Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

ECMO support is a high-risk setup for nosocomial infection, in particular for cardiac patients with open sternum for whom antibiotic prophylaxis is justified. Multidisciplinary surveillance offers an excellent approach for quality improvement in this challenging field.

There is international concern about the population of birth mothers who experience repeat court-ordered removal of children. This article reports the findings from a population profiling study that provides the first picture of the scale of women's repeat involvement in public law proceedings in England. Based on national records from the Children and Family Court Advisory and Support Service (Cafcass) (n ¼ 43,541 birth mothers, 2007-14), two subsets of mother, child and legal proceedings data were created. The aims of the study were to:(i) produce a descriptive profile of recurrent cases, (ii) estimate the probability and timing of recurrence and (iii) examine the relationship between maternal age and recurrence. Quantitative analysis comprised descriptive statistics for profiling purposes and methods of survival analysis to estimate probabilities. Findings indicate that the family justice system recycles a sizeable percentage of women (24 per cent) through repeat episodes of care proceedings, with young women aged sixteen to nineteen years most at risk of recurrence. Implications for social workers and the family courts are outlined with reference to new innovations in England.

English law on young people's consent to treatment and competence is complex and can even appear contradictory. For example, competent minors can consent, but their refusal can be overruled by the consent of a person with parental authority or by the court. This paper is an attempt to make sense of the topic for clinicians. It includes a discussion of the law and the small body of relevant research evidence. There are clinical case examples, checklists and guidelines for good practice. However, it is not a substitute for legal advice, which should be sought wherever doubt remains.

This article aims to advance debate about the ethics of targeted reproductive health care for birth mothers who have experienced recurrent care proceedings. Making reference to new research evidence that reports the scale of the problem of repeat care proceedings in England, the article considers the role that enhanced reproductive health care might play in helping mothers exit a cycle of care proceedings. Emerging practice initiatives are introduced which are all stretching the boundaries of statutory intervention, by working intensively with mothers following removal of children to public care. The central argument of this paper is that a positive interpretation of rights provides a warrant for providing enhanced access to contraception, but this must be part and parcel of a holistic, recovery focused approach to intervention.