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

Decentralized energy systems for clean electricity access

Innovative approaches are needed to address the needs of the 1.3 billion people lacking electricity, while simultaneously transitioning to a decarbonized energy system. With particular focus on the energy needs of the underserved, we present an analytic and conceptual framework that clarifies the heterogeneous continuum of centralized on-grid electricity, autonomous mini-or community grids, and distributed, individual energy services. A historical analysis shows that the present day is a unique moment in the history of electrification where decentralized energy networks are rapidly spreading, based on super-efficient end-use appliances and low-cost photovoltaics. We document how this evolution is supported by critical and widely available information technologies, particularly mobile phones and virtual financial services. These disruptive technology systems can rapidly increase access to basic electricity services and directly inform the emerging Sustainable Development Goals for quality of life, while simultaneously driving action towards low-carbon, Earth-sustaining, inclusive energy systems