedingor had other diagnoses that could intervene in the characterization as antiphospholipid syndrome. The median age of theincluded patients was 19.5 years (Min: 11, Max: 52). 9 patients (60%) used contraceptive methods, the reported methodswere combined oral contraceptives (26.7%), intrauterine devices (20%) and surgical methods (13.3%). Regarding theclinical characterization, it was found that the most frequent manifestations were the presence of bruises 40% (8) andepistaxis 40% (8). Most of the patients, 65% (13) had not received treatment for abnormal uterine bleeding. Laboratorytests showed the following: hemoglobin 13 g/dL (6.6 - 15.7), hematocrit 37.5% (20.3 - 46.1), platelets 279,000 cells/mm3(106,000 - 393,000), von Willebrand factor plasma antigen 68.5 IU (19.7 - 205), von Willebrand factor plasma activity 44IU (23 - 126).Conclusion: Abnormal uterine hemorrhage is a frequent manifestation in women with von Willebrand disease and canpresent at different stages of life, despite its diagnosis, women do not receive management of this clinical manifestation untiltheir consultation with gynecology

Naturaleza urbana. Plataforma de experiencias

Naturaleza Urbana presenta experiencias autogestionadas que, con el tiempo, se han posicionado como ejercicios alternativos de identificación, monitoreo y recuperación de la biodiversidad urbana. En otros casos, el modelo comunidad-gobierno ha permitido desarrollar diagnósticos y propuestas de gestión corresponsables y sistémicas, entendiendo por esto último iniciativas que nacen desde los valores mismos que cada comunidad le atribuye a su biodiversidad. Del mismo modo, se presentan esfuerzos gubernamentales que han enriquecido la visión ambiental de los principales instrumentos de planificación urbana, por ejemplo, integrando la condición propiamente urbana como oportunidad para aumentar la oferta ambiental de la ciudad, fortaleciendo las funciones y procesos de la biodiversidad y revitalizando, con ello, la calidad de vida del entorno urbano. Por su parte, las universidades y los centros de investigación se han sumado a la ola emergente de generación de conocimiento en biodiversidad urbana (fenómeno nacional e internacional), han brindado evidencia científica de su valor para el bienestar humano y han propuesto reflexiones y lineamientos cualitativos de biodiversidad, con miras a hacer del ordenamiento un ejercicio más coherente con cada contexto territorial en particular.Bogotá, D. C., ColombiaInstituto de Investigación de Recursos Biológicos Alexander von Humbold

Urban Nature

Preservation, restoration, monitoring of biodiversity and promotion of native species, in their strict and classical sense, could be unviable strategies in the cities. Management systems such as the protected areas acquire profoundly different connotations and objectives from the traditional ones when thought of in the context of a city. Similarly, although ecological restoration seeks to return to a baseline ecosystem, there is little that we know about the vegetation present on the urban borders of the main Colombian cities prior to the 20th century. Finally, the models for potential distribution of species could produce unreliable results, because their methodological bases were not conceived based on urban dynamics. In this context, to de ne urban biodiversity and what strategy must be applied for its conservation implies a challenge that, beyond being scienti c, is necessarily social and cultural and involves planning and design. Innovation is inevitable.Bogotá, D. C