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

Epidemiology of osteoporosis: a study of fracture mortality in Italy.

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The influence of environmental changes on local and regional vegetation patterns at Rieme (NW Belgium): implications for Final Palaeolithic habitation

Late-glacial vegetation changes were studied at Rieme, NW Belgium. Human occupation of this cover sand area occurred from the Final Palaeolithic onwards. The research area is situated on the northern side of a large cover sand ridge in an undulating landscape with small ridges and depressions. The past landscape was reconstructed using a multi-disciplinary approach, including geomorphological, sedimentological, loss-on-ignition, botanical (micro- and macrofossil) and zoological analyses. AMS 14C dating provided an accurate chronology for the sediments. Analyses were performed on three sequences located ~200–300 m apart. Our study shows that during the Bølling (GI-1e) wet meadows developed on the sandy soils and groundwater levels increased probably as result of permafrost melting. Shallow pools formed in depressions. During the Older Dryas (GI-1d) shrubs with juniper, seabuckthorn and willow developed. Many shallow depressions were overblown with sand and deposition of organic material almost ceased. In the early Allerød (GI-1c) open birch woodlands developed. Due to the final melting of permafrost, groundwater levels rose further and ponds with floating-leaved open water vegetation developed. Large water level fluctuations occurred in one of the ponds. Accumulation of organic deposits ceased during the mid- Allerød. Indirect evidence for human occupation during the Allerød (GI-1c) was found in indications of burning of the reed-swamps in combination with the presence of large herbivores. Final Palaeolithic people probably used the northern side of the cover sand ridge as hunting area, while they settled their temporary (base) camps on the steep southern side along the extensive and deeper Moervaart lake