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

Transfer reactions catalyzed by β-D-xylosidase from Penicillium wortmanni

The β-D-xylosidase from Penicillium wortmanni catalyses (i) the hydrolysis of β-D-xylopyranosides and α-L-arabinopyranosides, (ii) the transfer of the corresponding glycosyl residue to alcohols, and (iii) the dismutation of aryl β-D-xylopyranoside substrates. These reactions all occur with retention of configuration and can be rationalized by a symmetrical reaction scheme. The key intermediate is an enzyme–glycosyl complex with a lifetime that is sufficient for the diffusion away of the leaving (aglycon) group and the binding of an acceptor group before water reacts with the intermediate. The exact nature of this complex is unknown, but it must contain an aglycon site which binds preferentially alcohols and sugar molecules having the D-xylose structure