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

South African Paediatric Surgical Outcomes Study : a 14-day prospective, observational cohort study of paediatric surgical patients

BACKGROUND : Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low- and middle-income countries (LMICs). METHODS : We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. RESULTS : We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4–11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2–8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6–1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. CONCLUSIONS : The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings should be used to develop strategies to improve paediatric surgical outcomes in LMICs, and support the need for larger prospective, observational paediatric surgical outcomes research in LMICs. CLINICAL TRIAL REGISTRATION : NCT03367832.Jan Pretorius Research Fund; Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal; Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town; Department of Anaesthesia, University of the Witwatersrand; and the Paediatric Anaesthesia Community of South Africa (PACSA).https://bjanaesthesia.org2020-02-01gl2019Anaesthesiolog

Participatory Forest Carbon Assessment in South-eastern Tanzania: Experiences, costs and future challenges

The aim of this study was to determine the changes in forest carbon in three village forests in Tanzania during 2009-2012 using participatory forest carbon assessment, and to evaluate the capability of the local communities to undertake the assessment, and the costs involved. The results show that forest degradation is caused not only by disturbance as a result of anthropogenic activities; other causes include natural mortality of small trees as a result of canopy closure, and the attraction of wild animals to closed-canopy forests. Thus, mechanisms are required to compensate communities for carbon loss that is beyond their control. However, an increase in the abundance of elephants Loxodonta africana and other fauna should not be considered negatively by local communities and other stakeholders, and the importance of improved biodiversity in the context of carbon stocks should be emphasized by those promoting REDD+ (Reduced Emissions from Deforestation and Forest Degradation). This case study also shows that the cost per ha of USDUSD < 1 for participatory forest carbon assessment is less than that reported for Tanzania and elsewhere (USD 3-5); this is attributed to the large area of forest studied. However, the cost of data analysis and reporting in 2012 (USD 4,519) was significantly higher than the baseline cost (USD 1,793) established in 2009 because of the involvement of external experts

From Trade to Regional Integration: the Checkered History of Kiswahili in Uganda

Unlike in other Eastern African countries, notably Kenya and Tanzania, Kiswahili did not become an official language or lingua franca in Uganda until very recently. Using both secondary sources and archival material, this chapter aims to explore the reasons behind this (partial) marginalization, analyzing the history of the language in Uganda since it arrived there in the mid-1800s. It explores why, after a period of great popularity, Kiswahili began to be neglected and lost its currency among the Buganda elite. Kiswahili arrived from the east coast with Arab traders and spread thanks in part to the increase in the number of practicing Muslims in the kingdom of Buganda. In the late 1800s, during the so-called religious wars and the consequent marginalization of the Muslim community, Kiswahili suffered the same fate. A few decades later, it became one of Uganda’s main languages thanks to Muslim president Idi Amin Dada. The president’s army was notorious for the violence they used in their dealings with the population, and since Kiswahili was the language of the army, it started being considered as the language of violence – a language used by soldiers (and Muslims). After the end of the Amin regime, Kiswahili fell into decline once again, and it has only been with the new National Resistance Movement language policy and the resurgence of the East African Community in the late 1990s that it has regained a (partially) central role in Ugandan life. The proposal that it be made the official language of the East African Community has fueled the debate on the use of Kiswahili and its role in Ugandan society, and for many it remains a symbol of the country’s turbulent past. This chapter argues that its history and connections with the Muslim community and to an even greater extent, with the army, have sealed the language’s fate, leading to the current tensions and resistance to the East African Community’s choice. Despite being marginalized and not widely spoken, Kiswahili remains a controversial topic and a powerful symbol in Ugandan society

Prospective evaluation of 92 serum protein biomarkers for early detection of ovarian cancer

Background: CA125 is the best available yet insufficiently sensitive biomarker for early detection of ovarian cancer. There is a need to identify novel biomarkers, which individually or in combination with CA125 can achieve adequate sensitivity and specificity for the detection of earlier-stage ovarian cancer. Methods: In the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort, we measured serum levels of 92 preselected proteins for 91 women who had blood sampled ≤18 months prior to ovarian cancer diagnosis, and 182 matched controls. We evaluated the discriminatory performance of the proteins as potential early diagnostic biomarkers of ovarian cancer. Results: Nine of the 92 markers; CA125, HE4, FOLR1, KLK11, WISP1, MDK, CXCL13, MSLN and ADAM8 showed an area under the ROC curve (AUC) of ≥0.70 for discriminating between women diagnosed with ovarian cancer and women who remained cancer-free. All, except ADAM8, had shown at least equal discrimination in previous case-control comparisons. The discrimination of the biomarkers, however, was low for the lag-time of &gt;9–18 months and paired combinations of CA125 with any of the 8 markers did not improve discrimination compared to CA125 alone. Conclusion: Using pre-diagnostic serum samples, this study identified markers with good discrimination for the lag-time of 0–9 months. However, the discrimination was low in blood samples collected more than 9 months prior to diagnosis, and none of the markers showed major improvement in discrimination when added to CA125