Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Architecture and attachment: Carceral collectivism and the problem of prison reform in Russia and Georgia

This article looks at the trajectory of prison reform in post-Soviet Georgia and Russia. It attempts to understand recent developments through an analysis of the resilient legacies of the culture of punishment born out of the Soviet period. To do this, the article fleshes out the concept of carceral collectivism, which refers to the practices and beliefs that made up prison life in Soviet and now post-Soviet countries. The collapse of the Soviet Union in 1991 revealed a penal culture in notable need of reform. Less obvious, in retrospect, was how over the course of a century this predominantly ‘collectivist’ culture of punishment was instantiated in routine penal practices that stand in opposition to western penalities. The article shows how the social and physical structuring of collectivism and penal self-governance have remained resilient in the post-Soviet period despite diverging attempts at reform in Russia and Georgia. The article argues that persistent architectural forms and cultural attachment to collectivism constitute this resilience. Finally, the article asks how studies of collectivist punishment in the post-Soviet region might inform emerging debates about the reform and restructuring of individualizing, cell-based prisons in western jurisdictions