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

Criteria Based Audit of the Management of Severe Preeclampsia/ Eclampsia in a Nigerian Teaching Hospital

Background: This study discusses the usage of criteria –based audit in a Nigerian teaching hospital to evaluate the quality of care among patients with severe pre-eclampsia/eclampsia (SPE-E) against set standards and proffers possible interventions in order to improve the quality of care.Methods: The study was a prospective, descriptive hospital based study carried out from 1st of March to 31st of December, 2012. We conducted an 18 criterion-based audit on 52 consecutive cases of severe preeclampsia/eclampsia during the study period at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria.Results: There were 34 cases of severe pre-eclampsia and 18 eclamptic patients. The case fatality rate for SPE-E was 5.8 % and 13.5 % perinatal deaths among 59 infants delivered (multiple pregnancies inclusive). From the pre-determined standard of care based on 18 criteria, the performance score ranged from 17.3 to 100% (average 69.1%). Standard of care was optimal (100%) in taking detailed history and documentation, administering magnesium sulfate, initiating drug treatment for severe hypertension, respiratory rate monitoring and steroid treatment for fetal lung maturity and very sub-optimal for various laboratory investigations and initial consultant obstetrician input in the management of patients.Conclusion: For improvements in maternal and perinatal outcomes for patients with SPE-E, there should be strengthening of hospital facilities and avoidance of Phase 3 treatment delays in carrying out the comprehensive emergency obstetric and neonatal care needed. Hospital leaders should also be trained in hospital management for qualitative care.Keywords: Severe pre-eclampsia, eclampsia, criteria-based audit

The quest for accurate theoretical models of metalloenzymes: An aid to experiment

Enzymes are versatile oxidants in Nature that catalyze a range of reactions very efficiently. Experimental studies on the mechanism of enzymes are sometimes difficult due to the short lifetime of catalytic cycle intermediates. Theoretical modeling can assist and guide experiment and elucidate mechanisms for fast reaction pathways. Two key computational approaches are in the literature, namely quantum mechanics/molecular mechanics (QM/MM) on complete enzyme structures and QM cluster models on active site structures only. These two approaches are reviewed here. We give examples where the QM cluster approach worked well and, for instance, enabled the bioengineering of an enzyme to change its functionality. In addition, several examples are given, where QM cluster models were insufficient and full QM/MM structures were needed to establish regio-, chemo-, and stereoselectivities