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Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). Conclusion Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

De-identified individual participant data will be available including data dictionaries. Specifically, a case may be submitted for provision of individual participant data that underlie the results reported in this article, after de-identification (text, tables, figures, and appendices). Study documentation including the study protocol and statistical analysis plan may also be requested. Data will be available following publication ending 5 years after this date as per data handling measures specified in the study protocol. Access will be granted to requestors submitting a methodologically sound proposal to the corresponding author CO

Background: A significant proportion of forensic patients in England are long-stayers. This can be problematic as individuals are kept in restrictive environments at potentially inappropriate levels of security for many years, sometimes decades. Improvements to the current English forensic mental health system to meet the needs of long-stay forensic patients more effectively might be informed by the Dutch service for long-stay forensic patients.Aims: To compare the characteristics of representative samples of long-stay patients in England and in the Netherlands in an attempt to draw conclusions on the degree to which the Dutch service model might be relevant to England.Method: This cross-sectional study explores the relevance of the Dutch service model by comparing the characteristics of representative samples of long-stay patients in England (n = 401) and the Netherlands (n = 102). Descriptive statistics and analyses of differences between groups are presented. The Risk-Need-Responsivity model was used to guide the selection of the study variables and structure the interpretation of the findings.Results: Compared to their English counterparts, the long-stay Dutch patients were less likely to be diagnosed with schizophrenia, but more likely to have personality disorder and have committed sex offences. The English group were younger at first conviction and at first custodial sentence. The total number of offences and the proportion of violent offenders were similar, but the Dutch HCR-20 scores indicated a significantly higher risk of violence.Conclusions: Whilst there may be barriers to adopting the Dutch service model in England, the differences in the characteristics of the two groups studied here do not necessarily preclude this approach.

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