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

Experimental reality: principles for the design of augmented environments

The Laboratory of Design for Cognition at EDF R&D (LDC) is a living laboratory which we created in order to develop AE for collaborative work, more specifically “cognitive work” (white collars, engineers, office workers). It is a corporate laboratory in a large industry, where natural activity of real users is observed in a continuous manner in various spaces (project space, meeting room, lounge, etc.) The RAO room, an augmented meeting room, is used daily for “normal” meetings; it is also the “mother room” of all augmented meeting rooms in the company; where new systems, services and devices are tested. The LDC has gathered a unique set of data on the use of AE, and developed various observation and design techniques, described in this chapter. LDC uses novel techniques of digital ethnography, some of which were invented there (SubCam, offsat) some of which were developed elsewhere and adapted (360° video, WebDiver, etc.) At LDC have also been developed some new theories to explain behavior and guide innovation: cognitive attractors, experimental reality, and the triple-determination framework. Published as Chapter 5 in In S. Lahlou (ed.) Designing User Friendly Augmented Work Environments. From Meeting Rooms to Digital Collaborative Spaces. London: Springer, Computer Supported Cooperative Work Series, 200

Representation, interaction and interpretation : Making sense of the context in clinical reasoning

Background All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised. Aims Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning. Discussion We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning. Conclusion The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of ‘what is going on with this patient’ necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice