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

Interaction of wind and cold‐season hydrologic processes on erosion from complex topography following wildfire in sagebrush steppe

Wildfire is a natural component of sagebrush (Artemisia spp.) steppe rangelands that induces temporal shifts in plant community physiognomy, ground surface conditions, and erosion rates. Fire alteration of the vegetation structure and ground cover in these ecosystems commonly amplifies soil losses by wind- and water-driven erosion. Much of the fire-related erosion research for sagebrush steppe has focused on either erosion by wind over gentle terrain or water-driven erosion under high-intensity rainfall on complex topography. However, many sagebrush rangelands are geographically positioned in snow-dominated uplands with complex terrain in which runoff and sediment delivery occur primarily in winter months associated with cold-season hydrology. Current understanding is limited regarding fire effects on the interaction of wind- and cold-season hydrologic-driven erosion processes for these ecosystems. In this study, we evaluated fire impacts on vegetation, ground cover, soils, and erosion across spatial scales at a snow-dominated mountainous sagebrush site over a 2-year period post-fire. Vegetation, ground cover, and soil conditions were assessed at various plot scales (8 m2 to 3.42 ha) through standard field measures. Erosion was quantified through a network of silt fences (n = 24) spanning hillslope and side channel or swale areas, ranging from 0.003 to 3.42 ha in size. Sediment delivery at the watershed scale (129 ha) was assessed by suspended sediment samples of streamflow through a drop-box v-notch weir. Wildfire consumed nearly all above-ground live vegetation at the site and resulted in more than 60% bare ground (bare soil, ash, and rock) in the immediate post-fire period. Widespread wind-driven sediment loading of swales was observed over the first month post-fire and extensive snow drifts were formed in these swales each winter season during the study. In the first year, sediment yields from north- and south-facing aspects averaged 0.99–8.62 t ha−1 at the short-hillslope scale (~0.004 ha), 0.02–1.65 t ha−1 at the long-hillslope scale (0.02–0.46 ha), and 0.24–0.71 t ha−1 at the swale scale (0.65–3.42 ha), and watershed scale sediment yield was 2.47 t ha−1. By the second year post fire, foliar cover exceeded 120% across the site, but bare ground remained more than 60%. Sediment yield in the second year was greatly reduced across short- to long-hillslope scales (0.02–0.04 t ha−1), but was similar to first-year measures for swale plots (0.24–0.61 t ha−1) and at the watershed scale (3.05 t ha−1). Nearly all the sediment collected across all spatial scales was delivered during runoff events associated with cold-season hydrologic processes, including rain-on-snow, rain-on-frozen soils, and snowmelt runoff. Approximately 85–99% of annual sediment collected across all silt fence plots each year was from swales. The high levels of sediment delivered across hillslope to watershed scales in this study are attributed to observed preferential loading of fine sediments into swale channels by aeolian processes in the immediate post-fire period and subsequent flushing of these sediments by runoff from cold-season hydrologic processes. Our results suggest that the interaction of aeolian and cold-season hydrologic-driven erosion processes is an important component for consideration in post-fire erosion assessment and prediction and can have profound implications for soil loss from these ecosystems