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

Carbon Dynamics on the Louisiana Continental Shelf and Cross-Shelf Feeding of Hypoxia

Large-scale hypoxia regularly develops during the summer on the Louisiana continental shelf. Traditionally, hypoxia has been linked to the vast winter and spring nutrient inputs from the Mississippi River and its distributary, the Atchafalaya River. However, recent studies indicate that much of the shelf ecosystem is heterotrophic. We used data from five late July shelfwide cruises from 2006 to 2010 to examine carbon and oxygen production and identify net autotrophic areas of phytoplankton growth on the Louisiana shelf. During these summer times of moderate river flows, shelfwide pH and particulate organic carbon (POC) consistently showed strong signals for net autotrophy in low salinity (<25) waters near the river mouths. There was substantial POC removal via grazing and sedimentation in near-river regions, with 66–85 % of POC lost from surface waters in the low and mid-salinity ranges without producing strong respiration signals in surface waters. This POC removal in nearshore environments indicates highly efficient algal retention by the shelf ecosystem. Updated carbon export calculations for local estuaries and a preliminary shelfwide carbon budget agree with older concepts that offshore hypoxia is linked strongly to nutrient loading from the Mississippi River, but a new emphasis on cross-shelf dynamics emerged in this research. Cross-shelf transects indicated that river-influenced nearshore waters <15 m deep are strong sources of net carbon production, with currents and wave-induced resuspension likely transporting this POC offshore to fuel hypoxia in adjacent mid-shelf bottom waters.Griffith Sciences, Griffith School of EnvironmentNo Full Tex