Associations Between Extreme Temperatures and Cardiovascular Cause-Specific Mortality: Results From 27 Countries.

BACKGROUND: Cardiovascular disease is the leading cause of death worldwide. Existing studies on the association between temperatures and cardiovascular deaths have been limited in geographic zones and have generally considered associations with total cardiovascular deaths rather than cause-specific cardiovascular deaths. METHODS: We used unified data collection protocols within the Multi-Country Multi-City Collaborative Network to assemble a database of daily counts of specific cardiovascular causes of death from 567 cities in 27 countries across 5 continents in overlapping periods ranging from 1979 to 2019. City-specific daily ambient temperatures were obtained from weather stations and climate reanalysis models. To investigate cardiovascular mortality associations with extreme hot and cold temperatures, we fit case-crossover models in each city and then used a mixed-effects meta-analytic framework to pool individual city estimates. Extreme temperature percentiles were compared with the minimum mortality temperature in each location. Excess deaths were calculated for a range of extreme temperature days. RESULTS: The analyses included deaths from any cardiovascular cause (32 154 935), ischemic heart disease (11 745 880), stroke (9 351 312), heart failure (3 673 723), and arrhythmia (670 859). At extreme temperature percentiles, heat (99th percentile) and cold (1st percentile) were associated with higher risk of dying from any cardiovascular cause, ischemic heart disease, stroke, and heart failure as compared to the minimum mortality temperature, which is the temperature associated with least mortality. Across a range of extreme temperatures, hot days (above 97.5th percentile) and cold days (below 2.5th percentile) accounted for 2.2 (95% empirical CI [eCI], 2.1-2.3) and 9.1 (95% eCI, 8.9-9.2) excess deaths for every 1000 cardiovascular deaths, respectively. Heart failure was associated with the highest excess deaths proportion from extreme hot and cold days with 2.6 (95% eCI, 2.4-2.8) and 12.8 (95% eCI, 12.2-13.1) for every 1000 heart failure deaths, respectively. CONCLUSIONS: Across a large, multinational sample, exposure to extreme hot and cold temperatures was associated with a greater risk of mortality from multiple common cardiovascular conditions. The intersections between extreme temperatures and cardiovascular health need to be thoroughly characterized in the present day-and especially under a changing climate.

Global, regional, and national burden of heatwave-related mortality from 1990 to 2019: A three-stage modelling study.

BACKGROUND: The regional disparity of heatwave-related mortality over a long period has not been sufficiently assessed across the globe, impeding the localisation of adaptation planning and risk management towards climate change. We quantified the global mortality burden associated with heatwaves at a spatial resolution of 0.5°×0.5° and the temporal change from 1990 to 2019. METHODS AND FINDINGS: We collected data on daily deaths and temperature from 750 locations of 43 countries or regions, and 5 meta-predictors in 0.5°×0.5° resolution across the world. Heatwaves were defined as location-specific daily mean temperature ≥95th percentiles of year-round temperature range with duration ≥2 days. We first estimated the location-specific heatwave-mortality association. Secondly, a multivariate meta-regression was fitted between location-specific associations and 5 meta-predictors, which was in the third stage used with grid cell-specific meta-predictors to predict grid cell-specific association. Heatwave-related excess deaths were calculated for each grid and aggregated. During 1990 to 2019, 0.94% (95% CI: 0.68-1.19) of deaths [i.e., 153,078 cases (95% eCI: 109,950-194,227)] per warm season were estimated to be from heatwaves, accounting for 236 (95% eCI: 170-300) deaths per 10 million residents. The ratio between heatwave-related excess deaths and all premature deaths per warm season remained relatively unchanged over the 30 years, while the number of heatwave-related excess deaths per 10 million residents per warm season declined by 7.2% per decade in comparison to the 30-year average. Locations with the highest heatwave-related death ratio and rate were in Southern and Eastern Europe or areas had polar and alpine climates, and/or their residents had high incomes. The temporal change of heatwave-related mortality burden showed geographic disparities, such that locations with tropical climate or low incomes were observed with the greatest decline. The main limitation of this study was the lack of data from certain regions, e.g., Arabian Peninsula and South Asia. CONCLUSIONS: Heatwaves were associated with substantial mortality burden that varied spatiotemporally over the globe in the past 30 years. The findings indicate the potential benefit of governmental actions to enhance health sector adaptation and resilience, accounting for inequalities across communities.

Implementation of climate adaptation in the public health sector in Europe: qualitative thematic analysis.

BACKGROUND: Adaptation, to reduce the health impacts of climate change, is driven by political action, public support and events (extreme weather). National adaptation policies or strategies are limited in addressing human health risks and implementation of adaptation in the public health community is not well understood. AIM: To identify key issues in climate change adaptation implementation for public health in Europe. METHODS: Key informant interviews with decision-makers in international, national and local city governments in 19 European countries. Participants were recruited if a senior decision-maker working in public health, environmental health or climate adaptation. INTERVIEWS ADDRESSED: Barriers and levers for adaptation, policy alignment, networks and evidence needs. RESULTS: Thirty-two interviews were completed between June and October 2021 with 4 international, 5 national and 23 city/local government stakeholders. Respondents reported inadequate resources (funding, training and personnel) for health-adaptation implementation and the marginal role of health in adaptation policy. A clear mandate to act was key for implementation and resource allocation. Limited cross-departmental collaboration and poor understanding of the role of public health in climate policy were barriers to implementation. CONCLUSIONS: Across Europe, progress is varied in implementation of climate adaptation in public health planning. Providing appropriate resources, training, knowledge mobilization and supporting cross-departmental collaboration and multi-level governance will facilitate adaptation to protect human health.

Excess mortality in Europe coincides with peaks of COVID-19, influenza and respiratory syncytial virus (RSV), November 2023 to February 2024.

Since the end of November 2023, the European Mortality Monitoring Network (EuroMOMO) has observed excess mortality in Europe. During weeks 48 2023-6 2024, preliminary results show a substantially increased rate of 95.3 (95% CI:  91.7-98.9) excess all-cause deaths per 100,000 person-years for all ages. This excess mortality is seen in adults aged 45 years and older, and coincides with widespread presence of COVID-19, influenza and respiratory syncytial virus (RSV) observed in many European countries during the 2023/24 winter season.

Community factors and excess mortality in the COVID-19 pandemic in England, Italy and Sweden.

BACKGROUND: Analyses of coronavirus disease 19 suggest specific risk factors make communities more or less vulnerable to pandemic-related deaths within countries. What is unclear is whether the characteristics affecting vulnerability of small communities within countries produce similar patterns of excess mortality across countries with different demographics and public health responses to the pandemic. Our aim is to quantify community-level variations in excess mortality within England, Italy and Sweden and identify how such spatial variability was driven by community-level characteristics. METHODS: We applied a two-stage Bayesian model to quantify inequalities in excess mortality in people aged 40 years and older at the community level in England, Italy and Sweden during the first year of the pandemic (March 2020-February 2021). We used community characteristics measuring deprivation, air pollution, living conditions, population density and movement of people as covariates to quantify their associations with excess mortality. RESULTS: We found just under half of communities in England (48.1%) and Italy (45.8%) had an excess mortality of over 300 per 100 000 males over the age of 40, while for Sweden that covered 23.1% of communities. We showed that deprivation is a strong predictor of excess mortality across the three countries, and communities with high levels of overcrowding were associated with higher excess mortality in England and Sweden. CONCLUSION: These results highlight some international similarities in factors affecting mortality that will help policy makers target public health measures to increase resilience to the mortality impacts of this and future pandemics.

Quantitative Structure-Retention Relationship Analysis of Polycyclic Aromatic Compounds in Ultra-High Performance Chromatography.

A comparative quantitative structure-retention relationship (QSRR) study was carried out to predict the retention time of polycyclic aromatic hydrocarbons (PAHs) using molecular descriptors. The molecular descriptors were generated by the software Dragon and employed to build QSRR models. The effect of chromatographic parameters, such as flow rate, temperature, and gradient time, was also considered. An artificial neural network (ANN) and Partial Least Squares Regression (PLS-R) were used to investigate the correlation between the retention time, taken as the response, and the predictors. Six descriptors were selected by the genetic algorithm for the development of the ANN model: the molecular weight (MW); ring descriptor types nCIR and nR10; radial distribution functions RDF090u and RDF030m; and the 3D-MoRSE descriptor Mor07u. The most significant descriptors in the PLS-R model were MW, RDF110u, Mor20u, Mor26u, and Mor30u; edge adjacency indice SM09_AEA (dm); 3D matrix-based descriptor SpPosA_RG; and the GETAWAY descriptor H7u. The built models were used to predict the retention of three analytes not included in the calibration set. Taking into account the statistical parameter RMSE for the prediction set (0.433 and 0.077 for the PLS-R and ANN models, respectively), the study confirmed that QSRR models, associated with chromatographic parameters, are better described by nonlinear methods.

Lancet Countdown indicators for Italy: tracking progress on climate change and health

OBJECTIVES: to provide evidence of the health impacts of climate change in Italy. DESIGN: descriptive study. SETTING AND PARTICIPANTS: the indicators published in the 2022 Lancet Countdown report were adapted and refined to provide the most recent data relevant to Italy. MAIN OUTCOME MEASURES: twelve indicators were measured, organized within five sections mirroring those of the 2022 Lancet Countdown report: climate change impacts, exposures, and vulnerabilities; adaptation, planning, and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. RESULTS: the overall picture depicted by the analysis of the 12 indicators reveals two key findings. First, climate change is already affecting the health of Italian populations, with effects not being uniform across the Country and with the most vulnerable groups being disproportionately at risk. Second, results showed that Italy's mitigation response has been partial, with major costs to human health. Accelerated climate change mitigation through energy system decarbonisation and shifts to more sustainable modes of transport could offer major benefits to health from cleaner air locally and from more active lifestyles, and to climate change from reduction of global warming. The decarbonisation of agricultural systems would similarly offer health co-benefits to Italian population. Conclusions: through accelerated action on climate change mitigation, Italy has the opportunity of delivering major and immediate health benefits to its population. Developing a key set of local indicators to monitor the impacts of climate change and evaluate response actions, in terms of adaptation and mitigation, can help support and enhance policy and action to fight climate changes.

Health impact of air pollution and air temperature in Italy: evidence for policy actions

OBJECTIVES: to estimate the impact (number of deaths and attributable fraction) of air pollution (chronic exposure to PM2.5 and NO2) and high summer temperatures (acute exposure) on mortality in Italy. DESIGN: observational study. Time series analysis (for estimating acute effects of air temperature), and computation of deaths attributable to heat/pollution using standard health impact assessment functions. SETTING AND PARTICIPANTS: for the assessment of the impact due to chronic exposure to air pollutants, the study period considered was 2016-2019. For the assessment of the acute effects of air temperature and related impacts, the municipal daily series of deaths from all causes relating to the period 2003-2015 were used. MAIN OUTCOME MEASURES: mortality for all causes (effects and impacts of acute exposure to air temperature), cause-specific mortality (impact of chronic exposure to pollution). RESULTS: concerning chronic exposure to PM2.5, each year during 2016-2019, 72,083 deaths (11.7%) were estimated to be attributable to annual mean levels of PM2.5 above 5 µg/m3 (WHO-2021 Air Quality Guideline value). Of these, 39,628 were estimated in the regions of the Po Valley and 10,232 in the 6 Italian cities with >500,000 inhabitants. With reference to acute effects of air temperature, over 14,500 deaths (2.3%) were estimated to be attributable to daily temperature increases from the 75th to the 99th percentile of the municipality-specific distribution for the year 2015. Conclusions: high air pollution concentrations and summer temperatures are two environmental risk factors extremely relevant for public health. Although the prevention and mitigation interventions carried out in recent years have contributed to reducing the exposure of the population, there are still alarming numbers of deaths attributable to high levels of particulate matter, nitrogen oxides, and air temperature in the Italian population.

[Impact of heat and cold on cause -specific mortality in Italy]. / Impatto del caldo e del freddo sulla mortalità per causa in Italia.

OBJECTIVES: to estimate the impact of daily exposure to extreme air temperatures (heat and cold) on cause-specific mortality in Italy and to evaluate the differences in the association between urban, suburban and rural municipalities. DESIGN: time series analyses with two-stage approach were applied: in the first stage, multiple Poisson regression models and distributed lag non-linear models (DLNM) were used to define the association between temperature and mortality; in the second one, meta-analytic results were obtained by adopting BLUP (Best Linear Unbiased Prediction) coefficients at provincial level, which were then used to estimate the Attributable Fractions of cause-specific deaths. SETTING AND PARTICIPANTS: cause-specific deaths from 2006to 2015 in Italy have been analysed by region and overall. MAIN OUTCOME MEASURES: 5,648,299 total deaths included. Fractions (and relative 95% empirical confidence interval) of deaths attributable to increases from 75th to 99th percentiles of temperature, for heat, and decreases from 25th to 1st percentile, for cold. RESULTS: the overall impact of air temperature on causespecificmortality is higher for heat than for cold. When considering heat, the attributable fraction is higher for diseases of the central nervous system (3.6% 95% CI 1.9-4.9) and mental health disease (3.1% 95% CI 1.7-4.4), while considering cold, ischemic disease (1.3% 95% CI 1.1-1.6) and diabetes (1.3% 95% CI 0.7-1.8) showed the greater impact. By urbanization level, similar impacts were found for cold temperature, while for heat there was an indication of higher vulnerability in rural areas emerged. CONCLUSIONS: results are relevant for the implementation and promotion of preventive measures according to climate change related increase in temperature. The available evidence can provide the basis to identify vulnerable areas and population subgroups to which address current and future heat and cold adaptation plans in Italy.

DoE-Driven Development of an Organocatalytic Enantioselective Addition of Acetaldehyde to Nitrostyrenes in Water.

The development of an enantioselective enamine-catalysed addition of masked acetaldehyde to nitroalkenes via a rational approach helped to move away from the use of chloroform. The presented research allows the use of water as a reaction medium, therefore improving the industrial relevance of a protocol to access very important pharmaceutical intermediates. Critical to the success is the use of chemometrics-assisted 'Design of Experiments' (DoE) optimisation during the development of the presented new synthetic approach, which allows to investigate the chemical space in a rational way.

Reproducibility and diagnostic accuracy of pocket-sized ultrasound devices in ruling out compensated cirrhosis of mixed etiology.

OBJECTIVE: Fibrosis is the key prognostic factor in chronic liver disease patients. Liver surface nodularity (LSN) is the ultrasonographic sign with the highest accuracy to detect advanced liver fibrosis. The use of pocket-sized ultrasound devices (PUDs) has been assessed in several clinical settings but never as regards chronic liver disease (CLD) severity. Our study aimed at evaluating the feasibility, reproducibility, and diagnostic accuracy of PUD in LSN identification. METHODS: We enrolled all the consecutive adults referred for percutaneous liver biopsy. Two independent operators evaluated LSN by PUD; one sonographer used standard ultrasound (US). Transient elastography (TE) and liver biopsy were performed on all the patients. PUD reproducibility was evaluated by Cohen's k statistic. PUD, standard US, and TE results were compared with histology staging. RESULTS: A total of 104 consecutive patients (aged 54 ± 14 years) with mixed-etiology CLD were studied. Assessment by PUD was feasible in all the patients and showed very good inter-observer agreement with Cohen's k = 0.87 (95% CI 0.72-0.95). The diagnostic accuracy estimates for PUD in diagnosing compensated cirrhosis (F = 4) were 87.5% sensitivity, 76.8% specificity, positive likelihood ratio (LR) 3.78, and negative likelihood ratio (LR-) 0.16, while those for standard US and TE (> 12.5 kPa) were, respectively, 87.5% sensitivity, 72.6% specificity, LR+ 3.2, and LR- 0.17, and 87.5% sensitivity, 90.5% specificity, LR + 9.2, and LR- 0.13. CONCLUSIONS: PUD reproducibility in assessing LSN was excellent even with operators of different experience. PUD performed very well in excluding advanced CLD. PUD can be used as a first-line tool for screening patients to undergo more invasive techniques, thus shortening the time for clinical decision-making. KEY POINTS: • PUD is highly reproducible in assessing the sign of liver surface nodularity. • PUD showed high diagnostic accuracy in excluding the presence of advanced chronic liver disease. • PUD can be used as a first-line tool for screening patients with CLD who should undergo more invasive techniques.

Heat-health action planning in the WHO European Region: Status and policy implications.

Adverse health effects from extreme heat remain a major risk, especially in a changing climate. Several European countries have implemented heat health action plans (HHAPs) to prevent ill health and excess mortality from heat. This paper assesses the state of implementation of HHAPs in the WHO European Region and discusses barriers and successes since the early 2000s. The results are based on a web-based survey among 53 member states on the current national and federal HHAPs in place. Guided by the eight core elements of HHAPs as outlined by the WHO Regional Office for Europe guidance from 2008, we analyzed which elements were fully or partially implemented and which areas of improvement countries identified. HHAP adaptations to account for COVID-19 were sought via literature search and expert consultations. 27 member states provided information, of which 17 countries reported having a HHAP. Five out of eight core elements, namely agreement on a lead body, accurate and timely alert systems, heat-related health information plans, strategies to reduce health exposure, and care for vulnerable groups, were at least partially implemented in all 17 plans. Alert systems were implemented most often at 94%. The least often implemented items were real-time surveillance, long-term urban planning, and preparedness of health and social systems. Five countries had published COVID-19 guidance online. Our findings suggest a progressive improvement in the development and rollout of HHAPs overall and awareness of vulnerable population groups in WHO/Europe, while integration of HHAPs into long-term climate change and health planning remains a challenge.

A Novel FTIR-Based Chemometric Solution for the Assessment of Saffron Adulteration with Non-Fresh Stigmas.

The development of fast, non-destructive, and green methods with adequate sensitivity for saffron authentication has important implications in the quality control of the entire production chain of this precious spice. In this context, the highly suitable sensitivity of a spectroscopic method coupled with chemometrics was verified. A total number of 334 samples were analyzed using attenuated-total-reflectance Fourier-transform infrared (ATR-FTIR) spectroscopy; the collected spectra were processed by partial-least-squares discriminant analysis (PLS-DA) to evaluate the feasibility of this study for the discrimination between compliant saffron (fresh samples produced in 2020) and saffron samples adulterated with non-fresh stigmas produced in 2018 and 2016. PLS-DA was able to classify the saffron samples in accordance with the aging time and to discriminate fresh samples from the samples adulterated with non-fresh (legally expired) stigmas, achieving 100% of both sensitivity and specificity in external prediction. Moreover, PLS regression was able to predict the adulteration level with sufficient accuracy (the root-mean-square error of prediction was approximately 3-5%). In summary, ATR-FTIR and chemometrics can be employed to highlight the illegal blending of fresh saffron with unsold stocks of expired saffron, which may be a common fraudulent practice not yet considered in the scientific literature.

Effects of Hot Nights on Mortality in Southern Europe.

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.

Evaluation of the ERA5 reanalysis-based Universal Thermal Climate Index on mortality data in Europe.

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.

Real-time monitoring shows substantial excess all-cause mortality during second wave of COVID-19 in Europe, October to December 2020.

The European monitoring of excess mortality for public health action (EuroMOMO) network monitors weekly excess all-cause mortality in 27 European countries or subnational areas. During the first wave of the coronavirus disease (COVID-19) pandemic in Europe in spring 2020, several countries experienced extraordinarily high levels of excess mortality. Europe is currently seeing another upsurge in COVID-19 cases, and EuroMOMO is again witnessing a substantial excess all-cause mortality attributable to COVID-19.

Multi-Elemental Composition Data Handled by Chemometrics for the Discrimination of High-Value Italian Pecorino Cheeses.

The multi-elemental composition of three typical Italian Pecorino cheeses, Protected Designation of Origin (PDO) Pecorino Romano (PR), PDO Pecorino Sardo (PS) and Pecorino di Farindola (PF), was determined by Inductively Coupled Plasma Optical Emission Spectrometry (ICP-OES). The ICP-OES method here developed allowed the accurate and precise determination of eight major elements (Ba, Ca, Fe, K, Mg, Na, P, and Zn). The ICP-OES data acquired from 17 PR, 20 PS, and 16 PF samples were processed by unsupervised (Principal Component Analysis, PCA) and supervised (Partial Least Square-Discriminant Analysis, PLS-DA) multivariate methods. PCA revealed a relatively high variability of the multi-elemental composition within the samples of a given variety, and a fairly good separation of the Pecorino cheeses according to the geographical origin. Concerning the supervised classification, PLS-DA has allowed obtaining excellent results, both in calibration (in cross-validation) and in validation (on the external test set). In fact, the model led to a cross-validated total accuracy of 93.3% and a predictive accuracy of 91.3%, corresponding to 2 (over 23) misclassified test samples, indicating the adequacy of the model in discriminating Pecorino cheese in accordance with its origin.

Efficacy and safety of device-assisted enteroscopy ERCP in liver transplantation: A systematic review and meta-analysis.

BACKGROUND: Enterobiliary anastomoses are the main source of complications after liver transplantation. An endoscopic approach combining device-assisted enteroscopy and ERCP (DAE-ERCP) is technically feasible in postsurgical anatomy. AIMS: This study aimed at assessing the efficacy, feasibility, and safety of DAE-ERCP in liver-transplanted patients (LT) and other subsets (non-LT). METHODS: A systematic review and meta-analysis of studies involving DAE procedures in LT patients (between January 2000 and May 2017) was conducted. The main endpoints were as follows: endoscopic, diagnostic, therapeutic, and overall success rates, complications, and the need for surgery. RESULTS: A total of 155 studies were retrieved, and 6 relevant trials were analyzed. Overall, 132 subjects (72 LT and 60 non-LT) undergoing 257 DAE-ERCP (135 and 122) were included. Complications were rare (4/257), and no deaths occurred. These are the pooled success rates among LT and non-LT patients: 80%-100% and 82%-95% (enteroscopic), 75%-100% and 89%-100% (diagnostic), 67%-100% and 92%-100% (therapeutic), and 60%-100% and 79%-83% (overall results). The requirement for surgery was similar in the two subgroups. CONCLUSION: In managing biliary complications, the high diagnostic and therapeutic success rates of DAE-ERCP combined with its safety and feasibility encourage its application as a first-line approach to transplanted patients.

Publisher Correction to: Temporal dynamics in total excess mortality and COVID-19 deaths in Italian cities.

An amendment to this paper has been published and can be accessed via the original article.

Temporal dynamics in total excess mortality and COVID-19 deaths in Italian cities.

BACKGROUND: Standardized mortality surveillance data, capable of detecting variations in total mortality at population level and not only among the infected, provide an unbiased insight into the impact of epidemics, like COVID-19 (Coronavirus disease). We analysed the temporal trend in total excess mortality and deaths among positive cases of SARS-CoV-2 by geographical area (north and centre-south), age and sex, taking into account the deficit in mortality in previous months. METHODS: Data from the Italian rapid mortality surveillance system was used to quantify excess deaths during the epidemic, to estimate the mortality deficit during the previous months and to compare total excess mortality with deaths among positive cases of SARS-CoV-2. Data were stratified by geographical area (north vs centre and south), age and sex. RESULTS: COVID-19 had a greater impact in northern Italian cities among subjects aged 75-84 and 85+ years. COVID-19 deaths accounted for half of total excess mortality in both areas, with differences by age: almost all excess deaths were from COVID-19 among adults, while among the elderly only one third of the excess was coded as COVID-19. When taking into account the mortality deficit in the pre-pandemic period, different trends were observed by area: all excess mortality during COVID-19 was explained by deficit mortality in the centre and south, while only a 16% overlap was estimated in northern cities, with quotas decreasing by age, from 67% in the 15-64 years old to 1% only among subjects 85+ years old. CONCLUSIONS: An underestimation of COVID-19 deaths is particularly evident among the elderly. When quantifying the burden in mortality related to COVID-19, it is important to consider seasonal dynamics in mortality. Surveillance data provides an impartial indicator for monitoring the following phases of the epidemic, and may help in the evaluation of mitigation measures adopted.