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

Defining sepsis on the wards: results of a multi-centre point-prevalence study comparing two sepsis definitions

Our aim was to prospectively determine the predictive capabilities of SEPSIS-1 and SEPSIS-3 definitions in the emergency departments and general wards. Patients with National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled over a 24-h period in 13 Welsh hospitals. The primary outcome measure was mortality within 30 days. Out of the 5422 patients screened, 431 fulfilled inclusion criteria and 380 (88%) were recruited. Using the SEPSIS-1 definition, 212 patients had sepsis. When using the SEPSIS-3 definitions with Sequential Organ Failure Assessment (SOFA) score ≥ 2, there were 272 septic patients, whereas with quickSOFA score ≥ 2, 50 patients were identified. For the prediction of primary outcome, SEPSIS-1 criteria had a sensitivity (95%CI) of 65% (54–75%) and specificity of 47% (41–53%); SEPSIS-3 criteria had a sensitivity of 86% (76–92%) and specificity of 32% (27–38%). SEPSIS-3 and SEPSIS-1 definitions were associated with a hazard ratio (95%CI) 2.7 (1.5–5.6) and 1.6 (1.3–2.5), respectively. Scoring system discrimination evaluated by receiver operating characteristic curves was highest for Sequential Organ Failure Assessment score (0.69 (95%CI 0.63–0.76)), followed by NEWS (0.58 (0.51–0.66)) (p < 0.001). Systemic inflammatory response syndrome criteria (0.55 (0.49–0.61)) and quickSOFA score (0.56 (0.49–0.64)) could not predict outcome. The SEPSIS-3 definition identified patients with the highest risk. Sequential Organ Failure Assessment score and NEWS were better predictors of poor outcome. The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis-induced organ dysfunction

Geochemistry and Nd isotopic characteristics of Earth's Hadean mantle and primitive crust

International audienceThe Isua supracrustal belt (ISB) and the Nuvvuagittuq greenstone belt (NGB) are among the oldest suites of mafic volcanic rocks preserved on Earth and are the best candidates for representing its early crust. Despite the possible 500 Ma age difference between the belts, these mantle-derived rocks show compositional similarities, with features resembling rocks formed in subduction initiation environments. With the addition of new 142Nd data for the Garbenschiefer unit of the ISB reported here, high precision 142Nd data are now available for all the mafic lithologies from both belts. Mantle-derived rocks from both the ISB and NGB belts exhibit a range of 142Nd/144Nd ratios. The datasets for the two belts, however, are significantly different, suggesting a different origin for their 142Nd anomalies. Nearly all ISB samples have excesses in 142Nd, including the newly analyzed Garbenschiefer boninitic amphibolites (mean of +12ppm). Excesses in 142Nd/144Nd compared to the Nd standard for all the ISB rocks range between +8 and +20ppm, with a near Gaussian distribution around +12ppm. This distribution could simply reflect the analytical error (±5 ppm) around a single 142Nd/144Nd ratio indicating that the samples formed after the extinction of 146Sm from a source with a nearly uniform 142Nd/144Nd ratio. In contrast, the NGB shows a range of 142Nd/144Nd ratios from +8 to −18ppm relative to the modern Nd standard and displays a flat distribution of 142Nd/144Nd ratios. The ISB samples show no significant correlation between their 142Nd/144Nd and Sm/Nd ratios, consistent with their formation in the Eoarchean via melting of a Hadean depleted mantle. In contrast, all NGB samples display a 142Nd/144Nd vs. Sm/Nd correlation, consistent with their crystallization in the Hadean. The mantle sources for both the ISB and NGB mantle-derived rocks have a similar 142Nd/144Nd ratio at the possible age of formation of the NGB (∼4.3 Ga) suggesting the derivation of ISB and NGB rocks from a common early-formed depleted mantle source formed between 4.47 and 4.42 Ga with a 147Sm/144Nd ratio ∼0.218. This mantle appears to have been an important source component involved in the formation of the primitive crust during most of the Hadean and Eoarchean eons

Author Correction: Reassessing evidence of life in 3,700-million-year-old rocks of Greenland

Original article published in Nature, 563(7730), pp. 241-244. In Extended Data Fig. 1 of this Letter, the map showed the field-work location incorrectly; this figure has been corrected online.</p