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As of 1 May 2020, there had been 6808 confirmed cases of COVID-19 in Australia. Of these, 98 had died from the disease. The epidemic had been in decline since mid-March, with 308 cases confirmed nationally since 14 April. This suggests that the collective actions of the Australian public and government authorities in response to COVID-19 were sufficiently early and assiduous to avert a public health crisis - for now. Analysing factors that contribute to individual country experiences of COVID-19, such as the intensity and timing of public health interventions, will assist in the next stage of response planning globally. We describe how the epidemic and public health response unfolded in Australia up to 13 April. We estimate that the effective reproduction number was likely below one in each Australian state since mid-March and forecast that clinical demand would remain below capacity thresholds over the forecast period (from mid-to-late April).
Тема - темыBetacoronavirus , Coronavirus Infections/epidemiology , Pandemics , Pneumonia, Viral/epidemiology , Adolescent , Adult , Age Distribution , Aged , Aged, 80 and over , Australia/epidemiology , COVID-19 , Child , Child, Preschool , Communicable Disease Control/methods , Communicable Disease Control/organization & administration , Communicable Disease Control/statistics & numerical data , Coronavirus Infections/prevention & control , Female , Forecasting , Geography, Medical , Hospitalization/statistics & numerical data , Humans , Infant , Infant, Newborn , Male , Middle Aged , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Public Health , Quarantine , SARS-CoV-2 , Travel , Young Adult
BACKGROUND: As mortality from coronavirus disease 2019 (COVID-19) is strongly age-dependent, we aimed to identify population subgroups at an elevated risk for adverse outcomes from COVID-19 using age-/gender-adjusted data from European cohort studies with the aim to identify populations that could potentially benefit from booster vaccinations. METHODS: We performed a systematic literature review and meta-analysis to investigate the role of underlying medical conditions as prognostic factors for adverse outcomes due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including death, hospitalisation, intensive care unit (ICU) admission and mechanical ventilation within three separate settings (community, hospital and ICU). Cohort studies that reported at least age and gender-adjusted data from Europe were identified through a search of peer-reviewed articles published until 11 June 2021 in Ovid Medline and Embase. Results are presented as odds ratios with 95% confidence intervals and absolute risk differences in deaths per 1000 COVID-19 patients. FINDINGS: We included 88 cohort studies with age-/gender-adjusted data from 6 653 207 SARS-CoV-2 patients from Europe. Hospital-based mortality was associated with high and moderate certainty evidence for solid organ tumours, diabetes mellitus, renal disease, arrhythmia, ischemic heart disease, liver disease and obesity, while a higher risk, albeit with low certainty, was noted for chronic obstructive pulmonary disease and heart failure. Community-based mortality was associated with a history of heart failure, stroke, diabetes and end-stage renal disease. Evidence of high/moderate certainty revealed a strong association between hospitalisation for COVID-19 and solid organ transplant recipients, sleep apnoea, diabetes, stroke and liver disease. INTERPRETATION: The results confirmed the strong association between specific prognostic factors and mortality and hospital admission. Prioritisation of booster vaccinations and the implementation of nonpharmaceutical protective measures for these populations may contribute to a reduction in COVID-19 mortality, ICU and hospital admissions.
Тема - темыCOVID-19 , Hospitalization , Intensive Care Units , Humans , Cohort Studies , COVID-19/mortality , COVID-19/therapy , Hospitalization/statistics & numerical data , Prognosis , Europe/epidemiology , Male , Female
BACKGROUND: Risk assessment of patients with acute COVID-19 in a telemedicine context is not well described. In settings of large numbers of patients, a risk assessment tool may guide resource allocation not only for patient care but also for maximum health care and public health benefit. OBJECTIVE: The goal of this study was to determine whether a COVID-19 telemedicine risk assessment tool accurately predicts hospitalizations. METHODS: We conducted a retrospective study of a COVID-19 telemedicine home monitoring program serving health care workers and the community in Atlanta, Georgia, with enrollment from March 24 to May 26, 2020; the final call range was from March 27 to June 19, 2020. All patients were assessed by medical providers using an institutional COVID-19 risk assessment tool designating patients as Tier 1 (low risk for hospitalization), Tier 2 (intermediate risk for hospitalization), or Tier 3 (high risk for hospitalization). Patients were followed with regular telephone calls to an endpoint of improvement or hospitalization. Using survival analysis by Cox regression with days to hospitalization as the metric, we analyzed the performance of the risk tiers and explored individual patient factors associated with risk of hospitalization. RESULTS: Providers using the risk assessment rubric assigned 496 outpatients to tiers: Tier 1, 237 out of 496 (47.8%); Tier 2, 185 out of 496 (37.3%); and Tier 3, 74 out of 496 (14.9%). Subsequent hospitalizations numbered 3 out of 237 (1.3%) for Tier 1, 15 out of 185 (8.1%) for Tier 2, and 17 out of 74 (23%) for Tier 3. From a Cox regression model with age of 60 years or older, gender, and reported obesity as covariates, the adjusted hazard ratios for hospitalization using Tier 1 as reference were 3.74 (95% CI 1.06-13.27; P=.04) for Tier 2 and 10.87 (95% CI 3.09-38.27; P<.001) for Tier 3. CONCLUSIONS: A telemedicine risk assessment tool prospectively applied to an outpatient population with COVID-19 identified populations with low, intermediate, and high risk of hospitalization.
Тема - темыAmbulatory Care , COVID-19/therapy , Hospitalization/statistics & numerical data , Risk Assessment/methods , Telemedicine , Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Reproducibility of Results , Retrospective Studies , Young Adult
BACKGROUND: COVID-19, a viral respiratory disease first reported in December 2019, quickly became a threat to global public health. Further understanding of the epidemiology of the SARS-CoV-2 virus and the risk perception of the community may better inform targeted interventions to reduce the impact and spread of COVID-19. OBJECTIVE: In this study, we aimed to examine the association between chronic diseases and serious outcomes following COVID-19 infection, and to explore its influence on people's self-perception of risk for worse COVID-19 outcomes. METHODS: This study draws data from two databases: (1) the nationwide database of all confirmed COVID-19 cases in Portugal, extracted on April 28, 2020 (n=20,293); and (2) the community-based COVID-19 Barometer survey, which contains data on health status, perceptions, and behaviors during the first wave of COVID-19 (n=171,087). We assessed the association between relevant chronic diseases (ie, respiratory, cardiovascular, and renal diseases; diabetes; and cancer) and death and intensive care unit (ICU) admission following COVID-19 infection. We identified determinants of self-perception of risk for severe COVID-19 outcomes using logistic regression models. RESULTS: Respiratory, cardiovascular, and renal diseases were associated with mortality and ICU admission among patients hospitalized due to COVID-19 infection (odds ratio [OR] 1.48, 95% CI 1.11-1.98; OR 3.39, 95% CI 1.80-6.40; and OR 2.25, 95% CI 1.66-3.06, respectively). Diabetes and cancer were associated with serious outcomes only when considering the full sample of COVID-19-infected cases in the country (OR 1.30, 95% CI 1.03-1.64; and OR 1.40, 95% CI 1.03-1.89, respectively). Older age and male sex were both associated with mortality and ICU admission. The perception of risk for severe COVID-19 disease in the study population was 23.9% (n=40,890). This was markedly higher for older adults (n=5235, 46.4%), those with at least one chronic disease (n=17,647, 51.6%), or those in both of these categories (n=3212, 67.7%). All included diseases were associated with self-perceptions of high risk in this population. CONCLUSIONS: Our results demonstrate the association between some prevalent chronic diseases and increased risk of worse COVID-19 outcomes. It also brings forth a greater understanding of the community's risk perceptions of serious COVID-19 disease. Hence, this study may aid health authorities to better adapt measures to the real needs of the population and to identify vulnerable individuals requiring further education and awareness of preventive measures.
Тема - темыCOVID-19/therapy , Chronic Disease/epidemiology , Health Knowledge, Attitudes, Practice , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/mortality , Comorbidity , Databases, Factual , Female , Hospitalization/statistics & numerical data , Humans , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Portugal/epidemiology , Risk Assessment , Surveys and Questionnaires , Treatment Outcome
BACKGROUND: The clinical, laboratory, and imaging features of COVID-19 disease are variable. Multiple factors can affect the disease progression and outcome. OBJECTIVE: This study aimed to analyze the clinical, laboratory, and imaging features of COVID-19 in Jordan. METHODS: Clinical, laboratory, and imaging data were collected for 557 confirmed COVID-19 patients admitted to Prince Hamzah Hospital (PHH), Jordan. Analysis was performed using appropriate statistical tests with SPSS version 24. RESULTS: Of the 557 COVID-19 polymerase chain reaction (PCR)-positive cases admitted to PHH, the mean age was 34.4 years (SD 18.95 years; range 5 weeks to 87 years), 86.0% (479/557) were male, 41% (29/70) were blood group A+, and 57.1% (93/163) were overweight or obese. Significant past medical history was documented in 25.9% (144/557), significant surgical history in 12.6% (70/557), current smoking in 14.9% (83/557), and pregnancy in 0.5% (3/557). The mean duration of hospitalization was 16.4 (SD 9.3; range 5 to 70) days; 52.6% (293/557) were asymptomatic, and 12.9% (72/557) had more than 5 symptoms, with generalized malaise and dry cough the most common symptoms. Only 2.5% (14/557) had a respiratory rate over 25 breaths/minute, and 1.8% (10/557) had an oxygen saturation below 85%. Laboratory investigations showed a wide range of abnormalities, with lymphocytosis and elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer the most common abnormalities. Ground glass opacity was the most common imaging finding. Men had a significantly higher frequency of symptoms, incidence of smoking, reduced hemoglobin, increased monocyte %, elevated creatinine levels, and intensive care unit admissions compared with women (P<.05). Hospitalization duration was associated with increased age, male gender, symptom score, history of smoking, elevated systolic blood pressure, elevated respiratory rate, and elevated monocyte %, CRP, ESR, creatinine, and D-dimer (P<.05). CONCLUSIONS: Most COVID-19 cases admitted to PHH were asymptomatic. Variabilities in symptoms, signs, laboratory results, and imaging findings should be noted. Increased age, male gender, smoking history, and elevated inflammatory markers were significantly associated with longer duration of hospitalization.
Тема - темыCOVID-19/diagnosis , COVID-19/therapy , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/diagnostic imaging , COVID-19/epidemiology , Child , Child, Preschool , Cohort Studies , Cross-Sectional Studies , Female , Hospitalization/statistics & numerical data , Humans , Infant , Jordan/epidemiology , Laboratories , Male , Middle Aged , Pregnancy , Young Adult
BACKGROUND: The incidence and severity of coronavirus disease 2019 (COVID-19) among HIV-positive persons receiving antiretroviral therapy (ART) have not been characterized in large populations. OBJECTIVE: To describe the incidence and severity of COVID-19 by nucleos(t)ide reverse transcriptase inhibitor (NRTI) use among HIV-positive persons receiving ART. DESIGN: Cohort study. SETTING: HIV clinics in 60 Spanish hospitals between 1 February and 15 April 2020. PARTICIPANTS: 77 590 HIV-positive persons receiving ART. MEASUREMENTS: Estimated risks (cumulative incidences) per 10 000 persons and 95% CIs for polymerase chain reaction-confirmed COVID-19 diagnosis, hospitalization, intensive care unit (ICU) admission, and death. Risk and 95% CIs for COVID-19 diagnosis and hospital admission by use of the NRTIs tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC), tenofovir alafenamide (TAF)/FTC, abacavir (ABC)/lamivudine (3TC), and others were estimated through Poisson regression models. RESULTS: Of 77 590 HIV-positive persons receiving ART, 236 were diagnosed with COVID-19, 151 were hospitalized, 15 were admitted to the ICU, and 20 died. The risks for COVID-19 diagnosis and hospitalization were greater in men and persons older than 70 years. The risk for COVID-19 hospitalization was 20.3 (95% CI, 15.2 to 26.7) among patients receiving TAF/FTC, 10.5 (CI, 5.6 to 17.9) among those receiving TDF/FTC, 23.4 (CI, 17.2 to 31.1) among those receiving ABC/3TC, and 20.0 (CI, 14.2 to 27.3) for those receiving other regimens. The corresponding risks for COVID-19 diagnosis were 39.1 (CI, 31.8 to 47.6), 16.9 (CI, 10.5 to 25.9), 28.3 (CI, 21.5 to 36.7), and 29.7 (CI, 22.6 to 38.4), respectively. No patient receiving TDF/FTC was admitted to the ICU or died. LIMITATION: Residual confounding by comorbid conditions cannot be completely excluded. CONCLUSION: HIV-positive patients receiving TDF/FTC have a lower risk for COVID-19 and related hospitalization than those receiving other therapies. These findings warrant further investigation in HIV preexposure prophylaxis studies and randomized trials in persons without HIV. PRIMARY FUNDING SOURCE: Instituto de Salud Carlos III and National Institutes of Health.
Тема - темыAntiretroviral Therapy, Highly Active , Coronavirus Infections/epidemiology , HIV Infections/drug therapy , Pneumonia, Viral/epidemiology , Adenine/analogs & derivatives , Adult , Aged , Betacoronavirus , COVID-19 , Coronavirus Infections/mortality , Dideoxynucleosides , Drug Combinations , Emtricitabine , Female , HIV Infections/mortality , Hospitalization/statistics & numerical data , Humans , Incidence , Intensive Care Units/statistics & numerical data , Lamivudine , Male , Middle Aged , Pandemics , Pneumonia, Viral/mortality , Reverse Transcriptase Polymerase Chain Reaction , SARS-CoV-2 , Severity of Illness Index , Spain/epidemiology , Tenofovir
BACKGROUND: Low-dose glucocorticoids are frequently used for the management of rheumatoid arthritis (RA) and other chronic conditions, but the safety of long-term use remains uncertain. OBJECTIVE: To quantify the risk for hospitalized infection with long-term use of low-dose glucocorticoids in patients with RA receiving stable disease-modifying antirheumatic drug (DMARD) therapy. DESIGN: Retrospective cohort study. SETTING: Medicare claims data and Optum's deidentified Clinformatics Data Mart database from 2006 to 2015. PATIENTS: Adults with RA receiving a stable DMARD regimen for more than 6 months. MEASUREMENTS: Associations between glucocorticoid dose (none, ≤5 mg/d, >5 to 10 mg/d, and >10 mg/d) and hospitalized infection were evaluated using inverse probability-weighted analyses, with 1-year cumulative incidence predicted from weighted models. RESULTS: 247 297 observations were identified among 172 041 patients in Medicare and 58 279 observations among 44 118 patients in Optum. After 6 months of stable DMARD use, 47.1% of Medicare patients and 39.5% of Optum patients were receiving glucocorticoids. The 1-year cumulative incidence of hospitalized infection in Medicare patients not receiving glucocorticoids was 8.6% versus 11.0% (95% CI, 10.6% to 11.5%) for glucocorticoid dose of 5 mg or less per day, 14.4% (CI, 13.8% to 15.1%) for greater than 5 to 10 mg/d, and 17.7% (CI, 16.5% to 19.1%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). The 1-year cumulative incidence of hospitalized infection in Optum patients not receiving glucocorticoids was 4.0% versus 5.2% (CI, 4.7% to 5.8%) for glucocorticoid dose of 5 mg or less per day, 8.1% (CI, 7.0% to 9.3%) for greater than 5 to 10 mg/d, and 10.6% (CI, 8.5% to 13.2%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). LIMITATION: Potential for residual confounding and misclassification of glucocorticoid dose. CONCLUSION: In patients with RA receiving stable DMARD therapy, glucocorticoids were associated with a dose-dependent increase in the risk for serious infection, with small but significant risks even at doses of 5 mg or less per day. Clinicians should balance the benefits of low-dose glucocorticoids with this potential risk. PRIMARY FUNDING SOURCE: National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Тема - темыAntirheumatic Agents/adverse effects , Arthritis, Rheumatoid/drug therapy , Glucocorticoids/adverse effects , Infections/chemically induced , Aged , Antirheumatic Agents/administration & dosage , Antirheumatic Agents/therapeutic use , Female , Glucocorticoids/administration & dosage , Glucocorticoids/therapeutic use , Hospitalization/statistics & numerical data , Humans , Male , Retrospective Studies , Risk Factors
Coronavirus disease 2019 (COVID-19) has migrated to regions that were initially spared, and it is likely that different populations are currently at risk for illness. Herein, we present our observations of the change in characteristics and resource use of COVID-19 patients over time in a national system of community hospitals to help inform those managing surge planning, operational management, and future policy decisions.
Тема - темыCOVID-19/epidemiology , COVID-19/therapy , Hospitalization/statistics & numerical data , Adult , Age Factors , Aged , Aged, 80 and over , COVID-19/ethnology , COVID-19/mortality , Female , Hospitals, Community , Humans , Male , Middle Aged , SARS-CoV-2/isolation & purification , Virginia/epidemiology , Young Adult
In a single-center review of antibiotic prescribing in COVID-19 patients, 10% of patients received antimicrobials, and inpatients encounters had the highest rate and spectrum of prescribing. Prescribing rate, spectrum, and duration appeared to increase with disease severity in inpatients. Antimicrobial prescribing in patients managed in ambulatory encounters was less common.
Тема - темыAnti-Infective Agents/therapeutic use , Antimicrobial Stewardship , Bacterial Infections , COVID-19 , Coinfection , Practice Patterns, Physicians' , Antimicrobial Stewardship/methods , Antimicrobial Stewardship/standards , Bacterial Infections/epidemiology , Bacterial Infections/therapy , COVID-19/epidemiology , COVID-19/therapy , Coinfection/drug therapy , Coinfection/epidemiology , Continuity of Patient Care/statistics & numerical data , Drug Utilization/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Female , Hospitalization/statistics & numerical data , Humans , Male , Middle Aged , Minnesota/epidemiology , Outpatient Clinics, Hospital/statistics & numerical data , Practice Patterns, Physicians'/standards , Practice Patterns, Physicians'/statistics & numerical data , SARS-CoV-2/isolation & purification , Tertiary Care Centers/statistics & numerical data
Importance: Evidence describing the incidence of severe COVID-19 illness following vaccination and booster with BNT162b2, mRNA-1273, and Ad26.COV2.S vaccines is needed, particularly for high-risk populations. Objective: To describe the incidence of severe COVID-19 illness among a cohort that received vaccination plus a booster vaccine dose. Design, Setting, and Participants: Retrospective cohort study of adults receiving care at Veterans Health Administration facilities across the US who received a vaccination series plus 1 booster against SARS-CoV-2, conducted from July 1, 2021, to May 30, 2022. Patients were eligible if they had received a primary care visit in the prior 2 years and had documented receipt of all US Food and Drug Administration-authorized doses of the initial mRNA vaccine or viral vector vaccination series after December 11, 2020, and a subsequent documented booster dose between July 1, 2021, and April 29, 2022. The analytic cohort consisted of 1â¯610â¯719 participants. Exposures: Receipt of any combination of mRNA-1273 (Moderna), BNT162b2 (Pfizer-BioNTech), and Ad26.COV2.S (Janssen/Johnson & Johnson) primary vaccination series and a booster dose. Main Outcomes and Measures: Outcomes were breakthrough COVID-19 (symptomatic infection), hospitalization with COVID-19 pneumonia and/or death, and hospitalization with severe COVID-19 pneumonia and/or death. A subgroup analysis of nonoverlapping populations included those aged 65 years or older, those with high-risk comorbid conditions, and those with immunocompromising conditions. Results: Of 1â¯610â¯719 participants, 1â¯100â¯280 (68.4%) were aged 65 years or older and 132â¯243 (8.2%) were female; 1â¯133â¯785 (70.4%) had high-risk comorbid conditions, 155â¯995 (9.6%) had immunocompromising conditions, and 1â¯467â¯879 (91.1%) received the same type of mRNA vaccine (initial series and booster). Over 24 weeks, 125.0 (95% CI, 123.3-126.8) per 10â¯000 persons had breakthrough COVID-19, 8.9 (95% CI, 8.5-9.4) per 10â¯000 persons were hospitalized with COVID-19 pneumonia or died, and 3.4 (95% CI, 3.1-3.7) per 10â¯000 persons were hospitalized with severe pneumonia or died. For high-risk populations, incidence of hospitalization with COVID-19 pneumonia or death was as follows: aged 65 years or older, 1.9 (95% CI, 1.4-2.6) per 10â¯000 persons; high-risk comorbid conditions, 6.7 (95% CI, 6.2-7.2) per 10â¯000 persons; and immunocompromising conditions, 39.6 (95% CI, 36.6-42.9) per 10â¯000 persons. Subgroup analyses of patients hospitalized with COVID-19 pneumonia or death by time after booster demonstrated similar incidence estimates among those aged 65 years or older and with high-risk comorbid conditions but not among those with immunocompromising conditions. Conclusions and Relevance: In a US cohort of patients receiving care at Veterans Health Administration facilities during a period of Delta and Omicron variant predominance, there was a low incidence of hospitalization with COVID-19 pneumonia or death following vaccination and booster with any of BNT162b2, mRNA-1273, or Ad26.COV2.S vaccines.
Тема - темы2019-nCoV Vaccine mRNA-1273 , Ad26COVS1 , BNT162 Vaccine , COVID-19 , Immunization, Secondary , 2019-nCoV Vaccine mRNA-1273/therapeutic use , Ad26COVS1/therapeutic use , Adult , Aged , BNT162 Vaccine/therapeutic use , COVID-19/epidemiology , COVID-19/mortality , COVID-19/prevention & control , Female , Hospitalization/statistics & numerical data , Humans , Immunization, Secondary/statistics & numerical data , Incidence , Male , Pneumonia/epidemiology , Pneumonia/etiology , Retrospective Studies , SARS-CoV-2 , United States/epidemiology , Vaccination , Veterans Health Services/statistics & numerical data
This study assesses the association between COVID-19 mRNA booster immunization compared with vaccination with the primary mRNA vaccination series alone and odds of hospitalization for COVID-19.
Тема - темыCOVID-19 Vaccines , COVID-19 , Hospitalization , Immunization, Secondary , Humans , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/therapy , COVID-19 Vaccines/administration & dosage , COVID-19 Vaccines/therapeutic use , Hospitalization/statistics & numerical data , Immunization, Secondary/methods , Immunization, Secondary/statistics & numerical data , RNA, Messenger , Vaccination , Time Factors
BACKGROUND: Most research evaluating telehealth psychiatric treatment has been conducted in outpatient settings. There is a great lack of research assessing the efficacy of telehealth treatment in more acute, intensive treatment settings such as a partial hospital. In the face of the COVID-19 pandemic, much of behavioral health treatment has transitioned to a virtual format. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the effectiveness of our partial hospital program (PHP). METHOD: The sample included 207 patients who were treated virtually from May 2020 to September 2020 and a comparison group of 207 patients who were treated in the in-person partial program a year earlier. Patients completed self-administered measures of patient satisfaction, symptoms, coping ability, functioning, and general well-being. RESULTS: For both the in-person and telehealth methods of delivering partial hospital level of care, patients were highly satisfied with treatment and reported a significant reduction in symptoms and suicidality from admission to discharge. On the modified Remission from Depression Questionnaire, the primary outcome measure, both groups reported a significant (P < .01) improvement in functioning, coping ability, positive mental health, and general well-being. A large effect size of treatment (Cohen d > 0.8) was found in both treatment groups. The only significant difference in outcome between the patients treated in the different formats was a greater length of stay (mean ± SD of 13.5 ± 8.1 vs 8.5 ± 5.0 days, t = 7.61, P < .001) and greater likelihood of staying in treatment until completion (72.9% vs 62.3%, χ2 = 5.34, P < .05) in the virtually treated patients. CONCLUSIONS: Telehealth partial hospital treatment was as effective as in-person treatment in terms of patient satisfaction, symptom reduction, suicidal ideation reduction, and improved functioning and well-being. The treatment completion rate was higher in the telehealth cohort, and several patients who were treated virtually commented that they never would have presented for in-person treatment even if there was no pandemic. Telehealth PHPs should be considered a viable treatment option even after the pandemic has resolved.
Тема - темыBehavior Therapy , COVID-19 , Emergency Services, Psychiatric , Mental Disorders , Telemedicine , Adult , Behavior Therapy/methods , Behavior Therapy/trends , COVID-19/epidemiology , COVID-19/prevention & control , Emergency Service, Hospital/statistics & numerical data , Emergency Services, Psychiatric/methods , Emergency Services, Psychiatric/trends , Female , Hospitalization/statistics & numerical data , Humans , Infection Control/methods , Male , Mental Disorders/diagnosis , Mental Disorders/epidemiology , Mental Disorders/therapy , Mental Health/trends , Patient Safety , Patient Satisfaction , SARS-CoV-2 , Telemedicine/methods , Telemedicine/organization & administration , United States/epidemiology
OBJECTIVE: By forcing closure of schools, curtailing outpatient services, and imposing strict social distancing, the COVID-19 pandemic has abruptly affected the daily life of millions worldwide, with still unclear consequences for mental health. This study aimed to evaluate if and how child and adolescent psychiatric visits to hospital emergency departments (EDs) changed during the pandemic lockdown, which started in Italy on February 24, 2020. METHODS: We examined all ED visits by patients under 18 years of age in the 7 weeks prior to February 24, 2020, and in the subsequent 8 weeks of COVID-19 lockdown at two urban university hospitals, in Turin and Rome, Italy. ED visits during the corresponding periods of 2019 served as a comparison using Poisson regression modeling. The clinician's decision to hospitalize or discharge home the patient after the ED visit was examined as an index of clinical severity. RESULTS: During the COVID-19 lockdown, there was a 72.0% decrease in the number of all pediatric ED visits (3,395) compared with the corresponding period in 2019 (12,128), with a 46.2% decrease in psychiatric visits (50 vs 93). The mean age of psychiatric patients was higher in the COVID-19 period (15.7 vs 14.1 years). No significant changes were found in hospitalization rate or in the prevalence distribution of the primary reason for the psychiatric ED visit (suicidality, anxiety/mood disorders, agitation). CONCLUSIONS: In the first 8 weeks of the COVID-19-induced social lockdown, the number of child and adolescent psychiatric ED visits significantly decreased, with an increase in patient age. This decrease does not appear to be explained by severity-driven self-selection and might be due to a reduction in psychiatric emergencies or to the implementation of alternative ways of managing acute psychopathology.
Тема - темыAmbulatory Care/statistics & numerical data , COVID-19 , Emergencies/epidemiology , Emergency Services, Psychiatric , Hospitalization/statistics & numerical data , Mental Disorders , Physical Distancing , Adolescent , Age Factors , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/psychology , Child , Communicable Disease Control/methods , Education, Distance , Emergency Services, Psychiatric/organization & administration , Emergency Services, Psychiatric/statistics & numerical data , Female , Humans , Italy/epidemiology , Male , Mental Disorders/epidemiology , Mental Disorders/psychology , Mental Disorders/therapy , Mental Health/statistics & numerical data , Organizational Innovation , SARS-CoV-2
OBJECTIVE: To assess the prevalence of and risk factors for posttraumatic stress disorder (PTSD) in patients with COVID-19. METHODS: We conducted a cohort study between March and May 2020 at the Lille University Hospital (France), including all patients with laboratory-confirmed COVID-19. Psychological distress symptoms were measured 3 weeks after onset of COVID-19 symptoms using the Impact of Event Scale-6 items (IES-6). The evaluation of PTSD symptoms using the PTSD Checklist for DSM-5 (PCL-5) took place 1 month later. Bivariate analyses were performed to analyze the relationship between PCL-5 scores and the demographic and health variables. The significant variables were then introduced into a multivariable linear regression analysis to establish their relative contributions to the severity of PTSD symptoms. RESULTS: 180 patients were included in this study, and 138 patients completed the 2 evaluations. Among the 180 patients, 70.4% patients required hospitalization, and 30.7% were admitted to the intensive care unit. The prevalence of PTSD was 6.5%, and the predictive factors of PTSD included psychological distress at the onset of the illness and a stay in an intensive care unit. CONCLUSIONS: The prevalence of PTSD in patients with COVID-19 is not as high as that reported among patients during previous epidemics. Initial psychological responses were predictive of a PTSD diagnosis, even though most patients showing acute psychological distress (33.5% of the sample) improved in the following weeks. PTSD symptoms also increased following a stay in an intensive care unit. Future studies should assess the long-term consequences of COVID-19 on patients' mental health.
Тема - темыCOVID-19 , Hospitalization/statistics & numerical data , Intensive Care Units/statistics & numerical data , Psychological Distress , Stress Disorders, Post-Traumatic , Acute Disease , Adult , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/epidemiology , COVID-19/psychology , COVID-19/therapy , Female , Follow-Up Studies , France/epidemiology , Humans , Male , Middle Aged , Prevalence , Severity of Illness Index , Stress Disorders, Post-Traumatic/diagnosis , Stress Disorders, Post-Traumatic/epidemiology , Stress Disorders, Post-Traumatic/etiology
Тема - темыCOVID-19 , SARS-CoV-2 , Viral Load , Waste Water , COVID-19/epidemiology , COVID-19/virology , Hospitalization/statistics & numerical data , Humans , Italy/epidemiology , RNA, Viral/isolation & purification , SARS-CoV-2/isolation & purification , Vaccination/statistics & numerical data , Viral Load/statistics & numerical data , Waste Water/analysis , Waste Water/virology
Importance: The incidence of arterial thromboembolism and venous thromboembolism in persons with COVID-19 remains unclear. Objective: To measure the 90-day risk of arterial thromboembolism and venous thromboembolism in patients hospitalized with COVID-19 before or during COVID-19 vaccine availability vs patients hospitalized with influenza. Design, Setting, and Participants: Retrospective cohort study of 41â¯443 patients hospitalized with COVID-19 before vaccine availability (April-November 2020), 44â¯194 patients hospitalized with COVID-19 during vaccine availability (December 2020-May 2021), and 8269 patients hospitalized with influenza (October 2018-April 2019) in the US Food and Drug Administration Sentinel System (data from 2 national health insurers and 4 regional integrated health systems). Exposures: COVID-19 or influenza (identified by hospital diagnosis or nucleic acid test). Main Outcomes and Measures: Hospital diagnosis of arterial thromboembolism (acute myocardial infarction or ischemic stroke) and venous thromboembolism (deep vein thrombosis or pulmonary embolism) within 90 days. Outcomes were ascertained through July 2019 for patients with influenza and through August 2021 for patients with COVID-19. Propensity scores with fine stratification were developed to account for differences between the influenza and COVID-19 cohorts. Weighted Cox regression was used to estimate the adjusted hazard ratios (HRs) for outcomes during each COVID-19 vaccine availability period vs the influenza period. Results: A total of 85â¯637 patients with COVID-19 (mean age, 72 [SD, 13.0] years; 50.5% were male) and 8269 with influenza (mean age, 72 [SD, 13.3] years; 45.0% were male) were included. The 90-day absolute risk of arterial thromboembolism was 14.4% (95% CI, 13.6%-15.2%) in patients with influenza vs 15.8% (95% CI, 15.5%-16.2%) in patients with COVID-19 before vaccine availability (risk difference, 1.4% [95% CI, 1.0%-2.3%]) and 16.3% (95% CI, 16.0%-16.6%) in patients with COVID-19 during vaccine availability (risk difference, 1.9% [95% CI, 1.1%-2.7%]). Compared with patients with influenza, the risk of arterial thromboembolism was not significantly higher among patients with COVID-19 before vaccine availability (adjusted HR, 1.04 [95% CI, 0.97-1.11]) or during vaccine availability (adjusted HR, 1.07 [95% CI, 1.00-1.14]). The 90-day absolute risk of venous thromboembolism was 5.3% (95% CI, 4.9%-5.8%) in patients with influenza vs 9.5% (95% CI, 9.2%-9.7%) in patients with COVID-19 before vaccine availability (risk difference, 4.1% [95% CI, 3.6%-4.7%]) and 10.9% (95% CI, 10.6%-11.1%) in patients with COVID-19 during vaccine availability (risk difference, 5.5% [95% CI, 5.0%-6.1%]). Compared with patients with influenza, the risk of venous thromboembolism was significantly higher among patients with COVID-19 before vaccine availability (adjusted HR, 1.60 [95% CI, 1.43-1.79]) and during vaccine availability (adjusted HR, 1.89 [95% CI, 1.68-2.12]). Conclusions and Relevance: Based on data from a US public health surveillance system, hospitalization with COVID-19 before and during vaccine availability, vs hospitalization with influenza in 2018-2019, was significantly associated with a higher risk of venous thromboembolism within 90 days, but there was no significant difference in the risk of arterial thromboembolism within 90 days.


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Demographic trends and projections have important implications for the use of ecosystem services and sustainability in the delta. The study area accounts for ten per cent of the national population and recently appears to have low rates of population growth. Analysis of components of population change (fertility, mortality and migration) indicates that over the next few decades the population structure will undergo considerable change. These demographic trends are explained by declining fertility, greater life expectancy and high rates of out-migration. More specifically, the proportion of 65 and over is likely to increase from 6 per cent in 2011 to 15–16 per cent by 2051. Conversely, the proportion of children and youth (ages 0–14) would decline from 34 per cent to 15–16 per cent depending on the scenario considered.
1 Introduction
During the last decades, Bangladesh has undergone a demographic transition, with declining fertility accompanied by lower mortality and increased life expectancy. During this time, total fertility rate (TFR) dropped from 6.36 in 1950–1955 to 2.23 in 2010–2015 and is projected to reach 1.67 in 2050–2055 (UN 2013). While life expectancy has shown important improvements, maternal and child mortality remain high by international standards. Malnutrition, which is a key cause of child mortality and poor health, continues to constitute a key public health challenge. Population trends have been uneven across different geographic areas, and this uneven progress towards demographic transitions is likely to be further challenged by the consequences of environmental and climate change (Szabo et al. 2015a). This chapter examines key population dynamics in the south-west coast of Bangladesh with a specific focus on the components of population change, that is, fertility, mortality and migration, and discusses future population prospects and resulting policy implications.
Existing literature highlights the complex interlinkages between population dynamics, human well-being and sustainability (de Sherbinin et al. 2007; Hummel et al. 2013; Szabo et al. 2016b). For example, population density has been found to be both positively and negatively associated with economic growth and individual well-being (Tiffen 1995; Ahlburg et al. 2013). On one hand, population growth and population density may have a positive effect on people's quality of life because of greater provision of and accessibility to services, such as food, water and healthcare. On the other hand, however, rapid population growth, including growth of populations in urban areas, caused by natural increase and rural to urban migration, is likely to pose important challenges to the sustainability of urban settlements (Szabo et al. 2016b). Urbanisation is also linked to high mobility and migration rates, which are likely to contribute to increased household income, and thus poverty reduction through provision of remittances (Ratha 2013).
This chapter focuses specifically on the population dynamics and prospects in the study area (see Chap. 4, Fig. 4.2). In this region, the interlinkages between population dynamics and sustainability have been and are likely to continue to be of critical importance. The impacts of environmental and climate change, combined with a relatively rapid pace of urbanisation, and falling fertility and mortality rates will mean that economic growth of the region and Bangladesh, as a whole, will be affected (Szabo et al. 2015a). Past evidence suggests that population growth in the area has been accompanied by improved human well-being (Hossain et al. 2016). This has been possible, at least partially, because of the contribution of local ecosystem services. For example, Hossain and Szabo (2017) estimated that in the Narail district north of the study area, the total yearly market output of provisioning services was approximately USD 173 million. Examining population dynamics and prospects in the region will allow better local and national planning, thus contributing to further development of the country.
2 Population Growth and Structure
The total population of the south-west coast of Bangladesh is around 14 million which accounts for ten per cent of the national population. The most populous districts are Khulna and Barisal which includes the two cities of the same names, while the least populous districts are Jhalokati and Barguna. However, Jhalokati has the highest population density, approximately 966 people per square kilometre, while Bagerhat district is the least dense at around 373 people per square kilometre (Szabo et al. 2015a). Both Barisal and Khulna Divisions have experienced substantial population decline, while Dhaka and Chittagong (outside of the study area) had a net increase in terms of the share of total national population (Szabo et al. 2015a) (also see Fig. 19.1). The coastal districts appear to have relatively low rates of population growth; within all the districts the annual average growth rate has decreased between 2001 and 2011 compared to the intercensal period 1991–2001 (BBS 2012). For the entire south-west, the average annual population growth rate decreased from 1.03 to 0.15 per cent (Szabo et al. 2015a). Moreover, four districts—Barisal, Jhalokati, Bagerhat and Khulna—have seen a negative average annual growth rate between 2001 and 2011. Thus, in order to understand the demographics of this area, it is important to examine the interplay of the different components of population change, namely, fertility, mortality and migration.
In terms of population structure (Fig. 19.2), while the current population of the region is relatively young, the declining fertility rates have already had an effect on the population pyramid. More specifically, it can be seen that the bottom of the pyramid (ages 0–4) is significantly smaller compared to the two adjacent age groups. The female and male populations show approximately the same distribution, suggesting no disproportionate out-migration from one gender group. It is however important to highlight that this population structure is expected to change as Bangladesh, and the study area, continue undergoing the demographic transition. In particular, given both low fertility rates and rising environmental vulnerability, it may be expected that the population pyramid will dramatically change.
3 Components of Population Change
3.1 Fertility
Recent changes in fertility patterns have arguably been the most significant factor affecting population change in Bangladesh, including the south-west coast of the country. The coastal delta region is currently experiencing rapid demographic transition, and because of the continuous decline in TFR and consequently natural growth rate, the region is likely to see a less rapid population increase or even, in the long term, a population decline. As can be seen in Fig. 19.3, fertility rates have been decreasing since the early 1990s in both Khulna and Barisal Divisions. In Khulna, TFR dropped from 3.1 in 1993/1994 to 1.9 in 2014, while in Barisal it declined from 3.5 in 1993/1994 to 2.2 in 2014 (Mitra et al. 1994; NIPORT et al. 2016). There exist interesting interdistrict differentials in age-specific fertility with Satkhira showing the highest level of adolescent fertility and Pirojpur the highest level of fertility in older ages (40–49).
Factors affecting fertility levels in Bangladesh as a whole have been examined extensively given the relatively rapid pace of demographic transition since the 1970s. Less evidence exists regarding the specific study area; however, it is sensible to assume that similar factors apply at least at a strategic level. In his comparison of socio-economic development across South Asia, Asadullah et al. (2014) highlighted that the decline in fertility was mainly possible because of the increasingly easy access to contraceptives and reproductive health social awareness campaigns. Similarly, Chowdhury et al. (2013) point out that contraceptive use amongst couples in Bangladesh increased from less than 10 per cent in 1970 to 61 per cent in 2010, which led not only to a lower TFR but also contributed to reductions in mortality rates and gains in the overall socio-economic development. The recent trends in TFR indicate that the delta population is likely to experience smaller households and changing household-level dependency ratios. A recent paper by Szabo et al. (2016b) examining demographic patterns in a larger delta region covering almost five divisions highlighted a declining trend in average household size, from 5.1 in 2000 to 4.8 in 2010.
3.2 Mortality
Infant mortality and under-five mortality rates are overall lower when compared to the national average, with districts such as Barguna and Satkhira having the lowest infant mortality (Table 19.1). This might be explained by the fact that in some very important socio-demographic indicators, Barisal and Khulna Divisions show better scores than other divisions. For example, Barisal has the lowest percentage of ever-married women aged 15–49 with no education (15.1 per cent), followed by Khulna Division (21.6 per cent) (NIPORT et al. 2016). Moreover, if Bangladesh is divided into west and east, then the west (including the study area) has already achieved replacement fertility, while the divisions in the east such as Sylhet and Chittagong are lagging behind (Rabbi and Kabir 2015).
The two districts of Barguna and Satkhira have done relatively well in some of the development indicators as well, which may at least in part, help to explain the lower infant mortality within the study area (Table 19.1). For example, within the Barisal Division, Barguna has the second highest percentage of girls (79.4 per cent) aged 12–15 who completed primary education, the highest percentage of mothers receiving check-ups within two months of delivery (40.6 per cent), as well as within the first two days by any healthcare provider (NIPORT et al. 2012). In addition, the current use of contraception (any method) is relatively higher in the study area (approximately 66 per cent compared to the national average of 63 per cent) (NIPORT et al. 2011; also see Table 19.1). It is reasonable to expect such factors to play an important role in decreasing infant and under-five mortality.
Life expectancy figures for the study are scarce. According to World Health Organization (WHO) data, in Bangladesh the current life expectancy for females is 73.1 and 70.6 for males (compared to 57.7 for females and 56.7 for males in 1985–1990) (WHO 2014; UN 2013). Based on mortality data from the most recent population census, current life expectancy in the study area was estimated. According to these estimates, life expectancy for males varies from 70.9 for Khulna Division to 68.2 in Barisal Division; for females, life expectancy at birth was 73.1 in Khulna and 69.8 in Barisal. These considerable improvements in life expectancy can be explained by a number of factors, as highlighted by Chowdhury et al. (2013).
Environmental factors can affect mortality and population health in different ways. In terms of negative effects, direct factors such as cyclones and flooding can cause death and disease. There were between 225,000 and 500,000 deaths as a result of the 1970 Bhola cyclone; 3,300 and 190 deaths are associated with Cyclones Sidr (2007) and Aila (2009), respectively. The largest flood in Bangladesh in 1998 led to 138,000 deaths and affected 52 per cent of the entire population of Bangladesh at that time (Cash et al. 2013). Other than such rapid onset hazards, slow onset hazards also have the potential to affect population health indirectly. For example, salinisation of water and soil affects water quality for both agriculture (ultimately leading to food insecurity) and domestic consumption. Salinity in drinking water has been found to be associated with increased risk of pre-eclampsia and gestational hypertension in the coastal population of Bangladesh (Khan et al. 2014), while Dasgupta et al. (2016) suggest that salinity in drinking water is a significant determinant of infant mortality in coastal Bangladesh.
However, it should be acknowledged that through socio-economic development and adaptation, coastal Bangladesh is better prepared to cope with the aftermath of natural hazards and environmental disasters (Cash et al. 2013; Haque et al. 2012). In particular, over the last 50 years Bangladesh has learned how to adapt to cyclones, contributing to significant declines in cyclone-related deaths; for example, setting up cyclone shelters and low tech but reliable early warning systems (Haque et al. 2012). These advances in tackling mortality rates can be attributed to enhanced disaster management, greater focus on poverty reduction, a key vulnerability factor, interventions which draw on social capital of the coastal communities and identifying and targeting main drivers of mortality (Cash et al. 2013).
3.3 Migration
Migration is arguably the most complex and challenging component of population change as it is influenced by a diverse set of drivers. Black et al. (2011) identify five families of drivers of migration in the form of economic, political, social, demographic and environmental. Such "micro-scale" and "meso-scale" factors result in macro-scale effects in terms of population growth and distribution across a country. However, according to the classic economic model, migration decision-making process depends on individual choice (Harris and Todaro 1970). Nevertheless, research in the last four decades in this area has found that the process of decision making often depends on the family or household situations well as on the presence of social networks (Jampaklay et al. 2007; Winkels 2008). There is evidence that the migration decision-making process is not undertaken by individuals alone, but it occurs at a group level. This suggests that the classic push and pull factors may operate within a larger social context (Seto 2011).
In Bangladesh migration is a historical phenomenon. Migration patterns are not homogenous within the coastal districts as local push factors may influence people's decision to migrate. The census of 2011(BBS 2012) reports that 9.7 per cent of the total population of Bangladesh are lifetime internal migrants. Using a residual method, a crude net migration rate of around minus 4.5 persons (per 1,000 population) for Barisal Division and around plus 1 person (per 1,000 population) for Khulna Division for the year 2001 was estimated (Szabo et al. 2015a). However, calculations for 2010/2011 revealed an increase in out-migration rates, with a crude net migration of minus 12.5 persons (per 1,000 population) for the Barisal Division and minus 5.5 persons (per 1,000 population) for the Khulna Division, meaning that more people are leaving these divisions than are coming in as migrants.
Environmental stresses, economic vulnerability and prospects of remittance income are thought to result in high out-migration rates in coastal areas (Szabo et al. 2015b; Szabo et al. 2016a). As the Ganges-Brahmaputra-Meghna (GBM) delta constitutes a vulnerable social-ecological system (Sebesvari et al. 2016), there is a relatively high potential for migration. A large portion of internal migration in Bangladesh is not permanent, being either seasonal or temporary. A study in Bangladesh has shown that migrant characteristics, environmental change-related factors, conflict and adaptation strategies, as well as social networks —all have significant impacts on temporary migration (Joarder and Miller 2013). Migrants who had been previously working in agriculture or fishing are more likely to migrate permanently. Households who had reported asset loss due to environmental hazards have a higher probability of becoming permanent migrants, while events such as loss of livestock and crop failure were associated with higher likelihood of becoming temporary migrants.
Another study found that permanent migration from hazard-prone areas are quite low despite the major threats with the exception of erosion of land on which people live or where salinity intrusion makes agriculture impossible (Penning-Rowsell et al. 2013). Certain pull factors encouraging families and people to stay behind are quite strong, and migration as a response to natural hazards may be viewed as a last resort (Penning-Rowsell et al. 2013). Nevertheless, a modelling study by Hassani-Mahmooei and Parris (2012) suggests likely changes in population densities across Bangladesh due to migration from drought-prone western regions and cyclone- and flood-prone areas in the south, towards northern and eastern districts. The model predicted between three and ten million internal migrants in Bangladesh by 2051, by considering drivers such as incidences of extreme poverty, socio-economic vulnerability, demography, historical drought, cyclone and flooding patterns.
3.4 Urbanisation
Evidence suggests that the coastal delta region is not only particularly vulnerable in terms of environmental risks but also experiences unique demographic and urbanisation dynamics (Szabo et al. 2015a). While Bangladesh as a country has undergone a rapid process of urbanisation during the last decade (2011–2011), the coastal delta region saw a slight decline both in terms of urban population size and the proportion of urban population. In 2001, the study area had approximately 2.8 million urban dwellers which accounted for around 20 per cent of the total population in coastal delta (Table 19.2). By 2011, the population declined to 2.5 million, almost 19 per cent of the overall population in the study area. This decline was caused primarily by population dynamics in the Khulna district which experienced a large decline in its urban population, almost 40 per cent during the intercensal period (2001–2011). While without a detailed analysis it is difficult to determine why such a steep decline occurred, it is sensible to assume that both low fertility rate and high level of out-migration contributed to this pattern.
The recent district level census report (BBS 2012) confirms the findings presented in Table 19.2. While in 2001 the level of urbanisation in Khulna district was over 54 per cent, it was only 34 per cent in 2011. Comparatively, in the remaining districts of the Khulna Division (Bagerhat and Satkhira) the proportion of urban population remained at similar levels. In Barisal Division, the Barisal district saw the most rapid pace of urbanisation, with over 22 per cent of its population residing in urban areas in 2011, compared to nearly 17 per cent in 2001. These patterns of urbanisation show that overall the study area is highly diverse in terms of its internal dynamics. Further systematic qualitative or survey research is needed to elaborate the factors affecting urbanisation processes in the coastal delta.
4 Future Scenarios and Policy Recommendations
Population projections for the south-west coast of Bangladesh are uncertain: ongoing processes will continue towards urbanisation and demographic transitions. Szabo et al. (2015a) developed population projections based on three sets of assumptions about the excepted direction of change for different demographic components. These scenarios were aligned with the overall sustainability scenarios and named Business As Usual (BAU), Less Sustainable (LS) and More Sustainable (MS). The results of two out of three projection scenarios show that the population of the study area is likely to experience a significant decline before 2050 (Szabo et al. 2015a). Only in the MS scenario (one which presupposes lower rates of out-migration), population was expected to see a slight increase (Fig. 19.4).
It was also found that in the next decades the population structure in the coastal GBM delta will undergo considerable change regardless of the projection scenario. These future demographic trends can be explained by declining fertility, greater life expectancy and high rates of out-migration. The two key aspects of this shift will entail an ageing population and a declining proportion of younger people. More specifically, the proportion of 65 and over is likely to increase from 5.7 per cent in 2011 to 15 or 16 per cent in 2051 depending on the projection scenario. At the same time, the proportion of children and youth (ages 0–14) would decline from 34 per cent to 15 per cent under LS scenario and 16 per cent under the BAU and MS scenarios.
5 Summary
The demographic trends and projections presented in this chapter have important implications for the wider context of ecosystem services and sustainability in the delta region. First, they suggested the need for tailored district level policy interventions. While the demographic outcomes diverge, the policy priorities are common across the delta region: there is a need to enhance public services and public health, protect vulnerable populations and generate routes out of poverty building on sustainable resource use and mobility. Second, given the distinct demographic patterns of the study area, and the likelihood that migration will continue at some level regardless of rural interventions, the policy planning process should prioritise designing specific measures linked to population distribution at the regional and country level. The recent out-migration from the coastal GBM delta area has an important impact on other urban areas, such as Khulna and Dhaka, including the clustering of new populations in slums and informal settlements. Finally, given the interconnectedness of environmental and social factors and the impact of climate change on human well-being, it is critical to develop integrated strategies to reduce the vulnerability of disadvantaged groups. These groups may include migrants in destination areas (mostly urban centres) and those facing the challenges of ecosystem service decline and environmental degradation in rural areas.
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Szabo, S., Ahmad, S., Adger, W.N. (2018). Population Dynamics in the South-West of Bangladesh. In: Nicholls, R., Hutton, C., Adger, W., Hanson, S., Rahman, M., Salehin, M. (eds) Ecosystem Services for Well-Being in Deltas. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-71093-8_19
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Office for Research Protections | Scientific Diving Program
The Penn State Scientific Diving Program would like to remind you of two student opportunities from the AAUS Foundation that have quickly approaching deadlines:
1. Kevin Flanagan Travel Award - This award provides up to $800 in travel funds and a waived student registration fee for the recipient to attend the 2023 AAUS Diving for Science symposium to be held in Pensacola, Florida, April 23-29th. Applications are due January 15th and can be found under the Scholarship tab at www.aausfoundation.org. Students must be members of AAUS to apply, but should contact the AAUS office if there is a financial hardship preventing membership ($25/annually). Up to 3 recipients are awarded annually. More about the symposium, including a full schedule, can be found at https://aaus.org/AAUS/Annual_Symposium.aspx. Join us for a fantastic meeting!
2. AAUS/OWUSS Summer Internships - In conjunction with Our World Underwater Scholarship Society, AAUS offers two summer internships for 2023; one for a student to receive training in an AAUS Scientific Diver course and one for an already trained AAUS diver to participate in a scientific research project. Applications are due January 15th and can be found at https://www.owuscholarship.org/internships. If your organization is interested in hosting an intern, more information and the host application can be found here.


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About dog attack caterham
The following is a special story about dog attack caterham, which attracted a lot of discussion and attention from netizens in the United States on 29 29, 2023..
dog attack caterham 背景
Guildford's massive North Street regeneration plans rejected - Surrey Live M3 abnormal load convoy had 100ft long lorries and 'amazing' drivers - Surrey Live 'Miracle' at Surrey school helped Emily Blunt overcome speech ... - Surrey Live Why Dogs Attack, And What To Do If A Dangerous Canine ... - WBUR News Man follows children feeding squirrels and tells dog to 'rip them to pieces' - My London Caterham dog attack: Dog walker was mauled to death - BBC Surrey farmer's sheep has legs eaten by dog as attack leaves one dead and several injured - Surrey Live Seven warning signs a dog is about to attack – and what you should do next... - The Scottish Sun Channel 4's The Dog House is looking for Londoners to re-home a puppy for new series - My London The lost Surrey railway station that was site of World War II tragedy - Surrey Live Aldi wants to open 12 new stores in Surrey - is your town on the list? - Surrey Live New CEO, stores and strategy: Will Glossier survive? - Surrey Comet Woman walking dog in Sutton park attacked by thief who punched pet to try and steal it - My London Cute fox rescued after being trapped under boxes in Peckham shop storage room - My London Stacey Solomon says she 'dreads Boxing Day' as she pays respects to late dog with son Rex - My London Tiny puppy looks for home after ears were cropped 'with scissors or a knife' by cruel owner - My London The huge flagship Marks and Spencer store straddling three counties - Surrey Live Gatwick and Heathrow: World Cup fans warned about potential ... - Surrey Live Woman killed in dog attack was walking number of dogs, police say - North Wales Chronicle Caterham dog attack: No prosecutions after woman mauled to death - BBC Bisley manhunt for teenager sees helicopter called as police close roads - Surrey Live Londoners obsessed with 'adorable' dog on London Overground but some spot major problem - My London The number of people in Surrey who want face masks to be made mandatory again - Surrey Live Croydon family heartbroken as dog dies after eating poison in South London park - My London Surrey hospitals trialling nasal spray which could treat Covid - 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Surrey Live ITV Good Morning Britain fans heartbroken for Rob Rinder as he shares family tragedy - My London Windsor Great Park dog attack leaves pups 'severely injured' and owner 'blood-drenched' - Surrey Live Seven warning signs a dog is about to attack – and what you should do next... - The Sun Surrey housing estate used to be psychiatric hospital where Ronnie Kray was patient - Surrey Live Money saving, energy and heating experts at home renovation event near Surrey - Surrey Live Former Team GB rower died after being thrown from horse at 35mph - Hull Live Dog walker screamed out in desperation as 'frenzied' pets attacked her 'like wolves' - Express Dog walker mauled to death when eight pets suddenly turned on her 'like a pack of small wolves'... - The Scottish Sun Search for woman and boy seen walking past pensioner who died on Dormansland street - Surrey Live Police appeal for help to find missing Woking man - Surrey Live Dog picked up beloved Chihuahua and shook it to death after escaping from owner's car while he was arrested - My London Police hunt for Epsom man in connection with stalking - Surrey Comet 10 breeds of adorable dog that are most likely to bite - including the ... - The Scotsman When Woking FC met Pele during 1997 Wembley triumph - Surrey Live Petrol station robber threatened Surrey shopkeeper with bamboo cane - Surrey Live Missing Surrey puppy found drowned after police appeal - Surrey Live Surrey Alabama rot map shows location of every reported case of killer dog disease since 2012 - Surrey Live Surrey 'severe' cold weather alert issued as vulnerable people given 18C warning - Surrey Live Woman killed in Surrey dog attack was walking 'a number of dogs' at the time - Express Surrey weather warning issued after snow falls across the county and people could get 'injured' - Surrey Live The 6 seriously cute dogs still looking for a home after spending Christmas without a family - My London Woman horrified after seeing 'massive Great Dane' attack elderly woman's 'tiny terrier' in South London park - 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Channel 4's latest update - Surrey Live


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Islamic Law and International Humanitarian Law
This article analyses the fundamental ways in which Islamic Law and IHL regimes are similar and the also significant ways in which their applications diverge.
This article analyses the fundamental ways in which Islamic Law and IHL regimes are similar and the also significant ways in which their applications diverge.
Our editorial explores the rights and protections afforded to women and children during times of conflict, and argues that a nuanced approach is necessary to understand the issues that they face.
The editorial for warfare across domains gives an overview of the evolution and conduct of warfare in the air, at sea, in cyberspace, and in space.
This month's editorial introduces the need for harmony between International Humanitarian Law and the global counter-terrorism regime.
Overview of the laws applicable to peacekeeping missions & identification of issues related to accountability of peacekeepers.
This editorial explores the application of the law of armed conflict in Pakistan's domestic courts as well as the use of legal means to pursue strategic objectives.
This editorial focuses on the main issues relating to definitions, accountability, and applicability to non-state entities.
This editorial explores environmental damage during an armed conflict and the ways in which IHL protects the natural environment
How has globalization contributed to growing urban warfare and the debate surrounding the topic of using civilians as human shields in combat? How can the cardinal principles of international humanitarian law be applied to reduce human suffering in urbanised conflicts?
A discussion on the ways in which traditional rules and prohibitions of IHL would apply to emerging new weapons technologies.
End of content
End of content


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Pity the poor biographer of Edgar Allan Poe. E prima scriere-metaforă pe care o citesc! The short story, darkness, grotesqueness, irony, alcohol, death. Seriously, the guy in here is like stalker-crazy about a woman he never met and just glanced at in the theater. Quite different from what Poe is most notably known for, The Spectacles is a humorous cautionary tale about a man with bad eyesight. It was funny, but I'm not sure if I'm likely to reread this work. Virginia admired Poe very much.
The guy who spent his life on the outside is now, a century and a half after his death, considered a member of the inner circle of American literature. From here it gets all mushy as he pines for her, schemes ways to meet her, to comm This story reads as a romance novel, until. Can these men survive the hurricane and escape the force of the Maelström? A particluar old man catches his attention and he decides to follow him to learn more about him. When he puts on the spectacles, he sees that his bride is a toothless, 82 year old woman. His companion Talbot identifies the woman as Madame Eugenie Lalande, a wealthy widow, and promises to introduce the two.
Joel Myerson, Boston: Twayne, 1978, pp. The main character is C. It was around this time that Poe started writing. It was during these years that he established himself as a poet, a short story writer, and an editor. Poe attempted to mend his relationship with John Allan.
He was broke all his life, often begging for money that he soon spent on drink. They didn't kill each other A reporter asked Sir Arthur Conan Doyle in 1894 if he had been influenced by the work of Edgar Allan Poe. How does Dupin figure it out? The rest of the story is about our lovesick fool obsessing over this woman and how to get at her. After several days at sea, they encounter a violent storm. The story also has very strong Oedipal tones.
Which, as boring as it is, is absolutely vital to the rest of the story, so don't skip it! It's definitely a scary story. This copy has not survived, but is presumably reflected in text-05. And since his opinions and speculations would widely differ from those of all mankind that he would be considered a madman is evident. On January 19, 1809, Edgar Allan Poe was born in Boston, Massachusetts. All I can say is the narrator is not a great human being and deserves what happens to him. This text was printed in Liberty magazine for September 24, 1938 and was reprinted as a pamphlet by Richard Gimbel in 1938. His wife died of tuberculosis two years after its publication.
Shortly after Poe's death, this uber-rival published a slanderous account full of lies about the writer, who obviously couldn't do anything to defend himself, being dead and all. Alternatively, he might have preferred not to draw attention to the fact that it was just recently printed in the Dollar Newspaper, particularly because he was asking Horne to seek out an English publisher. The industry was also particularly hurt by the Panic of 1837. A number of his homes are dedicated museums today. The narrator is tortured by his love and longing.
She was accompanied by a much younger relative, Madame Stephanie Lalande. Nici n-am cuvinte să o descriu! Тъжно е, но и смешно, по онзи специфичен начин, характерен за комедията като жанр. Their love seems to be a bound between their souls without any importance of their looking. He placed a few stories with a Philadelphia publication and began work on his only drama, Politian. This same pride kept him from wearing spectacles.
Edgar Allan Poe: A to Z. Poe soon left the army and enrolled at West Point in state. Their wedding was fake, and he ended up marrying Madame Stephanie. Nuvela asta este, par excellence, o metaforă!!! He died penniless at the age of 40 after being found disheveled and unconscious in a Baltimore gutter. Edgar Allan Poe may have become engaged to Sarah Elmira Royster before he registered at the one-year-old University of Virginia in February 1826 — to study ancient and modern languages.


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Evergreen Laurels are members of the Prunus - Cherry family - which in itself is a member of the rose genus - Rosaceae. They are not related to Laurus, even if the name is similar. Laurus is the botanical genus of the Bay Tree.
So, Prunus laurocerasus and its cultivars are the plants we know in common garden parlance as 'Laurels'. There is another group of Laurels known as the Portuguese Laurel, and these - also in the Prunus group - are Prunus lusitanica.
All of the Laurels are evergreen and densely foliaged, which is the reason they are widely used as hedge or screen plants, and also for ground cover. Most laurels are upright growing, but there are a few which are low spreading evergreen shrubs - the ground over types.
All of the Laurels flower - exclusively cream white and normally held upright on attractive racemes - and generally sweetly scented. Those Laurels used for hedging, subject to the shears rarely flower as their flower buds are often cut off.
Prunus laurocerasus - in=mage above - (The Cherry Laurel) has a number of cultivars, having either bright or dark green foliage or also a variegated form with silver splashes on the foliage.
Prunus laurocerasus 'Rotundifolia' is by far the most popular of the Laurels used for hedges and screens. It has dense foliage which is a pleasant light green - especially when young, early in the growing season. Left to its own devices, is can reach a height of up to six metres and be more of a branched small tree rather than a shrub.
It has the positive advantage of being able to be cut back hard – very hard – when is has out-grown its situation. The round leaved Laurel makes a superb evergreen hedge, and simply needs to be clipped once, in late august to retain the desired height. If as a hedge small, it is best to prune, rather than clip the overgrown parts. But it does not suffer if 'attacked' with an electric trimmer.
If grown as a shrub or un-pruned screen, it will develop upright racemes of creamy white flower, which are very sweetly scented. Fruits – not unlike cherries – are produced later, red turning black. It should be noted that the fruits are poisonous if ingested. It bears the unfortunate common name of 'Cherry Laurel' simply because of the visual similarity NOT because of its edible fruits.
Prunus laurocerasus 'Otto Luyken' is very different, with narrow dark green leaves which are pointed and often grow upwards.
P. c. 'Otto Luyken' is a low growing shrub with a very compact habit, making it one of the best ground-cover shrubs of all. It is generally low growing and spreading, but puts on height over the years. This can be reduced if needed to ensure the dense carpet effect.
Early summer sees it resplendent with upright candle-like flower racemes, which often reappear – though to a slightly lesser extent – in late autumn.
This Laurel can easily spread to 2 metres in three to four years, and rarely be a problem as far as height in concerned. As with the other evergreen laurels, it is happy in full sun or partial shade – such as a woodland situation.
Prunus laurocerasus 'Zabeliana' is another low growing evergreen laurel, but with a different habit to P 'Otto Luyken, and different foliage. 'Zabeliana' is low and spreading but with a slightly drooping habit – rather than the erect habit of P. c. 'Otto Luyken'. The leaves – narrow and mid green, droop off the branches and are a good contrast to the upright racemes of flowers. It flowers in late spring/early summer, and often again in autumn.
Prunus 'Zabeliana' responds well to heavy pruning, but as a ground cover shrub, it will reach 2 metres or more in two years after planting.
The Portuguese Laurel, Prunus lusitanica, and is of upright growth habit making it very good for hedges and screens. The foliage is sometimes twisted – especially with the variegated form, but otherwise staunchly evergreen and quite attractive e when in flower. If the Portuguese Laurel is regularly clipped as a hedge then it will not flower.
The flowers are not as 'tidy' as the other laurels mentioned, being a bit lax in habit, but nonetheless attractive. If contained as a screen or hedge, then it will always be within reasonable bounds, but as with other upright Laurels, has the wherewithal to grow in excess of 5metres with a similar spread.
A word of warning is required about disposal of the foliage after pruning. If burned, the foliage emits a Cyanide gas, and should therefore be burned with that in mind, or otherwise disposed of.
All of the Laurels mentioned here can be easily propagated with ripe cuttings in early autumn in a cold frame. The basic 'Rotundifolia' can be struck with large cuttings inserted into the ground and protected until rooted with a makeshift low polythene cover/tunnel.
Identify Weeds in The Garden - How to deal with weeds. Diseases and Pest which harm your garden and plants, learn how to prevent, deter and erradicate your garden problems.Garden Problems
Pruning Guide. Shrubs flower better with correct pruning. Many illustrations and examples of what to do - and when. Includes evergreens, roses, flowering shrubs, spring flowering shrubs and pruning for stem effect. This is our most viewed and comprehensive section,Pruning
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