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

Hiv and Covid - A recipe for disaster

To the editor, As the latest variant of Covid-19, OMICRON (B.1.1.529), makes its entry into Pakistan,1 one can’t help but wonder about the possibility of new strains emerging from this region of the world in particular Sindh. These fears stem from speculations amongst the scientific community over the variants possible emergence from an individual who was immune deficient; cancer, organ transplant or someone with uncontrolled HIV.2 Sindh not only has the highest number of Covid cases in Pakistan3  but also reported the first case of omicron a few days ago in Karachi.1 This coupled with the recent acquired immunodeficiency syndrome (AIDS) outbreak of 2019 in Sindh with around 751 of the 26,041 testing positive and 604(80%) of them being children is particularly worrisome. It must be kept in mind that these numbers are dangerously underreported. The performance of the Sindh AIDS Control Programme is under question as they fail to contain the outbreak.4 All this makes one worry about the cocktail of strains that are likely to emerge from Sindh. HIV remains silent for a number of years and majority of those infected are unaware of the disease until they develop AIDS. These immune compromised individuals have a higher risk of mortality associated with Covid-19. The virus lingers in their bodies for a longer period of time allowing it to mutate and develop new ways to evade the immune system.2,5 In order to prevent new variants from emerging from Sindh, which is more likely than not it is imperative that the local government amp up their vaccination efforts alongside intensified effort to end HIV as a health care problem. This can only be done with awareness programmes educating the masses on the disease, and its severity with co infection with Covid-19. Testing needs to be readily available free of cost and people encouraged to get tested. Information about safe sex and how the disease is transmitted needs to be conveyed to individuals all the while being respectful towards cultural and religious beliefs. It is important that the government work alongside healthcare professionals and the international community in dealing with this problem while it is still manageable at the risk of a deadly new variant emerging from this region.</jats:p

Design and Measurement of a Modern Charging System Based on IoT

This paper presents a modern charging system to improve the reliability of locating the closest and available free charging slot to charge low-power smart-devices. Also, the presented system is based on the cloud and the used network is based on the internet of things technology. The basic idea of the charging system is to provide a public charging place for all individuals who wish to charge their smart devices when it is close to running out. First and foremost, the charging system was designed and implemented to have multiple power sources in the event that one of the system's power sources failed. Secondly, the charging system provides a special smart mobile application that has also been designed and implemented, which allows the user to know the locations of the charging systems on a map and choose the nearest available system near the user. After selecting the nearest charging system, the user will be able to know whether or not there is an available charging port and the number of associated devices in each system. The study successfully built this system in practical life.</jats:p