Summary Background Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality. Methods We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov , NCT03853824 . Findings Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported. Interpretation This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa. Funding Bill & Melinda Gates Foundation and the World Federati...

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This paper presents continuous, high resolution fossil pollen and microcharcoal records from Bo Langvlei, a lake in the Wilderness Embayment on South Africa’s southern Cape coast. Spanning the past ~1300 years and encompassing the Medieval Climate Anomaly (MCA; c. AD 950–1250) and the Little Ice Age (LIA; c. AD 1300–1850), these records provide a rare southern African perspective on past temperature, moisture and vegetation change during these much debated periods of the recent geological past. Considered together with other records from the Wilderness Embayment, we conclude that conditions in the region during the MCA chronozone were – in the context of the last 1300 years – likely relatively dry (reduced levels of Afrotemperate forest pollen) and perhaps slightly cooler (increased percentages of Stoebe-type pollen) than present. The most significant phase of forest expansion, and more humid conditions, occurred during the transition between the MCA and the most prominent cooling phase of the LIA. The LIA is clearly identified at this locality as a period of cool, dry conditions between c. AD 1600 and 1850. The mechanisms driving the changes observed in the Bo Langvlei pollen record appear to be generally linked to changes in temperature, and changes in the influence of tropical circulation systems. During warmer periods, moisture availability was higher at Bo Langvlei, and rainfall was perhaps less seasonal. During colder periods, precipitation resulting from tropical disturbances was more restricted, resulting in drier conditions. While increased precipitation has been reported during the LIA from Verlorenvlei in the Western Cape as a result of an equatorward displacement of the westerly storm-track at this time, the opposing response at Bo Langvlei suggests that any increased influence of westerlies was insufficient to compensate for the concurrent reduction in tropical/local rainfall in the region.

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