Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

BackgroundCOVID-19 is an international global health emergency and has posed a great challenge to mental well-being and resilience. Little is known about the mental health impact of COVID-19 among healthcare workers (HCWs) in sub-Saharan Africa or other low-resource settings.MethodsWe conducted a cross-sectional study between August and November 2020 among HCWs recruited from three major hospitals in Kenya. The survey questionnaire consisted of six components: demographic and work title characteristics; information regarding care of patients with COVID-19; and symptoms of depression, anxiety, insomnia, distress and burnout, measured using standardised questionnaires. Multivariable logistic regression analysis was performed to identify factors associated with mental health disorders.ResultsA total of 433 (65.2% response rate) individuals participated in the survey. Median age was 32.75 years, 58.4% were females and 68.8% were front-line workers. Depression, anxiety, insomnia, distress and burnout were reported in 53.6%, 44.3%, 41.1%, 31.0% and 45.8% of all participants, respectively. Front-line HCWs, females and doctors were at higher risk of mental health symptoms. Nearly half of participants reported inadequate resources or training to care for patients with COVID-19, and those in the government hospital were more likely to report mental health symptoms.ConclusionsThis is among the first studies examining mental health outcomes among HCWs during the COVID-19 pandemic in Kenya. Similar to other studies from around the world, HCWs directly involved with patients with COVID-19 reported higher rates of mental health symptoms. Mitigating strategies specific to Kenyan HCWs are urgently needed to help them cope with mental health symptoms during the pandemic.

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

Understanding the effects of socio-ecological shocks on land use/land cover (LULC) change is essential for developing land management strategies and for reducing adverse environmental pressures. Our study examines the impacts of the armed conflict in Syria, which began in mid-2011, and the related social and economic crisis on LULC between 2010 and 2018. We used remote sensing for change detection by applying a supervised maximum likelihood classification to Landsat images of the three target years 2010, 2014, and 2018. Based on the computed extent of our LULC classes and accuracy assessment, we calculated area-adjusted estimates and 95% confidence intervals. Our classification achieved an overall accuracy of 86.4%. Compared to 2010, we found an increase in spatial extent for bare areas (40,011 km2), forests (2576 km2), and urban and peri-urban areas (3560 km2), whereas rangelands (37,005 km2) and cultivated areas (9425 km2) decreased by 2018. It is not possible to determine whether the changes in LULC in Syria will be permanent or temporary. Natural conditions such as climate fluctuations had an impact on the uses of the natural environment and cultivated areas during the study period, especially in regions suffering from water stress. Although seasonal precipitation patterns and temperature affect LULC change, however, we could not identify a prevailing climate trend towards more drought-prone conditions. Our analysis focuses on (potential) direct and indirect implications of the Syrian conflict on LULC change, which most notably occurred between 2014 and 2018. Conflict-related main drivers were human activities and demographic changes, which are mainly attributable to large-scale population displacement, military operations, concomitant socio-economic status, and control of local resources. As the study provides quantitative and qualitative information on the dynamics of LULC changes in Syria, it may serve as a framework for further relevant conflict-related research and support planning, management practices, and sustainable development.

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D iagnosis and appropriate case management ofPlasmodium falciparum infection has greatly improved in many malaria-endemic settings through the use of rapid diagnostic tests (RDTs) that detect the histidine-rich protein 2 (HRP2) antigen (1). As the only Plasmodium species infecting humans to produce this antigen, the P. falciparum parasite expresses HRP2 in abundance and releases it into the bloodstream during blood-stage infection, making this marker a very sensitive and specific target for falciparum malaria (1,2). The pfhrp2 gene is located on chromosome 8 of the parasite genome, and a paralogous gene (pfhrp3) is located on chromosome 13. The 2 protein products share common epitopes for diagnostic antibodies, enabling the HRP3 antigen to also be detected to some extent by HRP2based RDTs (3-6).P. falciparum produces large quantities of these antigens during human blood-stage infection, but their biologic functions are not well elucidated, and pfhrp2-deleted and pfhrp3-deleted parasites still complete the human-mosquito lifecycle successfully (7). Reports of these gene deletions have increased over the past decade from multiple countries in Africa, South America, and Asia (https://apps.who.int/ malaria/maps/threats) (8). For countries that rely on HRP2-based RDTs for diagnosis of P. falciparum infection, those reports affirm the need to monitor the performance of this tool because deleted parasites could emerge and elicit false-negative results.P. falciparum infection represents ≈99.7% of all malaria cases in sub-Saharan Africa, and ≈300 million HRP2-based RDTs are used in this region annually (9). Studies in the east Africa countries of Eritrea (10) and Ethiopia (11,12) have found high prevalence of pfhrp2/pfhrp3 deletions, forcing changes away from HRP2-based RDTs to accurately diagnose P. falci-

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The use of remote sensing techniques and subsequent analysis by means of geographical information system (GIS) offers an effective method for monitoring temporal and spatial changes of landscapes. This work studies the urbanization processes and associated threats to natural ecosystems and resources in the metropolitan areas of Berlin and Erlangen-Fürth-Nürnberg-Schwabach (EFNS). To compute the land use/cover (LULC) of the study areas, a supervised classification of "maximum likelihood" using Landsat data for the years of 1972, 1985, 1998, 2003, and 2015 is used. Results show that the built-up area is the dominant land use in both regions throughout the study period. This land use has increased at the expense of green and open areas in EFNS and at the expense of agricultural land in Berlin. Likewise, 5% of forest in EFNS is replaced with urban infrastructure. However, the amount of forest in Berlin increased by 3%. While EFNS experienced relatively big changes in its water bodies from 1972 to 1985, changes in water bodies in Berlin were rather slight during the last 40 years. The overall accuracy of our remotely sensed LULC maps was between 88% and 94% in Berlin and between 85.87% and 87.4% for EFNS. The combination of remote sensing and GIS appears to be an indispensable tool for monitoring changes in LULC in urban areas and help improving LU planning to avoid environmental and ecological problems.