Does tourism affect the long term course of COVID-19 pandemic in a country of destination? Evidence from a popular Greek island in 2020 where control measures were implemented

Greece opened its points of entry on July 1, 2020, with specific guidelines for travellers arriving by sea, air or land. The aim of this article is to examine the effect of tourism on the long term course of the Coronavirus Disease 2019 (COVID-19) pandemic during the pre-vaccination era (June to December 2020) on the popular Greek island of Crete. To achieve this, a cross-sectional serosurvey, repeated at monthly intervals, was conducted to compare the seroprevalence in Crete with seroprevalence in the mainland of Greece. Crete welcomed nearly 2,000,000 travellers during the 2020 summer season. Left-over serum samples were collected and obtained from public and private laboratories located in Greece, including the island of Crete. These samples were tested for the presence of anti-SARS-CoV-2 IgG antibodies. A total of 55,938 samples were collected, 3,785 of which originated from Crete. In Crete, the seroprevalence ranged between 0% (June 2020) and 2.58% (December 2020), while the corresponding seroprevalence in Greece was 0.19% and 10.75%, respectively. We identified 4.16 times lower seropositivity in Crete (2.58%) in comparison with the mainland of Greece (10.75%) during December 2020. Moreover, the monthly infection fatality rate (IFR) in Crete was calculated at 0.09%, compared with 0.21% in mainland Greece for December 2020. The island of Crete presented more than four times lower seroprevalence than the mainland of Greece, despite being a highly attractive tourist destination. This evidence supports the idea that tourism may not have affected the long term course of the COVID-19 pandemic in Greece. However, due to contradicting results from previous studies, further investigation is needed

The MOBI-Kids Study Protocol: Challenges in Assessing Childhood and Adolescent Exposure to Electromagnetic Fields from Wireless Telecommunication Technologies and Possible Association with Brain Tumor Risk

The rapid increase in mobile phone use in young people has generated concern about possible health effects of exposure to radiofrequency (RF) and extremely low frequency (ELF) electromagnetic fields (EMF). MOBI-Kids, a multinational case-control study, investigates the potential effects of childhood and adolescent exposure to EMF from mobile communications technologies on brain tumor risk in 14 countries. The study, which aims to include approximately 1,000 brain tumor cases aged 10-24 years and two individually matched controls for each case, follows a common protocol and builds upon the methodological experience of the INTERPHONE study. The design and conduct of a study on EMF exposure and brain tumor risk in young people in a large number of countries is complex and poses methodological challenges. This manuscript discusses the design of MOBI-Kids and describes the challenges and approaches chosen to address them, including: (1) the choice of controls operated for suspected appendicitis, to reduce potential selection bias related to low response rates among population controls; (2) investigating a young study population spanning a relatively wide age range; (3) conducting a large, multinational epidemiological study, while adhering to increasingly stricter ethics requirements; (4) investigating a rare and potentially fatal disease; and (5) assessing exposure to EMF from communication technologies. Our experience in thus far developing and implementing the study protocol indicates that MOBI-Kids is feasible and will generate results that will contribute to the understanding of potential brain tumor risks associated with use of mobile phones and other wireless communications technologies among young people

Cabbage and fermented vegetables : From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID-19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS-CoV-2 binds to its receptor, the angiotensin-converting enzyme 2 (ACE2). As a result of SARS-CoV-2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT(1)R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID-19. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT(1)R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof-of-concept of dietary manipulations that may enhance Nrf2-associated antioxidant effects, helpful in mitigating COVID-19 severity.Peer reviewe

Nrf2-interacting nutrients and COVID-19 : time for research to develop adaptation strategies

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPAR gamma:Peroxisome proliferator-activated receptor, NF kappa B: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2 alpha:Elongation initiation factor 2 alpha). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT(1)R axis (AT(1)R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

The detection of viremia of hepatitis B (HBV) with the use of real time PCR in patients with chronic renal failure treated by haemodyalysis

Hepatitis B virus infection (HBV) is an important cause of liver disease in the end-stage renal failure patients (ESRF) treated by haemodialysis. Occult HBV infection is characterised by undetectable serum HBsAg but detectable HBV-DNA in serum or the liver. Occult HBV infection has been reported in patients with chronic liver disease but the existing data is limited in occult HBV infection among patients on long term haemodialysis. So far, data on the prevalence and clinical significance of occult HBV infection in patients with end-stage renal failure (ESRF) patients treated by haemodialysis (HD) are missing in our country. The aims of the present study were: · Το determine the HBV-viral load in a large sample of consecutive patients with end-stage renal failure (ESRF) patients treated by haemodialysis (HD) from Central Greece. · Το determine the prevalence of occult HBV infection in a large sample of consecutive patients with end-stage renal failure (ESRF) patients treated by haemodialysis (HD) from Central Greece. Additionally, the possible clinical impact of HBV-DNA positivity in these patients (either in the context of chronic or occult HBV infection) was assessed by comparing demographic, epidemiological, biochemical and HBV, HCV, HEV, HDV, HAV and HTLV serological markers between HBV-DNA-positive and HBV-DNA-negative patients. In total, 366 ESRF patients’ sera were investigated for the presence of HBV-DNA by polymerase chain reaction (real-time PCR). Twenty of them (5.5%) were serum hepatitis B surface antigen (HBsAg) positive. HBV-DNA was detected in 15 out the 366 patients with ESRF (4.1%). HBV-DNA seropositivity was strongly associated with HBsAg (p=0.000), anti-HBe (p=0.000) and anti-HBc presence (p=0.003) and negatively associated with anti-HBs presence (p=0.000). Three out of the 15 patients with HBV-viremia were HBsAg negative (20%). Of the remaining 346 HBsAg negative ESRF patients, the prevalence of occult HBV-infection was 0.9%. Occult HBV-DNA detection was not associated with a specific marker of past HBV infection. HBV-viremia is lower than the results of standard HBsAg testing would suggest in ESRF patients. The demographic, biochemical, and/or serological features of HBV-DNA positive subjects do not help to distinguish these individuals from those who are HBV-DNA negative. Even though, this cross-sectional study in HD patients could not demonstrate that occult HBV infection is a major health problem in Central Greece, close consideration and evaluation for the presence of occult HBV infection should be performed at least for those who are candidate for kidney transplantation, as the subsequent immunosuppression could have detrimental effects on the index patient. We believe that longitudinal studies are essential in an attempt to further clarify the clinical significance and outcome of occult HBV infection, as well as the possibility of nosocomial transmission of occult HBV infection in this setting.Ο ιός της ηπατίτιδας Β (HBV) θεωρείται μια σημαντική αιτία ηπατικής νόσου σε ασθενείς με τελικού σταδίου χρόνια νεφρική ανεπάρκεια που βρίσκονται σε θεραπεία υποκατάστασης. Ως «λανθάνουσα» ηπατίτιδα Β ορίζεται η παρουσία HBV-DNA στον ορό ή στο ήπαρ ασθενών με αρνητικό HBsAg. Η συχνότητα και η κλινική σημασία της λανθάνουσας ηπατίτιδας Β σε ασθενείς με τελικού σταδίου χρόνια νεφρική ανεπάρκεια που βρίσκονται σε θεραπεία υποκατάστασης παραμένει άγνωστη στη χώρα μας. Στόχοι της παρούσης εργασίας ήταν: · Ο προσδιορισμός της ιαιμίας από τον HBV με την χρήση πραγματικού χρόνου PCR σε όλη σχεδόν την ομάδα ασθενών που βρίσκονται σε θεραπεία υποκατάστασης για χρόνια νεφρική ανεπάρκεια στην περιφέρεια Θεσσαλίας. · Η εκτίμηση της κλινικής σημασίας της ιαιμίας από τον HBV σε σχέση με δημογραφικά, επιδημιολογικά, βιοχημικά καθώς και με τους ορολογικούς δείκτες HBV, HCV, HEV, HDV, HAV και HTLV μεταξύ των HBV-DNA-θετικών και HBV-DNA-αρνητικών ασθενών με χρόνια νεφρική ανεπάρκεια. Συνολικά, 366 οροί ασθενών εξετάστηκαν για την παρουσία HBV-DNA με την χρήση πραγματικού χρόνου αλυσιδωτής αντίδρασης πολυμεράσης (real-time PCR). Είκοσι από αυτούς (5.5%) ήταν θετικοί στο αντιγόνο επιφανείας της ηπατίτιδας B (HBsAg). Το HBV-DNA ανιχνεύθηκε σε 15 από τους 366 ασθενείς (4.1%). Η οροθετικότητα του HBV-DNA σχετίστηκε σημαντικά με την παρουσία των ορολογικών δεικτών HBsAg (p=0.000), αντι-HBe (p=0.000) και αντι-HBc (p=0.003) και αρνητικά με την παρουσία αντι-HBs (p=0.000). Τρεις από τους 15 ασθενείς με HBV-ιαιμία ήταν HBsAg αρνητικοί (20%). Από τους υπόλοιπους 346 αρνητικούς HBsAg ασθενείς, η συχνότητα της λανθάνουσας λοίμωξης από τον HBV ήταν 0.9%. Η ανίχνευση της λανθάνουσας HBV-DNA ιαιμίας δεν σχετίστηκε με κανέναν συγκεκριμένο ορολογικό δείκτη από παρελθούσα λοίμωξη Β. Το ποσοστό της HBV-ιαιμίας είναι χαμηλότερο από τα αποτελέσματα του καθορισμένου ελέγχου HBsAg που θα αναμενόταν σε ασθενείς με νεφρική ανεπάρκεια τελικού σταδίου. Τα δημογραφικά, βιοχημικά και/ή ορολογικά στοιχεία των HBV-DNA θετικών ατόμων δεν βοηθούν στη διάκριση αυτών από τα HBV-DNA αρνητικά άτομα. Συμπερασματικά, η πρώτη αυτή μελέτη σχεδόν ολόκληρου του δείγματος Ελλήνων ασθενών με χρόνια νεφρική ανεπάρκεια που βρίσκονται σε θεραπεία υποκατάστασης στην περιφέρεια Θεσσαλίας, δεν ανέδειξε την παρουσία σε σημαντικό ποσοστό λανθάνουσας ηπατίτιδας Β ως μεγάλο πρόβλημα υγείας στην Κεντρική Ελλάδα. Ίσως περισσότερη προσοχή και βαρύτητα για την πιθανή παρουσία λανθάνουσας ηπατίτιδας Β θα πρέπει να δίνεται σε ασθενείς υποψήφιους για μεταμόσχευση νεφρού καθώς η ανοσοκαταστολή σε αυτή την περίπτωση μπορεί ενδεχόμενα να επηρεάσει την κατάσταση του ασθενή. Εντούτοις, περαιτέρω προοπτικές μελέτες μακρύτερης διάρκειας χρειάζονται, ώστε να αποσαφηνιστεί με μεγάλη ακρίβεια η κλινική σημασία και ο ρόλος της λανθάνουσας λοίμωξης από τον HBV σε ασθενείς με χρόνια νεφρική ανεπάρκεια που βρίσκονται σε θεραπεία υποκατάστασης, καθώς και η πιθανότητα της ενδονοσοκομειακής μετάδοσης της λοίμωξης σε αυτούς τους ασθενείς

Prevalence of occult hepatitis B virus infection in haemodialysis patients from central Greece

AIM: To assess the hepatitis B virus (HBV)-DNA and the prevalence of occult HBV infection in end-stage renal failure (ESRF) patients from Central Greece