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

Formation and Structures of Hafnocene Complexes in MAO- and AlBui3/CPh3[B(C6F5)4]-Activated Systems

The formation of cationic species relevant to olefin polymerization based on (SBI)HfCl2, Me2C(C5H4)(Flu)HfCl2, Ph2C(C5H4)(Flu)HfCl2, and L'HfCl2 activated by MAO, AlMe3/CPh3[B(C6F5)4], and AlBui3/CPh3[B(C6F5)4] (SBI = rac-Me2Si(Ind)2; L' = C2H4(Flu)(5,6-C3H6-2-MeInd)) was studied by 1H, 13C, and 19F NMR spectroscopy. Thermally stable heterobinuclear intermediates of the type [LHf(µ-Me)2AlMe2]+[MeMAO]- and [LHf(µ-Me)2AlMe2]+[B(C6F5)4]- were identified when using MAO and AlMe3/CPh3[B(C6F5)4] as activators, respectively. The stability of these species explains the low productivity of hafnocene catalysts in the presence of AlMe3-containing activators, compared to zirconocenes. By contrast, in the ternary systems LHfCl2/AlBui3/CPh3[B(C6F5)4] hydride species were detected that must be responsible for the formation of the highly active sites in olefin polymerization. The ionic hydrido species differ significantly in stability. The formation of the mixed-alkyl complex L'Hf(Me)CH2SiMe3 proceeds with surprisingly high diastereoselectivity; the sterically more hindered isomer is produced preferentially. It reacts with CPh3[B(C6F5)4] to afford the ion pair [L'Hf-CH2SiMe3]+[B(C6F5)4]- as two diastereomers that exist in dynamic equilibrium. The rates of site epimerization of this ion pair indicate only small energy differences between the two isomers