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In late March 2018, a large part of the Eastern Mediterranean experienced an extraordinary episode of African dust, one of the most intense in recent years, here referred to as the "Minoan Red" event. The episode mainly affected the Greek island of Crete, where the highest aerosol concentrations over the past 15 yeas were recorded, although impacts were also felt well beyond this core area. Our study fills a gap in dust research by assessing the multi-sectoral impacts of sand and dust storms and their socioeconomic implications. Specifically, we provide a multi-sectoral impact assessment of Crete during the occurrence of this exceptional African dust event. During the day of the occurrence of the maximum dust concentration in Crete, i.e. March 22nd, 2018, we identified impacts on meteorological conditions, agriculture, transport, energy, society (including closing of schools and cancellation of social events), and emergency response systems. As a result, the event led to a 3-fold increase in daily emergency responses compare to previous days associated with urban emergencies and wildfires, a 3.5-fold increase in hospital visits and admissions for Chronic Obstructive Pulmonary Disease (COPD) exacerbations and dyspnoea, a reduction of visibility causing aircraft traffic disruptions (eleven cancellations and seven delays), and a reduction of solar energy production. We estimate the cost of direct and indirect effects of the dust episode, considering the most affected socio-economic sectors (e.g. civil protection, aviation, health and solar energy production), to be between 3.4 and 3.8 million EUR for Crete. Since such desert dust transport episodes are natural, meteorology-driven and thus to a large extent unavoidable, we argue that the efficiency of actions to mitigate dust impacts depends on the accuracy of operational dust forecasting and the implementation of relevant early warning systems for social awareness., The authors gratefully acknowledge the COST Association for funding the COST Action inDust (CA16202) as well as the WMO Sand and Dust Storm Warning Advisory and Assessment System (SDS-WAS) and the ERA4CS DustClim and the AXA Research Fund for funding the AXA Chair on Sand and Dust Storms (hosted by the Barcelona Supercomputing Center). We thank the scientific team of the PROTEAS CSP facility for the feedback provided and T. Bojic and R. Burbidge for facilitating the access to the EUROCONTROL archive. We thank the scientific team of the PROTEAS CSP facility for providing DNI data for this case study. Thanks are due to FCT/MCTES for the financial support to CESAM (UIDP/50017/2020+UIDB/50017/2020) through national funds, and also to the Icelandic Research Fund for the grant no. 207057-051. Authors S. Kazadzis and P. Kosmopoulos would like to acknowledge the European Commission project EuroGEO e-shape (grant agreement No 820852). Also, International Cooperative for Aerosol Prediction (ICAP) and NASA mission researchers are gratefully for providing aerosol data for this study. Aurelio Tobias was supported by MCIN/AEI/10.13039/501100011033 (grant CEX2018-000794-S). S. Kutuzov acknowledges the Megagrant project (agreement No. 075-15-2021-599, 8.06.2021).

Background and aim The associations between COVID-19 transmission and meteorological factors are scientifically debated. Several studies have been conducted worldwide, with inconsistent findings. However, often these studies had methodological issues, e.g., did not exclude important confounding factors, or had limited geographic or temporal resolution. Our aim was to quantify associations between temporal variations in COVID-19 incidence and meteorological variables globally. Methods We analysed data from 455 cities across 20 countries from 3 February to 31 October 2020. We used a time-series analysis that assumes a quasi-Poisson distribution of the cases and incorporates distributed lag non-linear modelling for the exposure associations at the city-level while considering effects of autocorrelation, long-term trends, and day of the week. The confounding by governmental measures was accounted for by incorporating the Oxford Governmental Stringency Index. The effects of daily mean air temperature, relative and absolute humidity, and UV radiation were estimated by applying a meta-regression of local estimates with multi-level random effects for location, country, and climatic zone. Results We found that air temperature and absolute humidity influenced the spread of COVID-19 over a lag period of 15 days. Pooling the estimates globally showed that overall low temperatures (7.5 °C compared to 17.0 °C) and low absolute humidity (6.0 g/m3 compared to 11.0 g/m3) were associated with higher COVID-19 incidence (RR temp =1.33 with 95%CI: 1.08; 1.64 and RR AH =1.33 with 95%CI: 1.12; 1.57). RH revealed no significant trend and for UV some evidence of a positive association was found. These results were robust to sensitivity analysis. However, the study results also emphasise the heterogeneity of these associations in different countries. Conclusion Globally, our results suggest that comparatively low temperatures and low absolute humidity were associated with increased risks of COVID-19 incidence. However, this study underlines regional heterogeneity of weather-related effects on COVID-19 transmission., This paper used Copernicus Climate Change Service (C3S) and Copernicus Atmosphere Monitoring Service (CAMS) information. Hence, the authors would like to thank the European Centre for Medium-Range Weather Forecasts (ECMWF) for its data generation on behalf of the European Union.

Katrin Burkart and colleagues1 present the results of an ambitious study on the global mortality burden attributable to non-optimal temperatures by the Global Burden of Diseases, Injuries,and Risk Factors Collaborators. They report that 2·98% of deaths globally could be attributed to non-optimal temperatures in 2019; 2·37% of deaths from low temperatures and 0·63% of deaths from high temperatures. Although estimates of the heat mortality burden are broadly consistent with existing literature, the contribution of cold temperatures to this burden differs substantially to assessments at global and regional scales.2, 3, 4 We believe that these differences are the result of crucial methodological limitations of the study,1 mainly the failure to adequately address the complexities of temperature–mortality relationships, probably resulting in an underestimation of the effects. Burkart and colleagues only accounted for the effects on the same day (ie, lag 0), whereas substantial epidemiological data shows the presence of lagged effects of temperature (up to 3 weeks for cold temperatures) or mortality displacement, or both.5 Additionally, the applied method does not account for seasonality or long-term trends—strong confounders in this analysis.5 In the appendix, we illustrate how markedly different the results of the two approaches are using data from Greater London, UK. A critical lens needs to be applied to any analytical framework to ensure its suitability and to increase confidence in the results. Burkart and colleagues’ analyses1 would have benefited from method developments in climate epidemiology from the past 20 years. Robust and reliable estimates of the burden of non-optimal temperatures are increasingly important in a changing climate.

Studies have investigated the effects of heat and temperature variability (TV) on mortality. However, few assessed whether TV modifies the heat-mortality association. Data on daily temperature and mortality in the warm season were collected from 717 locations across 36 countries. TV was calculated as the standard deviation of the average of the same and previous days' minimum and maximum temperatures. We used location-specific quasi-Poisson regression models with an interaction term between the cross-basis term for mean temperature and quartiles of TV to obtain heat-mortality associations under each quartile of TV, and then pooled estimates at the country, regional, and global levels. Results show the increased risk in heat-related mortality with increments in TV, accounting for 0.70% (95% confidence interval [CI]: -0.33 to 1.69), 1.34% (95% CI: -0.14 to 2.73), 1.99% (95% CI: 0.29-3.57), and 2.73% (95% CI: 0.76-4.50) of total deaths for Q1-Q4 (first quartile-fourth quartile) of TV. The modification effects of TV varied geographically. Central Europe had the highest attributable fractions (AFs), corresponding to 7.68% (95% CI: 5.25-9.89) of total deaths for Q4 of TV, while the lowest AFs were observed in North America, with the values for Q4 of 1.74% (95% CI: -0.09 to 3.39). TV had a significant modification effect on the heat-mortality association, causing a higher heat-related mortality burden with increments of TV. Implementing targeted strategies against heat exposure and fluctuant temperatures simultaneously would benefit public health., This study was supported by the Australian Research Council (DP210102076) and the Australian National Health and Medical Research Council (APP2000581). Y.W and B.W. were supported by the China Scholarship Council (nos. 202006010044 and 202006010043); S.L. was supported by an Emerging Leader Fellowship of the Australian National Health and Medical Research Council (no. APP2009866); Y.G. was supported by Career Development Fellowship (no. APP1163693) and Leader Fellowship (no. APP2008813) of the Australian National Health and Medical Research Council; J.K. and A.U. were supported by the Czech Science Foundation (project no. 20–28560S); N.S. was supported by the National Institute of Environmental Health Sciences-funded HERCULES Center (no. P30ES019776); Y.H. was supported by the Environment Research and Technology Development Fund (JPMEERF15S11412) of the Environmental Restoration and Conservation Agency; M.d.S.Z.S.C. and P.H.N.S. were supported by the São Paulo Research Foundation (FAPESP); H.O. and E.I. were supported by the Estonian Ministry of Education and Research (IUT34–17); J.M. was supported by a fellowship of Fundação para a Ciência e a Tecnlogia (SFRH/BPD/115112/2016); A.G. and F.S. were supported by the Medical Research Council UK (grant ID MR/R013349/1), the Natural Environment Research Council UK (grant ID NE/R009384/1), and the EU’s Horizon 2020 project, Exhaustion (grant ID 820655); A.S. and F.d.D. were supported by the EU’s Horizon 2020 project, Exhaustion (grant ID 820655); V.H. was supported by the Spanish Ministry of Economy, Industry and Competitiveness (grant ID PCIN-2017–046); and A.T. by MCIN/AEI/10.13039/501100011033 (grant CEX2018-000794-S). Statistics South Africa kindly provided the mortality data, but had no other role in the study.

The health risk associated with high temperatures has been declining during the last decade [[1]]. Among the factors that played an essential role in increasing the resilience of populations, air conditioning has been shown an effective heat adaptation strategy in several countries, including Spain [[2]]. However, the 6th Assessment Report of the Intergovernmental Panel on Climate Change (IPCC) indicates that the average temperature in Spain could rise up to 3°C [[3[] , making access to air conditioning a lifesaving question, especially for those populations more vulnerable to heat, such as elderly and low income communities [[4]]. According to the World Health Organization (WHO), housing conditions must maintain an adequate climatization for health, ranging between 18°C in winter and 24 °C in summer [[5]]. Therefore, the price of electricity turns into an essential issue to satisfy a minimum amount of energy services and ensure air conditioning during heat periods. Upsettingly, Spain faced an exceptionally hazardous situation this summer when the price of electricity in the daily market registered the highest values ever in history through five consecutive days in the course of August's heatwave week, from Monday 9th to Friday 13th (Figure 1). Since then, the electricity price has kept increasing, and the disparity experienced could exacerbate existing health and socioeconomic inequalities in the short term with the forthcoming cold season., None

Minimum mortality temperature (MMT) is an important indicator to assess the temperature-mortality association, indicating long-term adaptation to local climate. Limited evidence about the geographical variability of the MMT is available at a global scale.

The nonpharmaceutical interventions (NPIs) on COVID-19 can impact current and future dynamics of respiratory syncytial virus infections (RSV). In Tokyo, RSV activity declined by 97.9% (95%CI: 94.8% - 99.2%) during NPIs. A longer period of NPIs could expand susceptible populations, enhancing the potential for larger RSV outbreaks after NPIs ends.

Resumen: La visualización de datos es una herramienta relevante para explorar y comunicar resultados en la investigación médica, en especial cuando se trata de vigilancia epidemiológica. La aplicación web COVID19-Tracker analiza y produce de forma sistemática visualizaciones diarias de los datos de la epidemia de COVID-19 de casos diagnosticados y fallecimientos desde el 24 de febrero de 2020 en adelante. Se han desarrollado tres aplicaciones para: 1) análisis de la tendencia y proyecciones a corto plazo; 2) estimación de la tasa de letalidad; y 3) efecto del estado de alarma sobre la tendencia de datos incidentes. La aplicación online puede ser de utilidad para un mejor conocimiento de la epidemia de SARS-CoV-2 en España. Abstract: Data visualization is an important tool for exploring and communicating findings in medical research, and specially in epidemiological surveillance. The COVID19-Tracker web application systematically produces daily updated data visualization and analysis of SARS-CoV-2 epidemic in Spain. It collects automatically daily data on COVID-19 diagnosed cases and mortality, from February 24th, 2020 onwards. Three applications have already been developed: 1) to analyze data trends and estimating short-term projections; 2) to estimate the case fatality rate; and 3) to assess the effect of the lockdowns on the data trends. The application may help for a better understanding of the SARS-CoV-2 epidemic data in Spain.

BACKGROUND AND AIM: Although seasonal variations in mortality have been recognised for a long time, the role of temperature remains unclear. We aimed to assess seasonal variation in mortality and t...

BACKGROUND AND AIM: Minimum mortality temperature (MMT) and MMT percentile (MMTP) are important indicators for human adaptation to climate. Several studies reported that the MMT and MMTP have chang...

Background Ambient temperature may contribute to seasonality of mortality; in particular, a warming climate is likely to influence the seasonality of mortality. However, few studies have investigated seasonality of mortality under a warming climate. Methods Daily mean temperature, daily counts for all-cause, circulatory, and respiratory mortality, and annual data on prefecture-specific characteristics were collected for 47 prefectures in Japan between 1972 and 2015. A quasi-Poisson regression model was used to assess the seasonal variation of mortality with a focus on its amplitude, which was quantified as the ratio of mortality estimates between the peak and trough days (peak-to-trough ratio (PTR)). We quantified the contribution of temperature to seasonality by comparing PTR before and after temperature adjustment. Associations between annual mean temperature and annual estimates of the temperature-unadjusted PTR were examined using multilevel multivariate meta-regression models controlling for prefecture-specific characteristics. Results The temperature-unadjusted PTRs for all-cause, circulatory, and respiratory mortality were 1.28 (95% confidence interval (CI): 1.27–1.30), 1.53 (95% CI: 1.50–1.55), and 1.46 (95% CI: 1.44–1.48), respectively; adjusting for temperature reduced these PTRs to 1.08 (95% CI: 1.08–1.10), 1.10 (95% CI: 1.08–1.11), and 1.35 (95% CI: 1.32–1.39), respectively. During the period of rising temperature (1.3 °C on average), decreases in the temperature-unadjusted PTRs were observed for all mortality causes except circulatory mortality. For each 1 °C increase in annual mean temperature, the temperature-unadjusted PTR for all-cause, circulatory, and respiratory mortality decreased by 0.98% (95% CI: 0.54–1.42), 1.39% (95% CI: 0.82–1.97), and 0.13% (95% CI: − 1.24 to 1.48), respectively. Conclusion Seasonality of mortality is driven partly by temperature, and its amplitude may be decreasing under a warming climate., YC was supported by a Senior Research grant (2019R1A2C1086194) from the National Research Foundation of Korea (NRF), funded by the Ministry of Science, ICT (Information and Communication Technologies). YK was supported by JSPS KAKENHI Grant Number JP19K17104. AT was supported by the JSPS Invitational Fellowships for Research in Japan (Grant S18149). YG was supported by the Career Development Fellowship of the Australian National Health and Medical Research Council (Grants APP1107107 and APP1163693). AG was supported by the Medical Research Council UK (Grants MR/M022625/1 and MR/R013349/1), by the Natural Environment Research Council UK (Grant NE/R009384/1), and by the European Union’s Horizon 2020 Project Exhaustion (Grant ID: 820655). YH was supported by the Environment Research and Technology Development Fund (S-14) of the Environmental Restoration and Conservation Agency, Japan.

ObjectiveTo evaluate whether the implementation of the FAST‐M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low‐resource setting.DesignA before‐and‐after design.SettingFifteen government healthcare facilities in Malawi.PopulationWomen suspected of having maternal sepsis.MethodsThe FAST‐M complex intervention consisted of the following components: the FAST‐M maternal sepsis treatment bundle and the FAST‐M implementation programme. Performance of selected process outcomes was compared between a 2‐month baseline phase and 6‐month intervention phase with compliance used as a proxy measure of feasibility.Main outcome resultCompliance with vital sign recording and use of the FAST‐M maternal sepsis bundle.ResultsFollowing implementation of the FAST‐M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P P P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.ConclusionImplementation of the FAST‐M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low‐resource setting such as Malawi.Tweetable AbstractImplementation of a sepsis care bundle for low‐resources improved recognition & management of maternal sepsis.

Background Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. Objectives To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. Search methods We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. Selection criteria We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. Data collection and analysis At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. Main results Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.

Sports analytics is defined as the process that identifies and acquires knowledge and insight about players and teams’ performances. To do so, analysts use a wide variety of data sources coming from matches and individual players’ performances (O'Donoghue & Holmes 2014; Jayal, McRobert, Oatley & O’Donoghue, 2018). Nowadays, detailed data from different nature including technical skills, individual physiological performances, team formations, or injuries are analysed on a daily basis by the analytics departments belonging to sports clubs and professional franchises. Even private companies like STATS or OPTA generate important revenues offering their movement tracking values and advanced metrics to media and fans. In the emerging field of Sports Analytics, as in many others, analysts must be aware of spurious correlations. These can come up due to the size (not nature) of data, a common-causal variable or just due to serendipity. For this reason, we always must keep in mind the lessons of the statistician Stephen John Senn and his sharp quote on the matter: “Statistics is not just about merely warning that correlation is not causation. Sometimes correlation isn’t even correlation”. Thus, we will explain an example of how climate change can be affecting, or not, on the FIFA World Cup performance statistics. https://doi.org/10.5232/ricyde2019.057ed References/referencias Allmers, S., & Maennig, W. (2009). Economic impacts of the FIFA Soccer World Cups in France 1998, Germany 2006, and outlook for South Africa 2010. Eastern Economic Journal, 35 (4), 500-519. https://doi.org/10.1057/eej.2009.30 Castellano, J.; Casamichana, D., & Lago, C. (2012). The use of match statistics that discriminate between successful and unsuccessful soccer teams. Journal of Human Kinetics, 31 (1), 137-147. https://doi.org/10.2478/v10078-012-0015-7 Jayal, A., McRobert, A., Oatley, G., & O’Donoghue, P. (2018). Sports Analytics: Analysis, Visualisation and Decision Making in Sports Performance . Routledge. https://doi.org/10.4324/9781315222783 Kakamu, T.; Wada, K.; Smith, D. R.; Endo, S., & Fukushima T. (2017). Preventing heat illness in the anticipated hot climate of the Tokyo 2020 Summer Olympic Games. Environmental Health and Preventive Medicine 22 (68), 1-6. https://doi.org/10.1186/s12199-017-0675-y Matzarakis, A., & Frohlich, D. (2015). Sport events and climate for visitors-the case of FIFA World Cup in Qatar 2022. International Journal of Biometeorology, 59 (4), 481-586. https://doi.org/10.1007/s00484-014-0886-5 Mohr, M.; Nybo, L.; Grantham, J., & Racinais, S. (2012). Physiological Responses and Physical Performance during Football in the Heat. PLoS ONE, 7 (6), e39202. https://doi.org/10.1371/journal.pone.0039202 NASA (2018). Global Climate Change, Vital Signs of the Planet . [Internet] http://climate.nasa.gov/ (last accessed, Jul. 18) Nassis, G. P.; Brito, J.; Dvorak, J.; Chalabi, H.; & Racinais, S. (2015). The association of environmental heat stress with performance: analysis of the 2014 FIFA World Cup Brazil. British Journal of Sports Medicine, 49 (9), 609-613. https://doi.org/10.1136/bjsports-2014-094449 Nicolau, J. L., & Sharma, A. (2018). A generalization of the FIFA World Cup effect. Tourism Management, 66 (June), 315-317. https://doi.org/10.1016/j.tourman.2017.12.014 Liu, H.; Gomez, M. A.; Lago-Penas, C., & Sampaio, J. (2015). Match statistics related to winning in the group stage of 2014 Brazil FIFA World Cup. Journal of Sports Sciences, 33 (12), 1205-1213. https://doi.org/10.1080/02640414.2015.1022578 O’Donoghue, P., & Holmes, L. (2014). Data analysis in sport . Routledge. https://doi.org/10.4324/9781315816357 Pachuari R. K.; Allen, M. R.; Barros, V. R.; Broome, J.; Cramer, W.; Christ, R., et al. (2014). Climate change 2014: synthesis report. Contribution of working groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Intergovernmental Panel on Climate Change, Geneva. Retrieved from: https://epic.awi.de/id/eprint/37530/1/IPCC_AR5_SYR_Final.pdf Ramdas, B.; van Gaalen, R., & Bolton, J. (2015). The Announcement Impact of Hosting the FIFA World Cup on Host Country Stock Markets. Procedia Economics Finance, 30 , 226-238. https://doi.org/10.1016/S2212-5671(15)01290-3 Robinson, W. S. (1950). Ecological correlations and the behaviour of individuals. American Sociological Review, 15 (3), 351-357. https://doi.org/10.2307/2087176 Rumpf, M. C.; Silva, J. R.; Hertzog, M.; Farooq, A., & Nassis, G. (2017). Technical and physical analysis of the 2014 FIFA World Cup Brazil: winners vs. losers. The Journal of sports medicine and physical fitness, 57 (10), 1338-1343. Vandenbroucke, J. P.; Broadbent, A., & Pearce, N. (2016). Causality and causal inference in epidemiology: the need for a pluralistic approach. International Journal of Epidemiology, 45 (6), 1776-1786. https://doi.org/10.2307/2087176 Vigen, T. (2015). Spurious Correlations . Hachette Books. Wikipedia (2018). FIFA World Cup-related lists . [Internet] (last accessed, Jul. 18). Retrieved from: https://en.wikipedia.org/wiki/Category:FIFA_World_Cup-related_lists

Background: Despite the existing evidence, many physicians are reluctant to use opioid analgesia for acute abdominal pain. Methods: We performed updated conventional and network meta-analyses. For the first time to our knowledge, direct and indirect evidence of any type of opioid analgesia was estimated and compared using network meta-analysis. Results: There was no significant difference in the intensity of pain between the two cohorts (mean difference (MD) = 0.43 (-0.05 to 0.91), P = 0.08). In addition, no significant difference was detected in the rate of incorrect diagnoses between the opioid analgesia and the placebo cohorts (odds ratio (OR) = 0.79 (0.54 to 1.17), P = 0.24). Network meta-analysis demonstrated that the results of direct evidence of head-to-head comparisons of opioid analgesics with placebo were in accordance with the results of conventional meta-analysis. Moreover, estimation and comparison of the indirect evidence on the four opioid analgesics did not demonstrate significant differences in effect size. Conclusions: Any type of opioid analgesic can be used safely for acute abdominal pain without risk of impairment of diagnostic accuracy. J Clin Med Res. 2019;11(2):121-126 doi: https://doi.org/10.14740/jocmr3690

Climate change affects human health; however, there have been no large-scale, systematic efforts to quantify the heat-related human health impacts that have already occurred due to climate change. Here, we use empirical data from 732 locations in 43 countries to estimate the mortality burdens associated with the additional heat exposure that has resulted from recent human-induced warming, during the period 1991–2018. Across all study countries, we find that 37.0% (range 20.5–76.3%) of warm-season heat-related deaths can be attributed to anthropogenic climate change and that increased mortality is evident on every continent. Burdens varied geographically but were of the order of dozens to hundreds of deaths per year in many locations. Our findings support the urgent need for more ambitious mitigation and adaptation strategies to minimize the public health impacts of climate change., We thank the participants of the ISIMIP Health workshop in Barcelona in November 2018 where this work was discussed for the first time. This study was supported by the Medical Research Council UK (grant no. MR/M022625/1), the Natural Environment Research Council UK (grant no. NE/R009384/1) and the European Union’s Horizon 2020 Project Exhaustion (grant no. 820655). N.S. was supported by the NIEHS-funded HERCULES Center (P30ES019776). Y.H. was supported by the Environment Research and Technology Development Fund of the Environmental Restoration and Conservation Agency, Japan (JPMEERF15S11412). J.J.J.K.J. was supported by Academy of Finland (grant no. 310372). V.H. was supported by the Spanish Ministry of Economy, Industry and Competitiveness (grant no. PCIN-2017-046) and the German Federal Ministry of Education and Research (grant no. 01LS1201A2). J.K. and A.U. were supported by the Czech Science Foundation (grant no. 20-28560S). J.M. was supported by the Fundação para a Ciência e a Tecnologia (FCT) (SFRH/BPD/115112/2016). S.R. and F.d.R. were supported by European Union’s Horizon 2020 Project EXHAUSTION (grant no. 820655). M.H. was supported by the Japan Science and Technology Agency as part of SICORP, grant no. JPMJSC20E4. Y.G. was supported by the Career Development Fellowship of the Australian National Health and Medical Research Council (APP1163693). S.L. was support by the Early Career Fellowship of the Australian National Health and Medical Research Council (APP1109193). Y.L.L.G. was supported by the Taiwan Ministry of Science and Technology (MOST110-2918-I-002-007) as a visiting academic at the University of Sydney.

BackgroundPrevious studies investigating the relationship of influenza with acute myocardial infarction (AMI) have not distinguished between AMI types 1 and 2. Influenza and cold temperature can explain the increased incidence of AMI during winter but, because they are closely related in temperate regions, their relative contribution is unknown. Methods and ResultsThe temporal relationship between incidence rates of AMI with demonstrated culprit plaque (type 1 AMI) from the regional primary angioplasty network and influenza, adjusted for ambient temperature, was studied in Madrid region (Spain) during 5 influenza seasons (from June 2013 to June 2018). A time‐series analysis with quasi‐Poisson regression models and distributed lag‐nonlinear models was used. The incidence rate of type 1 AMI according to influenza vaccination status was also explored. A total of 8240 cases of confirmed type 1 AMI were recorded. The overall risk ratio (RR) of type 1 AMI during epidemic periods, adjusted for year, month, and temperature, was 1.23 (95% CI, 1.03–1.47). An increase of weekly influenza rate of 50 cases per 100 000 inhabitants resulted in an RR for type 1 AMI of 1.16 (95% CI, 1.09–1.23) during the same week, disappearing 1 week after. When adjusted for influenza, a decrease of 1ºC in the minimum temperature resulted in an increase of 2.5% type 1 AMI. Influenza vaccination was associated with a decreased risk of type 1 AMI in subjects aged 60 to 64 years (RR, 0.58; 95% CI, 0.47–0.71) and ≥65 years (RR, 0.53; 95% CI, 0.49–0.57). ConclusionsInfluenza and cold temperature were both independently associated with an increased risk of type 1 AMI, whereas vaccination was associated with a reduced risk among older patients., This work has been partially funded by unrestricted research grants from the Fundación para la Investigación Biomédica, University Hospital “Príncipe de Asturias” (Servicio Madrileño de Salud, Madrid, Spain) (to Drs García‐Lledó and de Abajo) and funding from Sanofi‐Pasteur S.A., a manufacturer of influenza vaccines (to Dr de Abajo). The funders had no role in the study design, data collection, data analysis, data interpretation, or writing the report. Dr Tobías received support from the Japanese Society for the Promotion of Science in its invitation‐to‐research fellowship program in Japan (S18149).

Many regions of the world are now facing more frequent and unprecedentedly large wildfires. However, the association between wildfire-related PMFor this time series study, data on daily counts of deaths for all causes, cardiovascular causes, and respiratory causes were collected from 749 cities in 43 countries and regions during 2000-16. Daily concentrations of wildfire-related PM65·6 million all-cause deaths, 15·1 million cardiovascular deaths, and 6·8 million respiratory deaths were included in our analyses. The pooled RRs of mortality associated with each 10 μg/mShort-term exposure to wildfire-related PMAustralian Research Council, Australian National HealthMedical Research Council.

Background: There is strong evidence concerning the impact of heat stress on mortality, particularly from high temperatures. However, few studies to our knowledge emphasize the importance of hot nights, which may prevent necessary nocturnal rest. Objectives: In this study, we use hot-night duration and excess to predict daily cause-specific mortality in summer, using multiple cities across Southern Europe. Methods: We fitted time series regression models to summer cause-specific mortality, including natural, respiratory, and cardiovascular causes, in 11 cities across four countries. We included a distributed lag nonlinear model with lags up to 7 days for hot night duration and excess adjusted by daily mean temperature. We summarized city-specific associations as overall-cumulative exposure-response curves at the country level using meta-analysis. Results: We found positive but generally nonlinear associations between relative risk (RR) of cause-specific mortality and duration and excess of hot nights. RR of duration associated with nonaccidental mortality in Portugal was 1.29 (95% confidence interval [CI] = 1.07, 1.54); other associations were imprecise, but we also found positive city-specific estimates for Rome and Madrid. Risk of hot-night excess ranged from 1.12 (95% CI = 1.05, 1.20) for France to 1.37 (95% CI = 1.26, 1.48) for Portugal. Risk estimates for excess were consistently higher than for duration. Conclusions: This study provides new evidence that, over a wider range of locations, hot night indices are strongly associated with cause-specific deaths. Modeling the impact of thermal characteristics during summer nights on mortality could improve decisionmaking for preventive public health strategies. D.R. was supported by a postdoctoral research fellowship of the Xunta de Galicia (Spain). R.L. was supported by a Royal Society Dorothy Hodgkin Fellowship. A.G. was supported by the Medical Research Council UK (Grant ID: MR/ M022625/1), the Natural Environment Research Council UK (Grant ID: NE/R009384/1), and the European Union’s Horizon 2020 Project Exhaustion (Grant ID: 820655) info:eu-repo/semantics/publishedVersion

More than a year since its emergence, there is conflicting evidence on the potential influence of weather conditions on SARS-CoV-2 transmission dynamics. We used a two-stage ecological modelling approach to estimate weather-dependent signatures in SARS-CoV-2 transmission in the early phase of the pandemic, using a dataset of 3 million COVID-19 cases reported until 31 May 2020, spanning 409 locations in 26 countries. We calculated the effective reproduction number (Re) over a location-specific early-phase time-window of 10-20 days, for which local transmission had been established but before non-pharmaceutical interventions had become established as measured by the OxCGRT Government Response Index. We calculated mean levels of meteorological factors, including temperature and humidity observed in the same time window used to calculate Re. Using a multilevel meta-regression approach, we modelled nonlinear effects of meteorological factors, while accounting for government interventions and socio-demographic factors. A weak non-monotonic association between temperature, absolute humidity and Re was identified, with a decrease in Re of 0.087 (95% CI: 0.025; 0.148) between mean temperature of 10.2°C (maximum) and 20°C (minimum) and a decrease in Re of 0.061 (95% CI: 0.011; 0.111) between absolute humidity of 6.6 g/m3 (maximum) and 11 g/m3 (minimum). However, government interventions explained twice as much of the variation in Re compared meteorological factors. We find little evidence of meteorological conditions having influenced the early stages of local epidemics, and conclude that population behaviour and governmental intervention are more important drivers of transmission.

The seasonal cycle of respiratory viral diseases is widely recognized.1 A typical seasonal pattern of annual influenza epidemics is observed during the winter season in the northern hemisphere and during the summer season in the southern hemisphere.1,2 This knowledge has suggested that the transmission of SARS-CoV-2 could follow a similar seasonal pattern. Hence, many studies have been conducted to understand the seasonal pattern of COVID-19 since the beginning of the pandemic.3,4 However, a common limitation is the short timeframe since COVID-19 had only been prevalent for less than a year. Consequently, previously reported seasonal patterns could be incomplete and spurious due to the short study period.4

BackgroundCurrent strategies for preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited to nonpharmacologic interventions. Hydroxychloroquine has been proposed as a postexposure therapy to prevent coronavirus disease 2019 (Covid-19), but definitive evidence is lacking. MethodsWe conducted an open-label, cluster-randomized trial involving asymptomatic contacts of patients with polymerase-chain-reaction (PCR)-confirmed Covid-19 in Catalonia, Spain. We randomly assigned clusters of contacts to the hydroxychloroquine group (which received the drug at a dose of 800 mg once, followed by 400 mg daily for 6 days) or to the usual-care group (which received no specific therapy). The primary outcome was PCR-confirmed, symptomatic Covid-19 within 14 days. The secondary outcome was SARS-CoV-2 infection, defined by symptoms compatible with Covid-19 or a positive PCR test regardless of symptoms. Adverse events were assessed for up to 28 days. ResultsThe analysis included 2314 healthy contacts of 672 index case patients with Covid-19 who were identified between March 17 and April 28, 2020. A total of 1116 contacts were randomly assigned to receive hydroxychloroquine and 1198 to receive usual care. Results were similar in the hydroxychloroquine and usual-care groups with respect to the incidence of PCR-confirmed, symptomatic Covid-19 (5.7% and 6.2%, respectively; risk ratio, 0.86 [95% confidence interval, 0.52 to 1.42]). In addition, hydroxychloroquine was not associated with a lower incidence of SARS-CoV-2 transmission than usual care (18.7% and 17.8%, respectively). The incidence of adverse events was higher in the hydroxychloroquine group than in the usual-care group (56.1% vs. 5.9%), but no treatment-related serious adverse events were reported. ConclusionsPostexposure therapy with hydroxychloroquine did not prevent SARS-CoV-2 infection or symptomatic Covid-19 in healthy persons exposed to a PCR-positive case patient. (Funded by the crowdfunding campaign YoMeCorono and others; BCN-PEP-CoV2 ClinicalTrials.gov number, NCT04304053.) In a trial involving asymptomatic contacts of patients with PCR-confirmed Covid-19 in Spain, the authors compared the use of hydroxychloroquine with usual care. Postexposure therapy with hydroxychloroquine did not prevent SARS-CoV-2 infection or symptomatic Covid-19 in healthy persons.

Background: Studies have quantified the associations between ambient temperature and all-cause enteric infections. Temperature sensitivity in enteric infections, however, may be pathogen dependent. Here, we sought to identify aetiology-specific associations between ambient temperature and enteric infections. Methods: We conducted a systematic review and meta-analysis study by searching PubMed, Web of Science, and Scopus for research articles published from 2000 to 2019. We only included studies that quantified the effects of ambient temperature increases on enteric infections. Two authors screened the studies, one extracted the data from the eligible studies, and four performed data verification. The overall risks were obtained by pooling the relative risk of enteric infection by aetiology for each 1°C temperature rise using random-effects modelling and robust variance estimation for the correlated effect estimates. Findings: The 2170 screened studies generated 80 eligible for systematic review and 56 eligible for meta-analysis. The overall increased risks per 1°C temperature rise were 1·05 (95%CI 1·04–1·07; I2 :97%) for salmonellosis, 1·07 (1·04–1·10; I2 :99%) for shigellosis, 1·02 (1·01–1·04; I2 :98%) for campylobacteriosis, 1·05 (1·04–1·07; I2 :36%) for cholera, 1·04 (1·01–1·07; I2 :98%) for Escherichia coli enteritis, and 1·15 (1·07–1·24; I2 :0%) for typhoid. Reduced risks per 1°C temperature rise were found for rotaviral enteritis at 0·96 (0·90–1·02; I2 :97%), and noroviral enteritis at 0·89 (0·81–0·99; I2 :96%). Interpretation: Enteric infections have varying associations with ambient temperature depending on their aetiology. Future projections for temperature-related enteric infections should account for differing temperature sensitivity in enteric pathogens. Funding: Japan Society for the Promotion of Science (Kakenhi) Grant-in-Aid for Scientific Research. Declaration of Interest: We declare no competing interests

Background: Exposure to cold or hot temperatures is associated with premature deaths. We aimed to evaluate the global, regional, and national mortality burden associated with non-optimal ambient temperatures. Methods: In this modelling study, we collected time-series data on mortality and ambient temperatures from 750 locations in 43 countries and five meta-predictors at a grid size of 0·5° × 0·5° across the globe. A three-stage analysis strategy was used. First, the temperature–mortality association was fitted for each location by use of a time-series regression. Second, a multivariate meta-regression model was built between location-specific estimates and meta-predictors. Finally, the grid-specific temperature–mortality association between 2000 and 2019 was predicted by use of the fitted meta-regression and the grid-specific meta-predictors. Excess deaths due to non-optimal temperatures, the ratio between annual excess deaths and all deaths of a year (the excess death ratio), and the death rate per 100 000 residents were then calculated for each grid across the world. Grids were divided according to regional groupings of the UN Statistics Division. Findings: Globally, 5 083 173 deaths (95% empirical CI [eCI] 4 087 967–5 965 520) were associated with non-optimal temperatures per year, accounting for 9·43% (95% eCI 7·58–11·07) of all deaths (8·52% [6·19–10·47] were cold-related and 0·91% [0·56–1·36] were heat-related). There were 74 temperature-related excess deaths per 100 000 residents (95% eCI 60–87). The mortality burden varied geographically. Of all excess deaths, 2 617 322 (51·49%) occurred in Asia. Eastern Europe had the highest heat-related excess death rate and Sub-Saharan Africa had the highest cold-related excess death rate. From 2000–03 to 2016–19, the global cold-related excess death ratio changed by −0·51 percentage points (95% eCI −0·61 to −0·42) and the global heat-related excess death ratio increased by 0·21 percentage points (0·13–0·31), leading to a net reduction in the overall ratio. The largest decline in overall excess death ratio occurred in South-eastern Asia, whereas excess death ratio fluctuated in Southern Asia and Europe. Interpretation: Non-optimal temperatures are associated with a substantial mortality burden, which varies spatiotemporally. Our findings will benefit international, national, and local communities in developing preparedness and prevention strategies to reduce weather-related impacts immediately and under climate change scenarios. Funding: Australian Research Council and the Australian National Health and Medical Research Council.

Background Globally too many mothers and babies die during childbirth; 98% of maternal deaths are avoidable. Skilled clinicians can reduce these deaths; however, there is a world-wide shortage of maternity healthcare workers. Malawi has enough to deliver 20% of its maternity care. A motivating work environment is important for healthcare worker retention. To inform a future trial, we aimed to assess the feasibility of implementing a motivational intervention (Appreciative Inquiry) to improve the working lives of maternity healthcare workers and patient satisfaction in Malawi. Methods Three government hospitals participated over 1 year. Its effectiveness was assessed through: a monthly longitudinal survey of working life using psychometrically validated instruments (basic psychological needs, job satisfaction and work-related quality of life); a before and after questionnaire of patient satisfaction using a patient satisfaction tool validated in low-income settings with a maximum score of 80; and a qualitative template analysis encompassing ethnographic data, semi-structured interviews and focus groups with staff. Results The intervention was attended by all 145 eligible staff, who also participated in the longitudinal study. The general trend was an increase in the scores for each scale except for the basic psychological needs score in one site. Only one site demonstrated strong evidence for the intervention working in the work-related quality of life scales. Pre-intervention, 162 postnatal women completed the questionnaire; post-intervention, 191 postnatal women participated. Patient satisfaction rose in all three sites; referral hospital 4.41 rise (95% CI 1.89 to 6.95), district hospital 10.22 (95% CI 7.38 to 13.07) and community hospital 13.02 (95% CI 10.48 to 15.57). The qualitative data revealed that staff felt happier, that their skills (especially communication) had improved, behaviour had changed and systems had developed. Conclusions We have shown that it is possible to implement Appreciative Inquiry in government facilities in Malawi, which has the potential to change the way staff work and improve patient satisfaction. The mixed methods approach revealed important findings including the importance of staff relationships. We have identified clear implementation elements that will be important to measure in a future trial such as implementation fidelity and inter-personal relationship factors.

Objective To evaluate the short term associations between nitrogen dioxide (NO2) and total, cardiovascular, and respiratory mortality across multiple countries/regions worldwide, using a uniform analytical protocol. Design Two stage, time series approach, with overdispersed generalised linear models and multilevel meta-analysis. Setting 398 cities in 22 low to high income countries/regions. Main outcome measures Daily deaths from total (62.8 million), cardiovascular (19.7 million), and respiratory (5.5 million) causes between 1973 and 2018. Results On average, a 10 μg/m3 increase in NO2 concentration on lag 1 day (previous day) was associated with 0.46% (95% confidence interval 0.36% to 0.57%), 0.37% (0.22% to 0.51%), and 0.47% (0.21% to 0.72%) increases in total, cardiovascular, and respiratory mortality, respectively. These associations remained robust after adjusting for co-pollutants (particulate matter with aerodynamic diameter ≤10 μm or ≤2.5 μm (PM10 and PM2.5, respectively), ozone, sulfur dioxide, and carbon monoxide). The pooled concentration-response curves for all three causes were almost linear without discernible thresholds. The proportion of deaths attributable to NO2 concentration above the counterfactual zero level was 1.23% (95% confidence interval 0.96% to 1.51%) across the 398 cities. Conclusions This multilocation study provides key evidence on the independent and linear associations between short term exposure to NO2 and increased risk of total, cardiovascular, and respiratory mortality, suggesting that health benefits would be achieved by tightening the guidelines and regulatory limits of NO2., HaK was supported by the National Natural Science Foundation of China (92043301, 82030103, and 91843302) and China Medical Board Collaborating Program (16-250). AG and FS were supported by the Medical Research Council, UK (MR/M022625/1), the Natural Environment Research Council, UK (NE/R009384/1), and the European Union’s Horizon 2020 Project Exhaustion (820655). VH was supported by the Spanish Ministry of Science and Innovation (PCIN-2017-046), and the German Federal Ministry of Education and Research (01LS1201A2). YH and MH were supported by the Environment Research and Technology Development Fund (JPMEERF15S11412) of the Environmental Restoration and Conservation Agency, Japan. JK and AU were supported by the Czech Science Foundation (18-22125S). ST was supported by the Shanghai Municipal Science and Technology Commission (18411951600). Y-LLG was supported by a Career Development Fellowship of the Australian National Health and Medical Research Council (APP1163693). SL was supported by an Early Career Fellowship of the Australian National Health and Medical Research Council (APP1109193). JJKJJ and NR were supported by the Academy of Finland (310372). The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

More than half of the working population in Latin American and Caribbean (LAC) countries is engaged in informal employment. The few previous studies indicate that this employment condition could have negative consequences for workers' health. The aim of the present study was to estimate the association between self-perceived health and informality in LAC countries according to gender and welfare state type., This study was partially supported by the Center for Research in Occupational Health (CiSAL) Universitat Pompeu Fabra (UPF), Barcelona.

Summary Background Many regions of the world are now facing more frequent and unprecedentedly large wildfires. However, the association between wildfire-related PM2·5 and mortality has not been well characterised. We aimed to comprehensively assess the association between short-term exposure to wildfire-related PM2·5 and mortality across various regions of the world. Methods For this time series study, data on daily counts of deaths for all causes, cardiovascular causes, and respiratory causes were collected from 749 cities in 43 countries and regions during 2000–16. Daily concentrations of wildfire-related PM2·5 were estimated using the three-dimensional chemical transport model GEOS-Chem at a 0·25° × 0·25° resolution. The association between wildfire-related PM2·5 exposure and mortality was examined using a quasi-Poisson time series model in each city considering both the current-day and lag effects, and the effect estimates were then pooled using a random-effects meta-analysis. Based on these pooled effect estimates, the population attributable fraction and relative risk (RR) of annual mortality due to acute wildfire-related PM2·5 exposure was calculated. Findings 65·6 million all-cause deaths, 15·1 million cardiovascular deaths, and 6·8 million respiratory deaths were included in our analyses. The pooled RRs of mortality associated with each 10 μg/m3 increase in the 3-day moving average (lag 0–2 days) of wildfire-related PM2·5 exposure were 1·019 (95% CI 1·016–1·022) for all-cause mortality, 1·017 (1·012–1·021) for cardiovascular mortality, and 1·019 (1·013–1·025) for respiratory mortality. Overall, 0·62% (95% CI 0·48–0·75) of all-cause deaths, 0·55% (0·43–0·67) of cardiovascular deaths, and 0·64% (0·50–0·78) of respiratory deaths were annually attributable to the acute impacts of wildfire-related PM2·5 exposure during the study period., Australian Research Council, Australian National Health & Medical Research Council.

Background Epidemiological evidence on short-term association between ambient carbon monoxide (CO) and mortality is inconclusive and limited to single cities, regions, or countries. Generalisation of results from previous studies is hindered by potential publication bias and different modelling approaches. We therefore assessed the association between short-term exposure to ambient CO and daily mortality in a multicity, multicountry setting. Methods We collected daily data on air pollution, meteorology, and total mortality from 337 cities in 18 countries or regions, covering various periods from 1979 to 2016. All included cities had at least 2 years of both CO and mortality data. We estimated city-specific associations using confounder-adjusted generalised additive models with a quasi-Poisson distribution, and then pooled the estimates, accounting for their statistical uncertainty, using a random-effects multilevel meta-analytical model. We also assessed the overall shape of the exposure–response curve and evaluated the possibility of a threshold below which health is not affected. Findings Overall, a 1 mg/m3 increase in the average CO concentration of the previous day was associated with a 0·91% (95% CI 0·32–1·50) increase in daily total mortality. The pooled exposure–response curve showed a continuously elevated mortality risk with increasing CO concentrations, suggesting no threshold. The exposure–response curve was steeper at daily CO levels lower than 1 mg/m3, indicating greater risk of mortality per increment in CO exposure, and persisted at daily concentrations as low as 0·6 mg/m3 or less. The association remained similar after adjustment for ozone but was attenuated after adjustment for particulate matter or sulphur dioxide, or even reduced to null after adjustment for nitrogen dioxide. Interpretation This international study is by far the largest epidemiological investigation on short-term CO-related mortality. We found significant associations between ambient CO and daily mortality, even at levels well below current air quality guidelines. Further studies are warranted to disentangle its independent effect from other traffic-related pollutants., EU Horizon 2020, UK Medical Research Council, and Natural Environment Research Council

Air temperature has been the most commonly used exposure metric in assessing relationships between thermal stress and mortality. Lack of the high-quality meteorological station data necessary to adequately characterize the thermal environment has been one of the main limitations for the use of more complex thermal indices. Global climate reanalyses may provide an ideal platform to overcome this limitation and define complex heat and cold stress conditions anywhere in the world. In this study, we explored the potential of the Universal Thermal Climate Index (UTCI) based on ERA5 – the latest global climate reanalysis from the European Centre for Medium-Range Weather Forecasts (ECMWF) – as a health-related tool. Employing a novel ERA5-based thermal comfort dataset ERA5-HEAT, we investigated the relationships between the UTCI and daily mortality data in 21 cities across 9 European countries. We used distributed lag nonlinear models to assess exposure-response relationships between mortality and thermal conditions in individual cities. We then employed meta-regression models to pool the results for each city into four groups according to climate zone. To evaluate the performance of ERA5-based UTCI, we compared its effects on mortality with those for the station-based UTCI data. In order to assess the additional effect of the UTCI, the performance of ERA5-and station-based air temperature (T) was evaluated. Whilst generally similar heat- and cold-effects were observed for the ERA5-and station-based data in most locations, the important role of wind in the UTCI appeared in the results. The largest difference between any two datasets was found in the Southern European group of cities, where the relative risk of mortality at the 1st percentile of daily mean temperature distribution (1.29 and 1.30 according to the ERA5 vs station data, respectively) considerably exceeded the one for the daily mean UTCI (1.19 vs 1.22). These differences were mainly due to the effect of wind in the cold tail of the UTCI distribution. The comparison of exposure-response relationships between ERA5-and station-based data shows that ERA5-based UTCI may be a useful tool for definition of life-threatening thermal conditions in locations where high-quality station data are not available., We would like to thank all the national data providers for supplying meteorological as well as health data (see more details in the Supplementary Material). The study was primarily supported by the Czech Science Foundation, project no. 18-22125S (AU and JK), the European Commission's HORIZON2020 ANYWHERE project (Enhancing Emergency Management and Response to Extreme Weather and Climate Events, Project ID 700099, CDN, HLC), and FATHUM (Forecasts for AnTicipatory HUManitarian action) part of the UKRI NERC/DFID SHEAR programme, grant number NE/P000525/1 (HLC). The following individual grants also supported this work: Medical Research Council-UK (Grant ID: MR/M022625/1), Natural Environment Research Council UK (Grant ID: NE/R009384/1), European Union's Horizon 2020 Project Exhaustion (Grant ID: 820655), Spanish Ministry of Economy, Industry and Competitiveness (Grant ID: PCIN-2017-046).

BackgroundPostpartum haemorrhage (PPH), defined as a blood loss of 500 mL or more after birth, is the leading cause of maternal death worldwide. The World Health Organization (WHO) recommends that all women giving birth should receive a prophylactic uterotonic agent. Despite the routine administration of a uterotonic agent for prevention, PPH remains a common complication causing one-quarter of all maternal deaths globally. When prevention fails and PPH occurs, further administration of uterotonic agents as 'first-line' treatment is recommended. However, there is uncertainty about which uterotonic agent is best for the 'first-line' treatment of PPH.ObjectivesTo identify the most effective uterotonic agent(s) with the least side-effects for PPH treatment, and generate a meaningful ranking among all available agents according to their relative effectiveness and side-effect profile.Search methodsWe searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 May 2020), and the reference lists of all retrieved studies.Selection criteriaAll randomised controlled trials or cluster-randomised trials comparing the effectiveness and safety of uterotonic agents with other uterotonic agents for the treatment of PPH were eligible for inclusion.Data collection and analysisTwo review authors independently assessed all trials for inclusion, extracted data and assessed each trial for risk of bias. Our primary outcomes were additional blood loss of 500 mL or more after recruitment to the trial until cessation of active bleeding and the composite outcome of maternal death or severe morbidity. Secondary outcomes included blood loss-related outcomes, morbidity outcomes, and patient-reported outcomes. We performed pairwise meta-analyses and indirect comparisons, where possible, but due to the limited number of included studies, we were unable to conduct the planned network meta-analysis. We used the GRADE approach to assess the certainty of evidence.Main resultsSeven trials, involving 3738 women in 10 countries, were included in this review. All trials were conducted in hospital settings. Randomised women gave birth vaginally, except in one small trial, where women gave birth either vaginally or by caesarean section. Across the seven trials (14 trial arms) the following agents were used: six trial arms used oxytocin alone; four trial arms used misoprostol plus oxytocin; three trial arms used misoprostol; one trial arm used Syntometrine® (oxytocin and ergometrine fixed-dose combination) plus oxytocin infusion. Pairwise meta-analysis of two trials (1787 participants), suggests that misoprostol, as first-line treatment uterotonic agent, probably increases the risk of blood transfusion (risk ratio (RR) 1.47, 95% confidence interval (CI) 1.02 to 2.14, moderate-certainty) compared with oxytocin. Low-certainty evidence suggests that misoprostol administration may increase the incidence of additional blood loss of 1000 mL or more (RR 2.57, 95% CI 1.00 to 6.64). The data comparing misoprostol with oxytocin is imprecise, with a wide range of treatment effects for the additional blood loss of 500 mL or more (RR 1.66, 95% CI 0.69 to 4.02, low-certainty), maternal death or severe morbidity (RR 1.98, 95% CI 0.36 to 10.72, low-certainty, based on one study n = 809 participants, as the second study had zero events), and the use of additional uterotonics (RR 1.30, 95% CI 0.57 to 2.94, low-certainty). The risk of side-effects may be increased with the use of misoprostol compared with oxytocin: vomiting (2 trials, 1787 participants, RR 2.47, 95% CI 1.37 to 4.47, high-certainty) and fever (2 trials, 1787 participants, RR 3.43, 95% CI 0.65 to 18.18, low-certainty). According to pairwise meta-analysis of four trials (1881 participants) generating high-certainty evidence, misoprostol plus oxytocin makes little or no difference to the use of additional uterotonics (RR 0.99, 95% CI 0.94 to 1.05) and to blood transfusion (RR 0.95, 95% CI 0.77 to 1.17) compared with oxytocin. We cannot rule out an important benefit of using the misoprostol plus oxytocin combination over oxytocin alone, for additional blood loss of 500 mL or more (RR 0.84, 95% CI 0.66 to 1.06, moderate-certainty). We also cannot rule out important benefits or harms for additional blood loss of 1000 mL or more (RR 0.76, 95% CI 0.43 to 1.34, moderate-certainty, 3 trials, 1814 participants, one study reported zero events), and maternal mortality or severe morbidity (RR 1.09, 95% CI 0.35 to 3.39, moderate-certainty). Misoprostol plus oxytocin increases the incidence of fever (4 trials, 1866 participants, RR 3.07, 95% CI 2.62 to 3.61, high-certainty), and vomiting (2 trials, 1482 participants, RR 1.85, 95% CI 1.16 to 2.95, high-certainty) compared with oxytocin alone. For all outcomes of interest, the available evidence on the misoprostol versus Syntometrine® plus oxytocin combination was of very low-certainty and these effects remain unclear. Although network meta-analysis was not performed, we were able to compare the misoprostol plus oxytocin combination with misoprostol alone through the common comparator of oxytocin. This indirect comparison suggests that the misoprostol plus oxytocin combination probably reduces the risk of blood transfusion (RR 0.65, 95% CI 0.42 to 0.99, moderate-certainty) and may reduce the risk of additional blood loss of 1000 mL or more (RR 0.30, 95% CI 0.10 to 0.89, low-certainty) compared with misoprostol alone. The combination makes little or no difference to vomiting (RR 0.75, 95% CI 0.35 to 1.59, high-certainty) compared with misoprostol alone. Misoprostol plus oxytocin compared to misoprostol alone are compatible with a wide range of treatment effects for additional blood loss of 500 mL or more (RR 0.51, 95% CI 0.20 to 1.26, low-certainty), maternal mortality or severe morbidity (RR 0.55, 95% CI 0.07 to 4.24, low-certainty), use of additional uterotonics (RR 0.76, 95% CI 0.33 to 1.73, low-certainty), and fever (RR 0.90, 95% CI 0.17 to 4.77, low-certainty).Authors' conclusionsThe available evidence suggests that oxytocin used as first-line treatment of PPH probably is more effective than misoprostol with less side-effects. Adding misoprostol to the conventional treatment of oxytocin probably makes little or no difference to effectiveness outcomes, and is also associated with more side-effects. The evidence for most uterotonic agents used as first-line treatment of PPH is limited, with no evidence found for commonly used agents, such as injectable prostaglandins, ergometrine, and Syntometrine®.

Background The evidence on the association between ultrafine (UFP) particles and mortality is still inconsistent. Moreover, health effects of specific UFP sources have not been explored. We assessed the impact of UFP sources on daily mortality in Barcelona, Helsinki, London, and Zurich. Methods UFP sources were previously identified and quantified for the four cities: daily contributions of photonucleation, two traffic sources (fresh traffic and urban, with size mode around 30 nm and 70 nm, respectively), and secondary aerosols were obtained from data from an urban background station. Different periods were investigated in each city: Barcelona 2013–2016, Helsinki 2009–2016, London 2010–2016, and Zurich 2011–2014. The associations between total particle number concentrations (PNC) and UFP sources and daily (natural, cardiovascular [CVD], and respiratory) mortality were investigated using city-specific generalized linear models (GLM) with quasi-Poisson regression. Results We found inconsistent results across cities, sources, and lags for associations with natural, CVD, and respiratory mortality. Increased risk was observed for total PNC and natural mortality in Helsinki (lag 2; 1.3% [0.07%, 2.5%]), CVD mortality in Barcelona (lag 1; 3.7% [0.17%, 7.4%]) and Zurich (lag 0; 3.8% [0.31%, 7.4%]), and respiratory mortality in London (lag 3; 2.6% [0.84%, 4.45%]) and Zurich (lag 1; 9.4% [1.0%, 17.9%]). A similar pattern of associations between health outcomes and total PNC was followed by the fresh traffic source, for which we also found the same associations and lags as for total PNC. The urban source (mostly aged traffic) was associated with respiratory mortality in Zurich (lag 1; 12.5% [1.7%, 24.2%]) and London (lag 3; 2.4% [0.90%, 4.0%]) while the secondary source was associated with respiratory mortality in Zurich (lag 1: 12.0% [0.63%, 24.5%]) and Helsinki (4.7% [0.11%, 9.5%]). Reduced risk for the photonucleation source was observed for respiratory mortality in Barcelona (lag 2, −8.6% [−14.5%, −2.4%]) and for CVD mortality in Helsinki, as this source is present only in clean atmospheres (lag 1, −1.48 [−2.75, −0.21]). Conclusions We found inconsistent results across cities, sources and lags for associations with natural, CVD, and respiratory mortality., This project has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 747882. While writing the manuscript, Dr. Rivas was funded by the postdoctoral fellowship programme Beatriu de Pinós (2018 BP 00114), funded by the Secretary of Universities and Research (Government of Catalonia) and by the Horizon 2020 programme of research and innovation of the European Union under the Marie Sklodowska-Curie grant agreement No 801370. Currently, Dr. Rivas is funded by the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 886121. This work was supported by FEDER funds; projects HOUSE (CGL2016-78594-R) and CAIAC (PID2019-108990RB-I00), the Government of Catalonia (AGAUR 2017 SGR41). The authors also acknowledge the Project PI16/00118 funded by the Instituto de Salud Carlos III and co-funded by the European Regional Development Fund (ERDF) “A way to make Europe”. HW’s post was partially funded by the UK National Institute for Health Research Health Protection Research Unit on Environmental Exposures and Health at Imperial College London in partnership with Public Health England, King’s College London and the MTC Toxicology Unit, Cambridge. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health & Social Care or Public Health England. This work was produced using statistical data from ONS. The use of the ONS statistical data in this work does not imply the endorsement of the ONS in relation to the interpretation or analysis of the statistical data. This work uses research datasets which may not exactly reproduce National Statistics aggregates.

Biomass burning (BB) including forest, bush, prescribed fires, agricultural fires, residential wood combustion, and power generation has long been known to affect climate, air quality and human health. With this work we supply a systematic review on the health effects of BB emissions in the framework of the WHO activities on air pollution. We performed a literature search of online databases (PubMed, ISI, and Scopus) from year 1980 up to 2020. A total of 81 papers were considered as relevant for mortality and morbidity effects. High risk of bias was related with poor estimation of BB exposure and lack of adjustment for important confounders. PM10 and PM2.5 concentrations originating from BB were associated with all-cause mortality: the meta-analytical estimate was equal to 1.31% (95% CI 0.71, 1.71) and 1.92% (95% CI -1.19, 5.03) increased mortality per each 10 μg m-3 increase of PM10 and PM2.5, respectively. Regarding cardiovascular mortality 8 studies reported quantitative estimates. For smoky days and for each 10 μg m-3 increase in PM2.5 concentrations, the risk of cardiovascular mortality increased by 4.45% (95% CI 0.96, 7.95) and by 3.30% (95% CI -1.97, 8.57), respectively. Fourteen studies evaluated whether respiratory morbidity was adversely related to PM2.5 (9 studies) or PM10 (5 studies) originating from BB. All found positive associations. The pooled effect estimates were 4.10% (95% CI 2.86, 5.34) and 4.83% (95% CI 0.06, 9.60) increased risk of total respiratory admissions/emergency visits, per 10 μg m-3 increases in PM2.5 and PM10, respectively. Regarding cardiovascular morbidity, sixteen studies evaluated whether this was adversely related to PM2.5 (10 studies) or PM10 (6 studies) originating from BB. They found both positive and negative results, with summary estimates equal to 3.68% (95% CI -1.73, 9.09) and 0.93% (95% CI -0.18, 2.05) increased risk of total cardiovascular admissions/emergency visits, per 10 μg m-3 increases in PM2.5 and PM10, respectively. To conclude, a significant number of studies indicate that BB exposure is associated with all-cause and cardiovascular mortality and respiratory morbidity., The systematic review was funded by WHO as part of a Grant Agreement with Ministry of Foreign Affairs, Norway. Angeliki Karanasiou acknowledges support received through the Ramón y Cajal program (grant RYC-2014-16885) of the Spanish Ministry of Science, Innovation and Universities. This work was supported by the Spanish Ministry of Science and Innovation (Excelencia Severo Ochoa, Project CEX2018-000794-S).

Summary Background Various retrospective studies have reported on the increase of mortality risk due to higher diurnal temperature range (DTR). This study projects the effect of DTR on future mortality across 445 communities in 20 countries and regions. Methods DTR-related mortality risk was estimated on the basis of the historical daily time-series of mortality and weather factors from Jan 1, 1985, to Dec 31, 2015, with data for 445 communities across 20 countries and regions, from the Multi-Country Multi-City Collaborative Research Network. We obtained daily projected temperature series associated with four climate change scenarios, using the four representative concentration pathways (RCPs) described by the Intergovernmental Panel on Climate Change, from the lowest to the highest emission scenarios (RCP 2.6, RCP 4.5, RCP 6.0, and RCP 8.5). Excess deaths attributable to the DTR during the current (1985–2015) and future (2020–99) periods were projected using daily DTR series under the four scenarios. Future excess deaths were calculated on the basis of assumptions that warmer long-term average temperatures affect or do not affect the DTR-related mortality risk. Findings The time-series analyses results showed that DTR was associated with excess mortality. Under the unmitigated climate change scenario (RCP 8.5), the future average DTR is projected to increase in most countries and regions (by −0·4 to 1·6°C), particularly in the USA, south-central Europe, Mexico, and South Africa. The excess deaths currently attributable to DTR were estimated to be 0·2–7·4%. Furthermore, the DTR-related mortality risk increased as the long-term average temperature increased; in the linear mixed model with the assumption of an interactive effect with long-term average temperature, we estimated 0·05% additional DTR mortality risk per 1°C increase in average temperature. Based on the interaction with long-term average temperature, the DTR-related excess deaths are projected to increase in all countries or regions by 1·4–10·3% in 2090–99. Interpretation This study suggests that globally, DTR-related excess mortality might increase under climate change, and this increasing pattern is likely to vary between countries and regions. Considering climatic changes, our findings could contribute to public health interventions aimed at reducing the impact of DTR on human health.

The transmission of coronaviruses can be affected by several factors, including the climate. Due to the rapid spread of COVID-19 and the urgent need for rapid responses to contain the pandemic, it is essential to understand the role that weather conditions on the transmission of SARS-CoV-2. We evaluate the influence of meteorological factors on the incidence of COVID-19 during the first wave of the epidemic in Catalonia. We conducted a geographical analysis at the county level to evaluate the association between mean temperature, absolute humidity, solar radiation, and the cumulative incidence of COVID-19. Next, we used a time-series design to assess the short-term effects of meteorological factors on the daily incidence of COVID-19. We found a geographical association between meteorological factors and the cumulative incidence of COVID-19, from the end of March to June 2020, and a lesser extent in the short-term on the daily incidence during the first wave of the epidemic in Spain. Our findings suggest that warm and wet climates may reduce the incidence of COVID-19 in Catalonia. However, policy makers must interpret with caution any COVID-19 risk predictions based on climate information alone., MS appreciates the funding from SUPERA COVID19 Fund, from SAUN (Santander Universidades), CRUE and CSIC; as well as from Pfizer Global Medical Grants. The funding sources did not participate in the design or conduct of the study, the collection, management, analysis, or interpretation of the data, or the preparation, review, or approval of the manuscript.

Supplemental Digital Content is available in the text., Background: Desert dust is assumed to have substantial adverse effects on human health. However, the epidemiologic evidence is still inconsistent, mainly because previous studies used different metrics for dust exposure and its corresponding epidemiologic analysis. We aim to provide a standardized approach to the methodology for evaluating the short-term health effects of desert dust. Methods: We reviewed the methods commonly used for dust exposure assessment, from use of a binary metric for the occurrence of desert dust advections to a continuous one for quantifying particulate matter attributable to desert dust. We presented alternative time-series Poisson regression models to evaluate the dust exposure–mortality association, from the underlying epidemiological and policy-relevant questions. A set of practical examples, using a real dataset from Rome, Italy, illustrate the different modeling approaches. Results: We estimate substantial effects of desert dust episodes and particulate matter with diameter

Acknowledgement: “This Protocol of a Cochrane Review was published in the Cochrane Database of Systematic Reviews 2020, Issue 9. Cochrane Protocols and Reviews are regularly updated as new evidence emerges and in response to feedback, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Protocol.'

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and associated COVID-19 have caused a global emergency that requires an engaged, integrated, interdisciplinary, and rapid response from the scientific community. Climate change, ecological change, and biodiversity loss might have played an important role in the occurrence of this zoonotic pandemic. Climatic and environmental factors, such as temperature, humidity, and air pollution, are potentially influencing the transmission, spread, and severity of SARS-CoV-2 infection. Strong scientific evidence about the contributions of these environmental determinants in the COVID-19 pandemic is needed, in combination with an understanding of the role of other important societal factors and public health interventions. This evidence will support the public health community in responding to the current crisis, and inform strategies to prevent the recurring effects of the COVID-19 pandemic and future emergencies.

IntroductionInternal temporomandibular joint (TMJ) disorders are present in approximately 80% of patients with symptomatic temporomandibular disorders. Among the minimally invasive therapies, we find the intra-articular infiltration of substances, such as corticosteroids, hyaluronic acid or platelet-rich plasma accompanied or not by an arthrocentesis. There are several studies on minimally invasive therapy for internal TMJ disorders; however, none compares the effectiveness of the different intra-articular corticosteroids to each other.The purpose of this study is to evaluate the effectiveness of the different intra-articular corticosteroids for the treatment of internal disorders of the TMJ and compare them to each other or to other minimally invasive therapies.Methods and analysisA systematic search will be carried out up to December 2019 in the electronic databases: Medline, Cochrane Library, EMBASE, SCOPUS and LILACS.Randomised clinical trials evaluating patients with internal disorders of the TMJ, with intra-articular corticosteroid therapy and comparing these to each other and/or to other minimally invasive therapy will be included. The main outcomes will be pain and range of motion measured through validated scales.Two review authors will independently screen search results, extract data from included studies and assess the risk of bias in those studies using the Revised Cochrane Risk of Bias Tool (RoB 2.0). In the case of any discrepancy and failure to reach consensus, this will be resolved by a third reviewer.A network meta-analysis will be conducted based on direct comparisons to generate indirect comparisons of the different treatments. Data will be combined in a meta-analysis using a random effects model.The principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system will be used to assess the overall quality of the body of evidence associated with the main results.Ethics and disseminationThis protocol will not require ethical approval. The results of this review will be disseminated through peer-reviewed publications.Trial registration numberCRD42019129014.

ObjectivesTo assess if there is any association between hyperemesis gravidarum (HG), psychological morbidity and infant bonding and to quantify any psychosocial consequences of HG.DesignTwo-point prospective case–control, multicentre survey study with antenatal and postnatal data collection.SettingThree London hospitals.ParticipantsPregnant women at ≤12 completed weeks gestation recruited consecutively over 2 years. Women with HG were recruited at the time of admission; controls recruited from a low risk antenatal clinic. 106 women were recruited to the case group and 108 to the control. Response rates at antenatal data collection were 87% and 85% in the case and control groups, respectively. Postnatally, the response rate was 90% in both groups.Primary and secondary outcome measuresPrimary outcomes were psychological morbidity in the antenatal and postnatal periods, infant bonding in the postnatal period and psychosocial implications of HG. Secondary outcomes were the effects of severity and longevity of HG and assessment of correlation between Edinburgh Postnatal Depression Scale scores and maternal-to-infant bonding scores.ResultsAntenatally, 49% of cases had probable depression compared with 6% of controls (OR 14.4 (5.29 to 39.44)). Postnatally, 29% of cases had probable depression versus 7% of controls (OR 5.2 (1.65 to 17.21)). There was no direct association between HG and infant bonding. 53% of women in the HG group reported needing four or more weeks of sick leave compared with 2% in the control group (OR 60.5 (95% CI 8.4 to 2535.6)).ConclusionsLong-lasting psychological morbidity associated with HG was evident. Significantly more women in the case group sought help for mental health symptoms in the antenatal period, however very few were diagnosed with or treated for depression in pregnancy or referred to specialist perinatal mental health services. HG did not directly affect infant bonding. Women in the case group required long periods off work, highlighting the socioeconomic impact of HG.

Aims We aimed to investigate the heterogeneity of seasonal suicide patterns among multiple geographically, demographically and socioeconomically diverse populations. Methods Weekly time-series data of suicide counts for 354 communities in 12 countries during 1986–2016 were analysed. Two-stage analysis was performed. In the first stage, a generalised linear model, including cyclic splines, was used to estimate seasonal patterns of suicide for each community. In the second stage, the community-specific seasonal patterns were combined for each country using meta-regression. In addition, the community-specific seasonal patterns were regressed onto community-level socioeconomic, demographic and environmental indicators using meta-regression. Results We observed seasonal patterns in suicide, with the counts peaking in spring and declining to a trough in winter in most of the countries. However, the shape of seasonal patterns varied among countries from bimodal to unimodal seasonality. The amplitude of seasonal patterns (i.e. the peak/trough relative risk) also varied from 1.47 (95% confidence interval [CI]: 1.33–1.62) to 1.05 (95% CI: 1.01–1.1) among 12 countries. The subgroup difference in the seasonal pattern also varied over countries. In some countries, larger amplitude was shown for females and for the elderly population (≥65 years of age) than for males and for younger people, respectively. The subperiod difference also varied; some countries showed increasing seasonality while others showed a decrease or little change. Finally, the amplitude was larger for communities with colder climates, higher proportions of elderly people and lower unemployment rates (p-values < 0.05). Conclusions Despite the common features of a spring peak and a winter trough, seasonal suicide patterns were largely heterogeneous in shape, amplitude, subgroup differences and temporal changes among different populations, as influenced by climate, demographic and socioeconomic conditions. Our findings may help elucidate the underlying mechanisms of seasonal suicide patterns and aid in improving the design of population-specific suicide prevention programmes based on these patterns., JY, DY and YC were supported by a Senior Research grant (2019R1A2C1086194) from the National Research Foundation of Korea (NRF), funded by the Ministry of Science, ICT (Information and Communication Technologies) and Government-wide R&D Fund project for Infectious Disease (HG18C0025). YK was supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number JP19K17104 in Japan. AG and FS were supported by the Medical Research Council UK (Grant ID: MR/R013349/1) and Natural Environment Research Council (Grant ID: NE/R009384/1). NS was supported by the NIEHS-funded HERCULES Center (P30ES019776).

Over a 10-year period (1984-1996) a child guidance clinic developed a service in the community for parents with young children with mental health problems. This included support for primary care staff and training courses. The clinical input to the young children developed from a clinic within the child guidance clinic (1984-87), to a specialist clinic for under fives (1990-91) to a service run by a nurse in the community (1994-95), with nurses referring to colleagues only the more complicated cases.The work in 1990-91 was compared with the work in 1994-95. The family and clinic scored the outcome of the work, by recording the severity of the problem, separately, on unanchored 5-point Likert scales before and after treatment. For the evaluation in 1994-95 a satisfaction questionnaire was also developed. The cost of running the two different clinics was calculated.The results indicated that there was a slight fall in the effect size for the clinical work in 1994-95, but this method of working was two-thirds of the cost of the previous clinic. The parents were satisfied with both services. The post-contact parental satisfaction questionnaire had face validity, construct validity and internal consistency.Nurses working on their own in the community can be a cost effective method for working with families with young children. Some families will need to be referred on to specialist teams and more work needs to be done to establish which families and when referral is appropriate. The questionnaire was shown to be a valid and reliable way of assessing family satisfaction.

Background Current strategies for preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections are limited to non-pharmacological interventions. Hydroxychloroquine (HCQ) has been proposed as a postexposure therapy to prevent Coronavirus disease 2019 (Covid-19) but definitive evidence is lacking. Methods We conducted an open-label, cluster-randomized trial including asymptomatic contacts exposed to a PCR-positive Covid-19 case in Catalonia, Spain. Clusters were randomized to receive no specific therapy (control arm) or HCQ 800mg once, followed by 400mg daily for 6 days (intervention arm). The primary outcome was PCR-confirmed symptomatic Covid-19 within 14 days. The secondary outcome was SARS-CoV-2 infection, either symptomatically compatible or a PCR-positive result regardless of symptoms. Adverse events (AEs) were assessed up to 28 days. Results The analysis included 2,314 healthy contacts of 672 Covid-19 index cases identified between Mar 17 and Apr 28, 2020. A total of 1,198 were randomly allocated to usual care and 1,116 to HCQ therapy. There was no significant difference in the primary outcome of PCR-confirmed, symptomatic Covid-19 disease (6.2% usual care vs. 5.7% HCQ; risk ratio 0.89 [95% confidence interval 0.54-1.46]), nor evidence of beneficial effects on prevention of SARS-CoV-2 transmission (17.8% usual care vs. 18.7% HCQ). The incidence of AEs was higher in the intervention arm than in the control arm (5.9% usual care vs 51.6% HCQ), but no treatment-related serious AEs were reported. Conclusions Postexposure therapy with HCQ did not prevent SARS-CoV-2 disease and infection in healthy individuals exposed to a PCR-positive case. Our findings do not support HCQ as postexposure prophylaxis for Covid-19., This study was mainly supported by the crowdfunding campaign JoEmCorono (https://www.yomecorono.com/) with the contribution of over 72,000 citizens and corporations. The study also received financial support from Laboratorios Rubió, Gebro Pharma, Zurich Seguros, SYNLAB Barcelona, and Generalitat de Catalunya. Laboratorios Rubió also contributed to the study with the required doses of hydroxychloroquine (Dolquine®).

From the end of February, the SARS-CoV-2 epidemic in Spain has been following the footsteps of that in Italy very closely. We have analyzed the trends of incident cases, deaths, and intensive care unit admissions (ICU) in both countries before and after their respective national lockdowns using an interrupted time-series design. Data was analyzed with quasi-Poisson regression using an interaction model to estimate the change in trends. After the first lockdown, incidence trends were considerably reduced in both countries. However, although the slopes have been flattened for all outcomes, the trends kept rising. During the second lockdown, implementing more restrictive measures for mobility, it has been a change in the trend slopes for both countries in daily incident cases and ICUs. This improvement indicates that the efforts overtaken are being successful in flattening the epidemic curve, and reinforcing the belief that we must hold on.

No effective treatments for coronavirus disease 2019 (COVID-19) exist. We aimed to determine whether early treatment with hydroxychloroquine (HCQ) would be efficacious for outpatients with COVID-19., The authors thank Gerard Carot-Sans, PhD, for providing medical writing support during the revisions of the subsequent drafts of the manuscript; the personnel from the Fights Aids and Infectious Diseases Foundation for their support in administration, human resources and supply chain management; Eric Ubals (Pierce AB) and Òscar Palao (Opentic) for website and database management; Óscar Camps and OpenArms nongovernmental organization for nursing home operations; and Anna Valentí and the Hospital Germans Trias i Pujol Human Resources Department for telephone monitoring. We thank Consorci Sanitari del Maresme, Centre Sociosanitari El Carme, l'Hospital General de Granollers and occupational hazards department of Hospital Germans Trias i Pujol for their contribution with patient enrollment. We are very grateful to Marc Clotet and Natalia Sánchez who coordinated the JoEmCorono crowd-funding campaign. We thank the Hospital Germans Trias Pujol Institutional Review Board and the Spanish Agency of Medicines and Medical Devices for their prompt action for consideration and approvals to the protocol. Financial support. This work was mainly supported by the crowd-funding campaign JoEmCorono (https://www.yomecorono.com/) with contributions from more than 72 000 citizens and corporations. The study also received financial support from Laboratorios Rubió, Laboratorios Gebro Pharma, Zurich Seguros, SYNLAB Barcelona, and Generalitat de Catalunya. Laboratorios Rubió also contributed to the study with the required doses of hydroxychloroquine (Dolquine®). Foundation Dorneur partly funded lab equipment at Irsi-Caixa.

Climate change is a severe public health challenge. Understanding to what extent fatal and non-fatal consequences of specific diseases are associated with temperature may help to improve the effectiveness of preventive public health efforts. This study examines the effects of temperature on deaths and hospital admissions by cardiovascular and respiratory diseases, empathizing the difference between mortality and morbidity., This work was partially funded by the Spanish Ministry of Science and Innovation (grant ID's: MTM2017-83850-P, PID2019-106341GB-I00).

Ship traffic emissions degrade air quality in coastal areas and contribute to climate impacts globally. The estimated health burden of exposure to shipping emissions in coastal areas may inform policy makers as they seek to reduce exposure and associated potential health impacts. This work estimates the PM2.5-attributable impacts in the form of premature mortality and cardiovascular and respiratory hospital admissions, from long-term exposure to shipping emissions. Health impact assessment (HIA) was performed in 8 Mediterranean coastal cities, using a baseline conditions from the literature and a policy case accounting for the MARPOL Annex VI rules requiring cleaner fuels in 2020. Input data were (a) shipping contributions to ambient PM2.5 concentrations based on receptor modelling studies found in the literature, (b) population and health incidence data from national statistical registries, and (c) geographically-relevant concentration-response functions from the literature. Long-term exposure to ship-sourced PM2.5 accounted for 430 (95% CI: 220–650) premature deaths per year, in the 8 cities, distributed between groups of cities: Barcelona and Athens, with >100 premature deaths/year, and Nicosia, Brindisi, Genoa, Venice, Msida and Melilla, with tens of premature deaths/year. The more stringent standards in 2020 would reduce the number of PM2.5-attributable premature deaths by 15% on average. HIA provided a comparative assessment of the health burden of shipping emissions across Mediterranean coastal cities, which may provide decision support for urban planning with a special focus on harbour areas, and in view of the reduction in sulphur content of marine fuels due to MARPOL Annex VI in 2020. © 2020 The Authors, The authors gratefully acknowledge the providers of health data and statistics: Nicosia (M. Athanasiadou, Health Monitoring Unit, Ministry of Health), Brindisi (M. Stafoggia, L. Bauleo, UOC Epidemiologia eziologica ed occupazionale, Dipartimento Epidemiologia del S.S.R. - ASL RME, Regione Lazio, Genoa-Venice (Istituto Superiore di sanità/Health Institute, http://old.iss.it/publ/ ), Misda (S. Distefano, Department for Policy in Health, Health Information and Research), Melilla ( https://pestadistico.inteligenciadegestion.mscbs.es/publicoSNS/Comun/ ), Athens (Hellenic Statistical Authority, http://www.statistics.gr/en/statistics/-/publication/SPO09/2014 ), and Barcelona (Servei Català de la Salut and the Registre de Mortalitat de Catalunya). The data provided by the Servei Català de la Salut and the Registre de Mortalitat de Catalunya, Servei de Gestió I Anàlisi de la Informació per a la Planificació Estratègica, Direcció General de Planificació en Salut, Departament de Salut were processed internally by CSIC. The authors also acknowledge fruitful technical discussions with Dr. A. Patton (Health Effects Institute, HEI). This work was partially funded by AGAUR (project 2017 SGR41 ) and by the Spanish Ministry of Science and Innovation (Project CEX2018-000794-S ). A. Karanasiou acknowledges support received through the Ramón y Cajal program (grant RYC-2014-16885 ) of the Spanish Ministry of Science, Innovation and Universities .