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

Otimização do processo de mineralização de compostos orgânicos utilizando sistemas eletro-Fenton e fotoeletro Fenton por irradiação UV artificial e solar

OPTIMIZATION OF THE MINERALIZATION PROCESS OF ORGANIC COMPOUNDS USING ELECTRO-FENTON AND PHOTO-FENTON SYSTEMS BY ARTIFICIAL AND SOLAR UV IRRADIATION Electrochemical advanced oxidation processes based on the Fenton s reaction, such as electro-Fenton (EF) and photoelectro-Fenton (PEF) using artificial and solar UV irradiation were employed in the treatment of effluents containing organic compounds (the textile dye AR 29 acid red 29, the drug paracetamol and the herbicide MCPA 2-methyl-4- chlorophenoxyacetic acid). Furthermore, kinetic studies of degradation of these compounds were performed, using factorial design in order to analyze simultaneously the influence of the parameters current, initial concentration of the catalyst Fe2+ and pH as well as the response surface methodology in order to optimize the experimental conditions. Finally, chromatographic techniques were also used for identification and quantification of the intermediates of the degradation process, among which aromatic compounds, carboxylic acids and inorganic ions. For the three investigated compounds, it was found that the main oxidant was the hydroxyl radical, OH produced by the Fenton s reaction between the catalyst Fe2+ added and the H2O2 electrogenerated by the O2 reduction at the surface of the diffusion air cathode as well as by the photolysis of hydroxylated Fe3+ species. Additionally, the use of the UV radiation, either by artificial or solar source, promoted the fast removal of Fe3+ complexes formed with carboxylic acids which were not actually removed by the OH radical. In the case of AR 29 dye, the highest efficiency was obtained for the PEF process (TOC total organic carbon removal of 95%), followed by EF process; the anodic oxidation presented the lowest performance. For paracetamol and MCPA, investigated only by the PEF process, values of TOC removal of 75 % and 74 % for the optimal conditions at 120 min electrolysis were obtained, respectively. Moreover, MCE mineralization current efficiency values of 71% for paracetamol and 72% for MCPA with EC energy consumption values of 93 kW h kg-1 TOC (7.0 kW h m-3) and 87.7 kW h kg-1 TOC (6.6 kW h m-3) were obtained, respectively. Finally, using distinct liquid chromatography techniques in order to identify and quantify the generated intermediates, plausible mechanisms for degradation of the three investigated compounds up to their complete conversion to CO2 and water were proposed.Financiadora de Estudos e ProjetosOTIMIZAÇÃO DO PROCESSO DE MINERALIZAÇÃO DE COMPOSTOS ORGÂNICOS UTILIZANDO SISTEMAS ELETRO-FENTON E FOTOELETROFENTON POR IRRADIAÇÃO UV ARTIFICIAL E SOLAR Processos eletroquímicos oxidativos avançados baseados na reação de Fenton, tais como eletro-Fenton (EF) e fotoeletro-Fenton por irradiação UV artificial (FEF) e solar (FEFS) foram empregados no tratamento de efluentes contendo compostos orgânicos (o corante têxtil AR 29 vermelho ácido 29, o fármaco paracetamol e o herbicida MCPA ácido 2-metil-4- clorofenoxiacético). Além disso, foram realizados estudos cinéticos da degradação destes compostos, empregando-se planejamentos fatoriais para analisar, simultaneamente, a influência das variáveis corrente, concentração inicial do catalisador Fe2+ e pH, bem como a metodologia de superfície de resposta para otimizar as condições experimentais. Finalmente, também foram utilizadas técnicas cromatográficas para identificação e quantificação dos intermediários do processo de degradação, dentre os quais compostos aromáticos, ácidos carboxílicos e íons inorgânicos. Para os três compostos investigados, constatou-se que o principal oxidante foi o radical hidroxila, OH produzido pela reação de Fenton entre o catalisador Fe2+ adicionado e o H2O2 eletrogerado pela redução de O2 na superfície do catodo de difusão de ar, bem como pela fotólise de espécies de Fe3+ hidroxiladas. Ademais, o emprego da radiação UV, seja por meio de fonte artificial ou solar, favoreceu a rápida remoção de complexos de Fe3+ formados com ácidos carboxílicos, os quais não eram efetivamente removidos pelo radical &#9679;OH. No caso do corante AR 29, a maior eficiência foi obtida para o processo FEF (95% de remoção do COT carbono orgânico total), seguido pelo processo EF; o processo de oxidação anódica apresentou o menor desempenho. Para os compostos paracetamol e MCPA, investigados somente pelo processo FEFS, foram obtidos valores de remoção de COT de 75% e 74% para as condições ótimas em 120 min de eletrólise, respectivamente. Além disso, foram obtidos valores de ECM eficiência de corrente de mineralização de 71% para o paracetamol e 72% para o MCPA com valores de CE consumo energético de 93 kW h kg-1 COT (7,0 kW h m-3) e 87,7 kW h kg-1 COT (6,6 kW h m-3), respectivamente. Por fim, empregando-se distintas técnicas de cromatografia líquida para identificação e quantificação dos intermediários gerados, foram propostos mecanismos plausíveis para os processos de degradação dos três compostos investigados, até completa conversão a CO2 e água