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

A review of vulnerability indicators for deltaic social–ecological systems

The sustainability of deltas worldwide is under threat due to the consequences of global environmental change (including climate change) and human interventions in deltaic landscapes. Understanding these systems is becoming increasingly important to assess threats to and opportunities for long-term sustainable development. Here, we propose a simplified, yet inclusive social–ecological system (SES)-centered risk and vulnerability framework and a list of indicators proven to be useful in past delta assessments. In total, 236 indicators were identified through a structured review of peer-reviewed literature performed for three globally relevant deltas—the Mekong, the Ganges–Brahmaputra–Meghna and the Amazon. These are meant to serve as a preliminary “library” of potential indicators to be used for future vulnerability assessments. Based on the reviewed studies, we identified disparities in the availability of indicators to populate some of the vulnerability domains of the proposed framework, as comprehensive social–ecological assessments were seldom implemented in the past. Even in assessments explicitly aiming to capture both the social and the ecological system, there were many more indicators for social susceptibility and coping/adaptive capacities as compared to those relevant for characterizing ecosystem susceptibility or robustness. Moreover, there is a lack of multi-hazard approaches accounting for the specific vulnerability profile of sub-delta areas. We advocate for more comprehensive, truly social–ecological assessments which respond to multi-hazard settings and recognize within-delta differences in vulnerability and risk. Such assessments could make use of the proposed framework and list of indicators as a starting point and amend it with new indicators that would allow capturing the complexity as well as the multi-hazard exposure in a typical delta SES