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.

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Objective: To examine the association between nutrition, physical activity, lifestyle, the combined behavior e"ect, and the schoolchildren's academic achievement. Design: Observational and cross-sectional study. Setting: West Bank, Palestine. Participants: A group of schoolchildren (n=1945) in grades 5-9 (11-16 years). Measurements: Students were surveyed about the their ’dietary, physical activity (PA), leisure time activity, and academic achievement. Academic achievement was measured using students' marks in Arabic, English, math, science courses, and the total average score. The linear regression model was conducted to analyze the relationship between dietary, PA, combined behavior, and academic achievement, while adjusted for demographic confounders; body mass index (BMI), and parental education. Results: Findings indicated that healthy nutrition and adequate levels of PA significantly predict achievement scores. In both boys and girls, high academic achievement was associated with a high intake of fruits and vegetables (AOR: 1.1 (0.72-1.68); 1.18(0.81-1.7), and (AOR: 1.21(0.8-1.82); 1.33(0.93-1.91), respectively. In both girls and boys, high academic achievement was associated with low intake of soft drink, beverages (juice with sugar) and energy drink (AOR: (0.75(0.47-1.19), 0.85(0.58-1.27)); (0.99(0.63-1.57), 0.76(0.52-1.12)); (0.66(0.38-1.15), 0.49(0.27-0.89)), respectively. The active and healthy nutrition group scored higher on Arabic, English, math, science, and total average score. Conclusions: There is a strong relationship between healthy nutrition, acceptable PA, and the average academic achievement within schoolchildren. Findings emphasize the importance of linking nutrition, school PA, and health policies for improving cognitive functions and academic performance of Palestinian schoolchildren. Thus, school-based healthy lifestyle educational, health behaviors policy, and recommendation programs may have a greater e"ect on students’ academic achievement.

Background: Promoting a healthy diet and lifestyle to reduce the national burden of nutrition-related problems among Palestinians requires an understanding of food consumption trends and patterns. Few studies have examined the food consumption patterns with the macro and micronutrient intakes and nutrition risk factors. The objective of this study was to study the food frequency and nutrient intake consumption patterns of Palestinian schoolchildren and their associations with the socioeconomic and risk factors. This is a national cross-sectional descriptive study conducted on Palestinian schoolchildren from the West Bank. The study examined the food consumption patterns of the macro and micronutrient intakes and nutrition risk factors among 1945 students aged 11-16 years. The data collected using the food frequency questionnaire and 24-hour recall that was administered by trained field workers. Food groups’ classification, nutrient intakes, body mass index (BMI) Z-scores, and socioeconomic di"erences were examined across the food groups’ patterns of consumption. We employed Z-score and K-Means cluster analysis to identify food consumption patterns and to examine factors associated with nutrient intakes. The food frequency results identified three food consumption clusters including the traditional, non-traditional, and mixed pattern. A total of 796 students (41%) were in traditional cluster, 458 (23.5%) in non-traditional cluster, and 691(35.5%) in mixed cluster. The nutrient intakes identified three clusters (High, Moderate, and Low consumption patterns) out of macronutrient, vitamins, and minerals categories. Most of the students located in the low consumption cluster for macronutrient, vitamins, and minerals clusters (66.9%, 67.7%, and 64 %) respectively. The traditional cluster was associated with healthy, non-obese, and physically active students and the non-traditional cluster was associated with unhealthy and obese students, but both shown significantly di"erent across the identified clusters. Imbalance in dietary intakes among schoolchildren reflects a lack of dietary diversity. High sugar, fats and oils, and beverages consumption, low consumption of grains, fruits, beans and legumes, and meat are noticed in Palestinian schoolchildren. The findings indicated the importance of considering the food groups' intake variations among Palestinian schoolchildren. As the segments relate to children’s health, nutrition diet programs should consider the high scores of non-traditional and mixed food consumption among school’s children.