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

Design of a modular testing platform for the handling and study of endovascular devices

A design for a modular testing platform to objectively evaluate the behavior and characteristics of specialized endovascular instruments (guidewires/catheters) was presented and discussed. The platform comprises of an instrument driving mechanism and an interchangeable channel module depending on the parameter that is being measured. This platform could be used to study and benchmark commercial endovascular instruments. Such a guide would be useful to assist clinicians in the selection of the best tools for a given procedure. and derive the behavioral model for each instrument

Optimal sizing of hybrid photovoltaic/diesel/battery nanogrid using a parallel multiobjective PSO-based approach: Application to desert camping in Hafr Al-Batin city in Saudi Arabia

Designing a nanogrid involves intricate considerations. Its primary system components, including PV systems, inverter type and control, batteries, and diesel generator, always offer a trade-off among conflicting design objectives – the cost of electricity and reliability, for example. This research proposes a synergistic Parallel Multiobjective PSO-based approach (PMOPSO), a merger of four optimization methods to optimally design a hybrid photovoltaic/diesel/battery nanogrid. The merged approaches are the Speed-Constrained Multiobjective Particle Swarm Optimization (SMPSO), MultiObjective Particle Swarm Optimization Algorithm Based on Decomposition (MPSO-D), Novel multiobjective particle swarm optimization (NMPSO), and Competitive Mechanism-Based Multiobjective Particle Swarm Optimizer (CMPSO). The developed approach allows the designer/operator to test multiple component models based on cost and reliability and choose the design that gives the best-suited solution. The four combined algorithms are run in parallel, and the obtained solutions are aggregated together in an archive pool where only non-dominated solutions are kept. A desert camp in the sub-urban area of Hafr Al-Batin city, situated in the Western region of Saudi Arabia, is used as a test case. The approach obtains a well-spread and large Pareto Front (PF), offering many options (solutions) to the designer/operator in a single run. The results achieved a superior set of solutions than those obtained by using each of the four combined PSO-based algorithms individually. Therefore, the developed technique provides improved and viable design solutions for a hybrid nanogrid