Extra Risk Research Articles

The effects of night-time warming on mortality burden under future climate change scenarios: a modelling study

The health impacts of climate warming are usually quantified based on daily average temperatures. However, extra health risks might result from hot nights. We project the future mortality burden due to hot nights. We selected the hot night excess (HNE) to represent the intensity of night-time heat, which was calculated as the excess sum of high temperature during night time. We collected historical mortality data in 28 cities from three east Asian countries, from 1981 to 2010. The associations between HNE and mortality in each city were firstly examined using a generalised additive model in combination with a distributed lag non-linear model over lag 0-10 days. We then pooled the cumulative associations using a univariate meta-regression model at the national or regional levels. Historical and future hourly temperature series were projected under two scenarios of greenhouse-gas emissions from 1980-2099, with ten general circulation models. We then projected the attributable fraction of mortality due to HNE under each scenario. Our dataset comprised 28 cities across three countries (Japan, South Korea, and China), including 9 185 598 deaths. The time-series analyses showed the HNE was significantly associated with increased mortality risks, the relative mortality risk on days with hot nights could be 50% higher than on days with non-hot nights. Compared with the rise in daily mean temperature (lower than 20%), the frequency of hot nights would increase more than 30% and the intensity of hot night would increase by 50% by 2100s. The attributable fraction of mortality due to hot nights was projected to be 3·68% (95% CI 1·20 to 6·17) under a strict emission control scenario (SSP126). Under a medium emission control scenario (SSP245), the attributable fraction of mortality was projected to increase up to 5·79% (2·07 to 9·52), which is 0·95% (-0·39 to 2·29) more than the attributable fraction of mortality due to daily mean temperature. Our study provides evidence for significant mortality risks and burden in association with night-time warming across Japan, South Korea, and China. Our findings suggest a growing role of night-time warming in heat-related health effects in a changing climate. The National Natural Science Foundation of China, Shanghai International Science and Technology Partnership Project.

Developing a Multimodal Model for Detecting Higher-Grade Prostate Cancer Using Biomarkers and Risk Factors.

A technique to predict crucial clinical prostate cancer (PC) is desperately required to prevent diagnostic errors and overdiagnosis. To create a multimodal model that incorporates long-established messenger RNA (mRNA) indicators and conventional risk variables for identifying individuals with severe PC on prostatic biopsies. Urinary has gathered for mRNA analysis following a DRE and before a prostatic examination in two prospective multimodal investigations. A first group (n = 489) generated the multimodal risk score, which was then medically verified in a second group (n = 283). The reverse transcription qualitative polymerase chain reaction determined the mRNA phase. Logistic regression was applied to predict risk in patients and incorporate health risks. The area under the curve (AUC) was used to compare models, and clinical efficacy was assessed by using a DCA. The amounts of sixth homeobox clustering and first distal-less homeobox mRNA have been strongly predictive of high-grade PC detection. In the control subjects, the multimodal method achieved a total AUC of 0.90, with the most important aspects being the messenger riboneuclic acid features' PSA densities and previous cancer-negative tests as a nonsignificant design ability to contribute to PSA, aging, and background. An AUC of 0.86 was observed for one more model that added DRE as an extra risk component. Two methods were satisfactorily verified without any significant changes within the area under the curve in the validation group. DCA showed a massive net advantage and the highest decrease in inappropriate costs.

Skin cancers under Janus kinase inhibitors: A World Health Organization drug safety database analysis

Janus kinase (JAK) inhibitors are targeted therapies with a potential imunomodulatory and anti-inflammatory effect, indicated in various dysimmune pathologies. Skin cancers have been reported to occur in patients treated with JAK inhibitors. However, drug safety in clinical trials did not confirm that risk, but these studies are performed on controlled population and in a limited time of follow up. The aim of this study is to evaluate in real life condition if a disproportionality signal exists between JAK inhibitors treatment and skin cancers. We performed cases/non cases analysis in VigiBase® (the World Health Organization international database of suspected adverse drug reaction) using information component to search for a disproportionality signal of skin cancers from JAK inhibitor. We extracted all reports of skin cancers from the French Pharmacovigilance database occurring since 1978 up to 31st December 2019 for the three existing JAK inhibitors on market: ruxolitinib, tofacitinib and baricitinib. Only melanoma, squamous cell carcinoma and Merkel cell carcinoma were analyzed, according to the pathophysiology of these cancers and their link with immunosuppression. A disproportionality signal was found positive for squamous cell carcinoma with ruxolitinib (IC025=3.92) and tofacitinib (IC025=0.82), for melanoma with ruxolitinib (IC025=0.81) and tofacitinib (IC025=0.74), and Merkel cell carcinoma with ruxolitinib (IC025=4) and tofactinib (IC025=1.01) and only for Merkel cell carcinoma with baricitinib (IC025=0.53). Moreover, Merkel cell carcinoma, a very rare skin cancer more prevalent in immunodepressed patients was particularly represented in our sample and was associated with a significant disproportionality signal with all the studied JAK inhibitors. Our study shows that JAK inhibitors could be associated with an extra risk to develop skin cancers. Could an anti-viral or immunovigilance disruption mechanism brought by JAK inhibitors explain an over-risk with Merkel cell carcinoma, which were notably represented in our sample? Considering pharmacovigilance method limitations, further pharmacoepidemiological studies are required to assess a causal link between JAK inhibitors treatment and skin cancers development.

The Association Between Informal Caregiving and Poor Self-rated Health Among Ever-married Women in Japan: A Nationally Representative Survey.

BackgroundThe number of people providing informal caregiving, including dual care, which is the combination of child and nursing care, is increasing. Due to the burden of multiple responsibility, dual care could negatively affect the health of informal caregivers. Previous research has not studied the effects of combining different types of informal caregiving. Therefore, we examined, among Japanese women, 1) the association between types of informal caregiving and self-rated health (SRH), and 2) difference in this association according to caregivers’ socio-economic conditions.MethodsWe analyzed the nationally representative 2013 Comprehensive Survey of Living Conditions data of 104,171 women aged 20–59 years. The odds ratios (ORs) for poor SRH by type of informal caregiving (no care, childcare, nursing care, and dual care) were estimated using logistic regression. We also conducted sub-group analyses by socio-economic conditions (equivalent monthly household expenditure and educational attainment).ResultsCompared to the no care group, the adjusted ORs for poor SRH of the childcare, nursing-care, and dual care groups were 0.92 (95% confidence interval [CI], 0.88–0.97), 1.33 (95% CI, 1.21–1.47), and 1.42 (95% CI, 1.23–1.64), respectively. There was no extra risk arisen from combining childcare and nursing care. The sub-group analyses indicated that neither household expenditure nor educational attainment affected the association between caregiving type and poor SRH.ConclusionOur study found that informal nursing care and dual care impose a health burden on female caregivers, regardless of their socio-economic conditions. This highlights the importance of addressing the effects of informal caregiving on the health of women.

Increased use of birth interventions during the COVID-19 pandemic?: An exploratory qualitative study.

Context: Since the onset of the COVID-19 pandemic policies have been implemented to limit disease transmission and manage patient flow in clinical settings, including perinatal healthcare settings. Emergent literature indicates increased medicalization of childbirth during the pandemic, however experiences of pregnancy and birth remain unexplored. Understanding the impact of pandemic policies on healthcare practices is important for planning better care in future. Objective: To examine how people in Canada who gave birth during the COVID-19 pandemic were affected by pandemic-related policies, especially policies aimed at limiting interpersonal contact to reduce SARS-CoV-2 transmission. Study Design: exploratory qualitative descriptive study. Dataset: Semi-structured telephone interviews. Population studied: 67 participants were recruited. Study inclusion was extended to anyone aged 18 years or more who was located in Canada and was pregnant or had given birth during the COVID-19 pandemic. Intervention/Instrument (for interventional studies): N/A. Outcome Measures: N/A. Results: Findings suggest that the pandemic has resulted in an overall scaling back of perinatal care alongside the heavy use of interventions (e.g., induction of labour, cesarean section) in response to pandemic stresses and uncertainties on the part of both healthcare providers and pregnant people themselves. Some participants pushed for non-medically necessary interventions as a means of averting the possibility that their partner would be banned from attending the birth (e.g. if the partner contracted COVID-19). Some participants reported being offered interventions as a means of controlling patient flow and in response to clinicians' fears of healthcare system collapse in the event of escalating infection rates. Conclusions: For some people in Canada, giving birth during the COVID-19 pandemic entails medicalization and implementation of non-medically necessary interventions. If healthcare systems are increasing intervention use at the same time that the "safety net" intended to catch the complications from those interventions is reduced, then birthing people are being exposed to extra risk precisely when it is most important to minimize it. Continuity of care throughout pregnancy and postpartum, labour support persons, and non-medical forms of care are all essential components of safe maternal healthcare, however pandemic perinatal care demonstrates that they are not viewed as such.

EP475: Long-term follow-up on fetuses diagnosed in second trimester with isolated single umbilical artery and normal chromosomal microarray

Fetuses diagnosed with isolated Fetal Single Umbilical Artery (iSUA), defined when no additional anatomical abnormalities are detected, and are not associated with significantly increased risk for chromosomal anomalies. However, information on their long-term outcome is lacking. The objective of the current study is to examine the long-term outcomes of fetuses diagnosed in second trimester with iSUA and normal chromosomal microarray assay (CMA). A retrospective review was conducted including all cases referred to our center with iSUA and a normal CMA between 2016 to 2020 (study group). Obstetrical and postnatal medical files were reviewed. Parents were contacted for a structured interview including neurodevelopment development assessment using Ages & Stages Questionary-3 (ASQ-3). A total of 282 cases of iSUA were referred for prenatal counseling, 48 (17%) opted to perform an invasive diagnostic test. The final study group consisted of 45 patients. Pregnancy follow-up was conducted in a dedicated clinic and included prenatal echocardiography and a 3rd-trimester malformation scan. Post-natal follow-up range was 3±2.2 years. In 9 (20%) cases of the study group additional findings were detected downstream: 4 (45%) cases prenatally (esophageal atresia, congenital anomaly of kidney, Severe Intrauterine growth retardation, and VACTERL association). Five cases (55%) showed abnormal findings only postnatally: 3 cases (6.6%) with malformations (brachial cyst and polydactyly and GLI1 pathogenic variant, sacral malformation and heterotopia due to FLNA pathogenic variant, and one case with coloboma - in assessment). 2 cases (4.4%) with functional abnormalities (one with recurrent meningitis and strabismus and one with prematurity and diplegic cerebral palsy) all being under evaluation. Two (4%) additional cases were diagnosed with neurodevelopment delay. ASQ-3 scores in all other study group participants were in the normal range. Fetuses diagnosed with iSUA and normal CMA in the second trimester are at increased risk for anatomical and functional complications including single-gene disorders. Additional findings might be disclosed in later stages of pregnancy but more importantly – can evolve postnatally only. Therefore, an extra risk should be given to the counselee and exome analysis should be considered. Further studies are required to reinforce this data

Income, trading, and performance: Evidence from retail investors

We examine whether household income influences the trading styles of retail investors and their investment performance. To investigate this question, we use a unique dataset of branch-level trading that contains all retail investors and observe that those investors with high income trade more and earn significantly higher returns in the stock market. In addition, this income effect becomes stronger for highly risky stocks, such as gambling or lottery-like stocks. These findings are in line with the information model theorized by Peress (2004) in which wealthy investors take extra risks by trading more stocks.

Effects of the Y-shape stud and outer insulating layer on heat dissipation and wall temperature of the hot cyclone in a circulating fluidized bed boiler

• The heat dissipation process of a hot cyclone was numerically simulated. • Three key parameters of the heat dissipation were well linear with stud number. • The arrangement had a slight impact on heat dissipation at a certain stud number. • The insulating layer may let the steel layer temperature increase rapidly. • Suggestions for the hot cyclone wall design were given. The hot cyclones in circulating fluidized bed (CFB) boilers often face the problems of high heat dissipation and high wall temperature in the operation, which may decrease the strength of the steel layer and present a danger to workers. To solve these problems, the heat dissipation characteristics through the cyclone wall and the key parameters of this process need to be known. In this study, a numerical simulation was conducted to estimate the wall temperature field of a hot cyclone in a 440 t/h CFB boiler. The effects of the Y-shape stud arrangement and the outer insulating layer on the heat flux and the wall temperature were qualitatively and also quantitatively analyzed. It was found that the Y-shape stud does enhance the heat dissipation of the cyclone wall. A denser Y-shape stud arrangement results in higher temperatures of the steel layer and also the outer surface. Moreover, the heat flux of the inner surface, the maximum temperature of the steel layer, and the outer surface are all well linear with the stud number. However, how the studs arrange on the steel layer has very sight effects on the heat flux and wall temperature at a certain stud number. Adding an insulating layer on the outer wall surface can reduce the heat dissipating capacity of the hot cyclone and also decrease the outer surface temperature. The effects of Y-shape studs on the heat dissipation and wall temperature are also weakened. While the outer insulating layer results in a rapid increase of the steel layer temperature, which may bring extra risk to the cyclone wall. Based on the simulation results, reducing the unnecessary studs and covering an insulating layer thinner than 20 mm are suggested.

Sanitary safety of the 2021 French Intensive Care Society medical conference: a case/control study

BackgroundIn-person mass gathering events (MGE) are returning after a period of restrictions, yet few prospective scientific evaluations of their safety are available.MethodsProspective observational study, including both attendees of the French Intensive Care Society (FICS) annual meeting held in Paris between June the 9th and June the 11th, 2021 and matched controls (healthcare professionals who stayed in the ICU during the conference). SARS-CoV-2 lateral flow test was performed on day 7. Follow-up occurred until day 21.ResultsOut of the 1824 healthcare professionals attending the congress (all of which fulfilled legal requirements: 7 days or more following a second dose of vaccine or a negative PCR test performed within less than 72 h), 520 (28.5%) agreed to participate. Follow-up data were received for 216 (41.5%) out of the 520 included attendees, and for 191 matched controls. No positive SARS-CoV-2 lateral flow test was reported in the attendees or in the matched controls. The probability of SARS-CoV-2 infection during the MGE was less than 1.7% in the attendees (95% confidence interval [0;1.7%]), less than 2% in the controls (95%CI [0;2%]) and the difference in probabilities of infection was less than 1.9% (95% CI [0;1.9%]).ConclusionDuring a low incidence period, in this population of congress attendees screened for SARS-CoV-2 by a lateral flow test at day 7, no positive cases could be documented, no concomitant infection occurred in the matched controls; suggesting no extra risk of infection during the MGE.Trial Registration: ClinicalTrial.gov, #NCT04918160.

Pharmacokinetics of Esomeprazole in Critically Ill Patients.

BackgroundEsomeprazole, a potent proton pump inhibitor (PPI), is widely used for the prevention of stress ulcers in intensive care unit (ICU) patients.ObjectiveThis study investigates the pharmacokinetics (PK) of esomeprazole in critically ill patients.MethodsThe study included eligible adult ICU patients who received endotracheal intubation assisted mechanical ventilation for more than 48 h and had at least an extra risk factor for stress ulcers. All enrolled patients received once-daily intravenous (IV) esomeprazole 40 mg. After the first dose of esomeprazole was administrated, serial blood samples were collected at 3, 5, 15, 30 min and 1, 2, 4, 6, 8, and 10 h. The total sample concentrations of esomeprazole were measured by UPLC-MS/MS. Esomeprazole PK parameters were analyzed using noncompartmental analysis.ResultsA total of 30 patients were evaluable. Mean age and body mass index (BMI) were 61.97 years and 23.14. PK sampling on the first dose resulted in the following median (IQR) parameters: AUC0−∞ 8.06 (6.65–9.47) mg·h/L; MRT0−∞ 4.70 (3.89–5.51) h; t1/2 3.29 (2.7–3.87) h; V 24.89 (22.09–27.69) L; CL 6.13 (5.01–7.26) L/h; and Cmax 2.56 (2.30–2.82) mg/L.ConclusionsAccording to the label of esomeprazole, our study showed different esomeprazole PK parameters in ICU patients compared with healthy volunteers. Esomeprazole has unique pharmacokinetic parameters in critically ill patients.

How Does Bank Competition Affect Banking Stability? The Case of an Emerging Market

This paper examines the role of interbank competition on banking stability in Jordan, an emerging market. Using competition estimates measured by Lerner index, the paper examines the impact of competition on two important dimensions of banking stability, namely, credit risk and liquidity risk. The empirical results suggest that the effect of banking competition on stability differs according to the dimension of stability. After controlling for bank-level control variables and macroeconomic conditions, the empirical results of the impact of market power measured by Lerner index on credit risk show that an increase in price competition leads to more risk taking from banks. On the other hand, the impact of price competition on the second dimension of banking stability (liquidity risk) implies that an increase in price competition improves the liquidity position of banks. However, these results hold only for the sample of non-Islamic banks. Islamic banks may face wider mismatch between its assets and liabilities due to its inability to use conventional debt instruments offered by the market and hence it keeps larger cash buffers to compensate for this extra risk.

A Systematic Review of Subsurface Radiofrequency Treatments in Plastic Surgery.

BackgroundSubsurface radiofrequency (RF) treatments produce skin contraction by causing coagulation of the underlying subcutaneous fat. This method is marketed to fill a treatment gap for patients who do not wish to have surgery. A systematic review of this subject has not been previously published.MethodsAn electronic search was performed using PubMed to identify the literature describing subsurface RF treatments.ResultsThirty articles were evaluated. An InMode device was used in 23 studies, and a Thermi device was used in 6 studies, with or without liposuction. Treatment areas included the face, neck, body, breasts, and labia. Most studies relied on patient satisfaction scores and physician review of photographs. The most frequent complications were induration and nodules. Most patients experienced prolonged swelling and numbness. Several studies reported marginal mandibular neuropraxias. The skin response after treatment of the abdomen was poor, and seromas were common. The incidence of burns improved after modification of the InMode device. Breast treatment did not appear to be effective in treating ptosis. Patient satisfaction scores were modest. Most studies (77%) were published by authors with a known conflict of interest. In some studies, the photographs did not accurately depict the treatment result. Institutional review board approval and disclosure of off-label regulatory status were often missing.DiscussionThermal treatment of the subcutaneous tissue introduces extra risks without a compensatory benefit. Comparisons in terms of safety, cost, recovery time, results, and complications do not favor energy-based devices. A treatment gap may be fictitious; properly informed patients may be treated with existing surgical procedures at all ages.ConclusionsLittle evidence supports the efficacy and safety of subcutaneous RF treatments as an improvement over results that may be obtained using traditional surgical methods such as submental lipectomy, liposuction, and abdominoplasty. Photographic integrity is often lacking. Financial conflict of interest is pervasive. Marketing precedes the science. Plastic surgeons need to be aware of these serious limitations and the off-label regulatory status of these devices, before purchasing expensive equipment and recommending subsurface RF treatments to patients.

Multimorbidity and adverse events of special interest associated with Covid-19 vaccines in Hong Kong

Prior research using electronic health records for Covid-19 vaccine safety monitoring typically focuses on specific disease groups and excludes individuals with multimorbidity, defined as ≥2 chronic conditions. We examine the potential additional risk of adverse events 28 days after the first dose of CoronaVac or Comirnaty imposed by multimorbidity. Using a territory-wide public healthcare database with population-based vaccination records in Hong Kong, we analyze a retrospective cohort of patients with chronic conditions. Thirty adverse events of special interest according to the World Health Organization are examined. In total, 883,416 patients are included and 2,807 (0.3%) develop adverse events. Results suggest vaccinated patients have lower risks of adverse events than unvaccinated individuals, multimorbidity is associated with increased risks regardless of vaccination, and the association of vaccination with adverse events is not modified by multimorbidity. To conclude, we find no evidence that multimorbidity imposes extra risks of adverse events following Covid-19 vaccination.

Association of age with depth of invasion and extra capsular spread in patients with oral squamous cell carcinoma: A retrospective study

Introduction: Oral malignancy is most common tumors in Pakistan. The age of the greater part of the patient’s reaches somewhere in the range of 50 and 70 years and old age is an indirect risk factor for malignant growths. It is challenging to treat the older patients with oral squamous cell carcinoma due to poor performance and the adjusted physiology and the additional comorbidities that may influence the decision of surgery and adjuvant treatment, whenever scheduled. Above mentioned factors in elderly group might affect the option of treatment and may vary from the ideal treatment. We aim to evaluate the association of age with depth of invasion and to assess the association of age with extra capsular spread and risk factors in patients with oral cancer. Material/Methods: This is a retrospective study. Total 360 patients underwent the surgery from 2011 to 2017 of which 260 patients fulfilled the inclusion criteria for our study. The chi-square test was applied to check the association between ages with a depth of invasion of tumor. Results: There were 260 patients who underwent treatment for oral cancer it was subdivided in 3 age groups and multiple addictions are most common in every age group 51% (n=133). Majority of the patients had final stage III and IVA with 31% (n=80) and 35% (n=92). Age has a significant association with the depth of invasion, about 56% (n=144) has >10 mm depth of invasion of tumor with 95% of CI (P-value=0.01). There was no extracapsular spread in 82% (n=214) and yes in 18% (n=46) of the patients with 95% of CI (p-value= 0.149) which was insignificant in patients with oral cancer. Conclusion: This study shows that oral cancer has increased depth of invasion in younger population as compared to elderly population and there is no association between age and extracapsular spread in patients. Majority of patients were found to have moderately differentiated oral cancer. Keywords: oral squamous cell carcinoma; extra capsular spread; depth of invasion; head and neck neoplasms.

Modern Strategies for the Diversification of the Supply of Natural Compounds: The Case of Alkaloid Painkillers.

Plant-derived natural compounds have been used for treating diseases since prehistorical times. The supply of many plant-derived natural compounds for medicinal purposes, such as thebaine, morphine, and codeine, is primarily dependent on opium poppy crop harvesting. This dependency adds an extra risk factor to ensuring the supply chain because crops are highly susceptible to environmental conditions. Emerging technologies, such as biocatalysis, might help to solve this problem by diversifying the sources of supply of these compounds. Here we review the first committed step in the production of alkaloid painkillers, the production of S-norcoclaurine, and the enzymes involved. The improvement of these enzymes can be carried out experimentally by directed evolution and rational design strategies, supported by computational methods, to create variants that produce the S-norcoclaurine precursor for alkaloid painkillers in heterologous organisms, meeting the pharmaceutical industry standards and needs without depending on opium poppy crops.

Vizija novog ekonomskog sistema posle prelaska pandemije u endemiju iz perspektive Srbije

Vizija novog ekonomskog sistema posle prelaska pandemije u endemiju iz perspektive Srbije

The efficacy and safety of acetaminophen use following liver resection: a systematic review.

Acetaminophen is commonly used for post-operative analgesia following liver resection. It is metabolised by the liver and appropriate administration and dosage is in question in in patients undergoing hepatectomy. A systematic review was conducted to investigate safety and efficacy of acetaminophen use. MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar were searched for instances of toxicity, liver dysfunction, and analgesic efficacy in patients undergoing hepatectomy. Two randomised controlled trials and four prospective observational studies were included. The studies were of moderate quality. Four studies investigated post-operative levels of acetaminophen and its urinary metabolites, finding no evidence of toxicity. One study noted that glutathione levels decreased but not to clinically deficient levels. Administration of acetaminophen plus morphine versus morphine alone did not increase adverse events and a morphine sparing effect of acetaminophen was demonstrated in two studies. Use of acetaminophen for adult patients undergoing liver resection surgery as post-operative analgesia at a standard dosage is safe for baseline analgesia. All studies analysed support that toxicity is not reached; and that acetaminophen provides a morphine sparing effect without adverse effects. Acetaminophen dose reduction should be considered in patients where extra risk factors for hepatotoxicity are present.

AGE-DEPENDENT DOSE DUE TO INTAKE OF 40K, 228RA, 226RA IN SPRING WATER IN PETRA DISTRICT, JORDAN.

A HpGe detector was used to measure radioactivity concentrations of 40K, 228Ra and 226Ra in spring water from villages in Petra district in southern Jordan. The concentrations of 40K, 228Ra, 226Ra were 0.64-2.72Bq/l, 0.05-0.08Bq/l and 0.15-0.22Bq/l, respectively. These values were compared to the concentrations of the corresponding radionuclides in studies from Jordan and near countries. The annual effective doses (${D}_{\mathrm{eff}}$) due to the intake of 40K, 228Ra and 226Ra, for the different age groups were calculated. The highest ${D}_{\mathrm{eff}}$ values due to the intake of 226Ra and 228Ra were found in the infants age group, whereas the lowest were found in the adults age group in every site. The annual effective doses in this study were compared to the committed annual effective doses from ingestion in UNSCEAR. The annual effective doses in this study were much higher than the committed values in UNSCEAR. The life time risk for radiation-induced cancer for the whole population was calculated for every sample and it revealed no extra risk over the one recommended by WHO.

Impact of COVID-19-associated Mucormycosis in Kidney Transplant Recipients: A Multicenter Cohort Study.

COVID-19-associated mucormycosis (CAM) is a recently emerging entity. There is a lack of reports of CAM in organ transplant recipients. We conducted a multicenter (n = 18) retrospective research in India during November 2020 to July 2021. The purpose of this study was to explore the clinical spectrum, outcome and risk factors for mortality of CAM in kidney transplant recipients (KTRs). The incidence of CAM was 4.4% (61/1382 COVID-19-positive KTRs) with 26.2% mortality. The median age of the cohort was 45 (38-54) y. Twenty (32%) were not hospitalized and 14 (22.9%) were on room air during COVID-19. The proportion of postdischarge CAM was 59.1%, while concurrent CAM was reported in 40.9%. The presentation of CAM was 91.8% rhino-orbital-cerebral mucormycosis and 8.2% pulmonary with 19.6% and 100% mortality, respectively. In the univariable analysis, older age, obesity, difficulty of breathing, high-flow oxygen requirement, and delay in starting therapy were significantly associated with mortality. In the multivariable logistic regression analysis, patients requiring high-flow oxygen therapy [odds ratio (95% confidence interval) = 9.3 (1.6-51); P = 0.01] and obesity [odds ratio (95% confidence interval) = 5.2 (1-28); P = 0.05] was associated with mortality. The median follow-up of the study was 60 (35-60) d. We describe the largest case series of CAM in KTRs. Morality in pulmonary CAM is extremely high. Severe COVID-19 pose extra risk for the development of CAM and associated mortality. Our report will help in better understanding the conundrum and management of CAM.

Mobile Extracorporeal Membrane Oxygenation for Covid-19 Does Not Pose Extra Risk to Transport Team.

Previous experience has shown that transporting patients on extracorporeal membrane oxygenation (ECMO) is a safe and effective mode of transferring critically ill patients requiring maximum mechanical ventilator support to a quaternary care center. The coronavirus disease 2019 (COVID-19) pandemic posed new challenges. This is a multicenter, retrospective study of 113 patients with confirmed severe acute respiratory syndrome coronavirus 2, cannulated at an outside hospital and transported on ECMO to an ECMO center. This was performed by a multidisciplinary mobile ECMO team consisting of physicians for cannulation, critical care nurses, and an ECMO specialist or perfusionist, along with a driver or pilot. Teams practised strict airborne contact precautions with eyewear while caring for the patient and were in standard Personal Protective Equipment. The primary mode of transportation was ground. Ten patients were transported by air. The average distance traveled was 40 miles (SD ±56). The average duration of transport was 133 minutes (SD ±92). When stratified by mode of transport, the average distance traveled for ground transports was 36 miles (SD ±52) and duration was 136 minutes (SD ±93). For air, the average distance traveled was 66 miles (SD ±82) and duration was 104 minutes (SD ±70). There were no instances of transport-related adverse events including pump failures, cannulation complications at outside hospital, or accidental decannulations or dislodgements in transit. There were no instances of the transport team members contracting COVID-19 infection within 21 days after transport. By adhering to best practices and ACE precautions, patients with COVID-19 can be safely cannulated at an outside hospital and transported to a quaternary care center without increased risk to the transport team.