Association between consumption of vegetables and COVID-19 mortality at a country level in Europe

Background Many foods have an antioxidant activity, and nutrition may mitigate COVID-19. To test the potential role of vegetables in COVID-19 mortality in Europe, we performed an ecological study. Methods The European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database was used to study the country consumption of Brassica vegetables (broccoli, cauliflower, head cabbage (white, red and savoy cabbage), leafy brassica) and to compare them with spinach, cucumber, courgette, lettuce and tomato. The COVID-19 mortality per number of inhabitants was obtained from the Johns Hopkins Coronavirus Resource Center. EuroStat data were used for potential confounders at the country level including Gross Domestic Product (GDP) (2019), population density (2018), percentage of people over 64 years (2019), unemployment rate (2019) and percentage of obesity (2014, to avoid missing values). Mortality counts were analyzed with quasi-Poisson regression models to model the death rate while accounting for over-dispersion. Results Of all the variables considered, including confounders, only head cabbage and cucumber reached statistical significance with the COVID-19 death rate per country. For each g/day increase in the average national consumption of some of the vegetables (head cabbage and cucumber), the mortality risk for COVID-19 decreased by a factor of 11, down to 13.6 %. Lettuce consumption increased COVID-19 mortality. The adjustment did not change the point estimate and the results were still significant. Discussion The negative ecological association between COVID-19 mortality and the consumption of cabbage and cucumber supports the a priori hypothesis previously reported. The hypothesis needs to be tested in individual studies performed in countries where the consumption of vegetables is common.

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Association between consumption of fermented vegetables and COVID-19 mortality at a country level in Europe

10.1101/2020.07.06.20147025 ◽

2020 ◽

Cited By ~ 2

Author(s):

Susana C Fonseca ◽

Ioar Rivas ◽

Dora Romaguera ◽

Marcos Quijal ◽

Wienczyslawa Czarlewski ◽

...

Keyword(s):

Death Rate ◽

Missing Values ◽

Statistical Significance ◽

Fermented Milk ◽

Point Estimate ◽

Fermented Foods ◽

Country Level ◽

Ecological Association ◽

Fermented Vegetables ◽

Over Dispersion

AbstractBackgroundMany foods have an antioxidant activity and nutrition may mitigate COVID-19. Some of the countries with a low COVID-19 mortality are those with a relatively high consumption of traditional fermented foods. To test the potential role of fermented foods in COVID-19 mortality in Europe, we performed an ecological study.MethodsThe European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database was used to study the country consumption of fermented vegetables, pickled/marinated vegetables, fermented milk, yoghurt and fermented sour milk. We obtained the COVID-19 mortality per number of inhabitants from the Johns Hopkins Coronavirus Resource Center. EuroStat data were used for data on potential confounders at the country level including Gross Domestic Product (GDP) (2019), population density (2018), percentage of people older than 64 years (2019), unemployment rate (2019) and percentage obesity (2014, to avoid missing values). Mortality counts were analyzed with quasi-Poisson regression models - with log of population as an offset - to model the death rate while accounting for over-dispersion.ResultsOf all the variables considered, including confounders, only fermented vegetables reached statistical significance with the COVID-19 death rate per country. For each g/day increase in the average national consumption of fermented vegetables, the mortality risk for COVID-19 decreased by 35.4% (95% CI: 11.4%, 35.5%). Adjustment did not change the point estimate and results were still significant.DiscussionThe negative ecological association between COVID-19 mortality and consumption of fermented vegetables supports the a priory hypothesis previously reported. The hypothesis needs to be tested in individual studies performed in countries where the consumption of fermented vegetables is common.

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Nebulized morphine for analgesia in an emergency setting

Journal of Opioid Management ◽

10.5055/jom.2009.0003 ◽

2018 ◽

Vol 5 (1) ◽

pp. 23 ◽

Cited By ~ 4

Author(s):

Vincent Bounes, MD ◽

Jean Louis Ducassé, MD ◽

Annie Momo Bona, MD ◽

Florent Battefort, MD ◽

Charles-Henri Houze-Cerfon, MD ◽

...

Keyword(s):

Pain Relief ◽

Acute Pain ◽

Rating Scale ◽

Numerical Rating Scale ◽

Statistical Significance ◽

A Priori ◽

Primary Outcome Measure ◽

Point Estimate ◽

Emergency Setting ◽

Significant Difference

Objective: To evaluate the efficacy and safety of inhaled morphine delivered in patients experiencing severe acute pain in an emergency setting.Patients and Methods: Patients were eligible for inclusion if they were aged 18 years or older, with a severe acute pain defined by a numerical rating scale (NRS) score of 60/100 or higher. The intervention involved administering a single dose of 0.2 mg/kg morphine nebulized using a Misty-Neb nebulizer system. NRSs were recorded and were repeated at 1, 3, 5, and 10 minute after the end of inhalation (T10). The protocol-defined primary outcome measure was pain relief (defined by an NRS score of 30/100 or lower) at T10. Secondary outcomes included differences between pain scores at baseline and at T10 and incidence of adverse events.Results: A total of 28 patients were included in this study. No patient experienced pain relief 10 minutes after the end of inhalation, and no adverse effects were recorded. Respective initial and final median NRS scores were 80 (70-90) and 70 (60-80), p < 0.0001. Despite achieving statistical significance, the value of this point estimate is less than the 14 NRS difference that was defined a priori as representing a minimum clinically significant difference in pain severity.Conclusion: 0.2 mg/kg nebulized morphine is not effective in managing acute pain in an emergency setting. In spite of the potential advantages of the pulmonary route of administration, opioids should be intravenous prescribed at short fixed intervals to control severe acute pain in an emergency setting.

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What does and does not correlate with COVID-19 death rates

10.1101/2020.06.09.20126805 ◽

2020 ◽

Cited By ~ 2

Author(s):

Christopher R. Knittel ◽

Bora Ozaltun

Keyword(s):

Linear Regression ◽

Public Transportation ◽

Death Rate ◽

Negative Binomial ◽

Statistical Significance ◽

County Level ◽

Linear Regression Models ◽

Death Rates ◽

Socio Economic Variables ◽

Home Values

AbstractWe correlate county-level COVID-19 death rates with key variables using both linear regression and negative binomial mixed models, although we focus on linear regression models. We include four sets of variables: socio-economic variables, county-level health variables, modes of commuting, and climate and pollution patterns. Our analysis studies daily death rates from April 4, 2020 to May 27, 2020. We estimate correlation patterns both across states, as well as within states. For both models, we find higher shares of African American residents in the county are correlated with higher death rates. However, when we restrict ourselves to correlation patterns within a given state, the statistical significance of the correlation of death rates with the share of African Americans, while remaining positive, wanes. We find similar results for the share of elderly in the county. We find that higher amounts of commuting via public transportation, relative to telecommuting, is correlated with higher death rates. The correlation between driving into work, relative to telecommuting, and death rates is also positive across both models, but statistically significant only when we look across states and counties. We also find that a higher share of people not working, and thus not commuting either because they are elderly, children or unemployed, is correlated with higher death rates. Counties with higher home values, higher summer temperatures, and lower winter temperatures have higher death rates. Contrary to past work, we do not find a correlation between pollution and death rates. Also importantly, we do not find that death rates are correlated with obesity rates, ICU beds per capita, or poverty rates. Finally, our model that looks within states yields estimates of how a given state’s death rate compares to other states after controlling for the variables included in our model; this may be interpreted as a measure of how states are doing relative to others. We find that death rates in the Northeast are substantially higher compared to other states, even when we control for the four sets of variables above. Death rates are also statistically significantly higher in Michigan, Louisiana, Iowa, Indiana, and Colorado. California’s death rate is the lowest across all states.It is important to understand that this research, and other observational analyses like it, only identify correlations: these relationships are not necessarily causal. However, these correlations may help policy makers identify variables that may potentially be causally related to COVID-19 death rates and adopt appropriate policies after understanding the causal relationship.

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Do Common User Interface Design Patterns Improve Navigation?

Proceedings of the Human Factors and Ergonomics Society Annual Meeting ◽

10.1177/154193120204601416 ◽

2002 ◽

Vol 46 (14) ◽

pp. 1315-1319 ◽

Cited By ~ 10

Author(s):

Carlos A. Maldonado ◽

Marc L. Jlesnick

Keyword(s):

Web Sites ◽

Interface Design ◽

Design Patterns ◽

Performance Metrics ◽

Statistical Significance ◽

A Priori ◽

Improve Performance ◽

Subjective Preference ◽

On Line ◽

Quantitative Performance

The Internet has become a growing channel for consumer purchases. Half of all U.S. consumers made at least one purchase on-line in 2001. However, many consumers report frustration with the lack of support for navigation within many Internet retailers' web sites. Several design patterns have been suggested to overcome these limitations, such as expanded hierarchies and breadcrumbs. This study investigated the effects of these design patterns on users' quantitative performance and subjective preference for ecommerce web sites. Expanded hierarchies, a design pattern that is commonly used by many retail web sites, degraded all of the performance metrics assessed in the study. Users required more time, made more errors, used more clicks, and had lower satisfaction scores for sites designed with expanded hierarchies. The results for breadcrumbs suggest that they may improve performance. The inclusion of breadcrumbs reduced the number of clicks required by users to complete the tasks, but other performance metrics did not reach statistical significance. The results indicate that design patterns that are believed to improve performance a priori may not yield the results expected.

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Intrauterine Growth and Cerebral Palsy in Twins: A European Multicenter Study

Twin Research and Human Genetics ◽

10.1375/twin.9.3.460 ◽

2006 ◽

Vol 9 (3) ◽

pp. 460-466 ◽

Cited By ~ 14

Author(s):

Svetlana V. Glinianaia ◽

Stephen Jarvis ◽

Monica Topp ◽

Pascale Guillem ◽

Mary J. Platt ◽

...

Keyword(s):

Cerebral Palsy ◽

Statistical Significance ◽

A Priori ◽

Population Based ◽

Aggregated Data ◽

Growth Standards ◽

Intrauterine Growth ◽

Increased Risk ◽

Multi Center Study ◽

Rate Ratios

AbstractPopulation-based studies in twins have been of insufficient size to explore the relationship between risk of cerebral palsy and intrauterine growth. Earlier studies in singletons have suggested an optimum size at birth for minimum cerebral palsy risk between the 75th and 90th percentiles of weight for gestational age. We aggregated data from nine European cerebral palsy registers for 1976 to 1990. Using sex-specific fetal growth standards for twins, a z score of weight-for-gestation was derived for each of the 373 twin cases. The rates of cerebral palsy in each z-score band were compared to the rate in the a priori reference band of 0.67 to less than 1.28 (equivalent to the 75th to less than 90th percentiles). In twins born at 32 weeks' gestation or more (92% of all twins), cerebral palsy rates were higher for both light and heavy-forgestation babies compared to an optimum (i.e., minimum risk) in the reference band. However, the rate ratio for heavy babies (90th percentile or greater) did not reach conventional (95% confidence intervals [CI]) statistical significance (rate ratios = 1.76; 90% CI 1.02–3.03). For twins born at less than 32 weeks, the significantly higher risk for cerebral palsy was observed consistently in all z-score bands less than average compared to the reference band. This multi-center study demonstrates that for twins born at 32 weeks' gestation or more, an increased risk of cerebral palsy is associated with deviations from optimal intrauterine growth at about 1 standard deviation above mean weight, as was earlier reported for singletons. For twins born at less than 32 weeks' gestation, this pattern is only demonstrable for babies weighing below the optimum weight-for-gestation.

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Effect of Biological Maturation on Performance of the Athletic Ability Assessment in Australian Rules Football Players

International Journal of Sports Physiology and Performance ◽

10.1123/ijspp.2019-0683 ◽

2021 ◽

Vol 16 (1) ◽

pp. 28-36

Author(s):

Daniel K. Rogers ◽

Ian McKeown ◽

Gaynor Parfitt ◽

Darren Burgess ◽

Roger G. Eston

Keyword(s):

Statistical Significance ◽

A Priori ◽

Developmentally Appropriate ◽

Peak Height ◽

Height Velocity ◽

Football Players ◽

Peak Height Velocity ◽

Athletic Ability ◽

Biological Maturation ◽

Australian Rules Football

Purpose: To determine the effect of biological maturation on athletic movement competency as measured using the Athletic Ability Assessment-6. Methods: Fifty-two junior Australian Rules football players were split into 3 groups based on proximity to peak height velocity, while 46 senior players were split into 2 groups based on playing status. The subjects completed the Athletic Ability Assessment-6 (inclusive of the overhead squat, double lunge, single-leg Romanian dead lift, push-up, and chin-up). All subjects were filmed and retrospectively assessed by a single rater. A 1-way analysis of variance and effect-size statistics (Cohen d) with corresponding 90% confidence intervals were used to describe between-groups differences in the component movement scores. The statistical significance was set a priori at P < .05. Results: There were significant between-groups differences for all component movements (P < .05). Post hoc testing revealed that older, more mature subjects possessed greater competency in all movements except the overhead squat. The effect sizes revealed predominantly moderate to very large differences in competency between the senior and junior groups (range of d [90% confidence interval]: 0.70 [0.06 to 1.30] to 3.01 [2.18 to 3.72]), with unclear to moderate differences found when comparing the 3 junior groups (0.08 [−0.50 to 0.65] to 0.97 [0.22–1.61]). Conclusions: The findings suggest that biological maturation may be associated with changes in athletic movement competency in youth Australian Rules football players. Therefore, it is recommended that strength and conditioning coaches monitor maturity status when working with 12- to 15-y-old players. This can allow for a comparison of an individual’s athletic movement competency to maturity-based standards and help guide developmentally appropriate training programs.

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The Nested Structure of Cancer Symptoms

Methods of Information in Medicine ◽

10.3414/me09-01-0083 ◽

2010 ◽

Vol 49 (06) ◽

pp. 581-591 ◽

Cited By ~ 9

Author(s):

G. Bellala ◽

A. Ganesan ◽

R. Krishna ◽

P. Saxman ◽

C. Scott ◽

...

Keyword(s):

Cancer Patients ◽

Statistical Significance ◽

A Priori ◽

Symptom Assessment ◽

Cancer Symptoms ◽

Network Analyses ◽

Nested Structure ◽

Complex Relationships ◽

Patients Experience ◽

Symptom Overlap

Summary Objective: Although many cancer patients experience multiple concurrent symptoms, most studies have either focused on the analysis of single symptoms, or have used methods such as factor analysis that make a priori assumptions about how the data is structured. This article addresses both limitations by first visually exploring the data to identify patterns in the co-occurrence of multiple symptoms, and then using those insights to select and develop quantitative measures to analyze and validate the results. Methods: We used networks to visualize how 665 cancer patients reported 18 symptoms, and then quantitatively analyzed the observed patterns using degree of symptom overlap between patients, degree of symptom clustering using network modularity, clustering of symptoms based on agglomerative hierarchical clustering, and degree of nestedness of the symptoms based on the most frequently co-occurring symptoms for different sizes of symptom sets. These results were validated by assessing the statistical significance of the quantitative measures through comparison with random networks of the same size and distribution. Results: The cancer symptoms tended to co-occur in a nested structure, where there was a small set of symptoms that co-occurred in many patients, and progressively larger sets of symptoms that co-occurred among a few patients. Conclusions: These results suggest that cancer symptoms co-occur in a nested pattern as opposed to distinct clusters, thereby demonstrating the value of exploratory network analyses to reveal complex relationships between patients and symptoms. The research also extends methods for exploring symptom co-occurrence, including methods for quantifying the degree of symptom overlap and for examining nested co-occurrence in co-occur-rence data. Finally, the analysis also suggested implications for the design of systems that assist in symptom assessment and management. The main limitation of the study was that only one dataset was considered, and future studies should attempt to replicate the results in new data.

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O IMPACTO DA APRENDIZAGEM INTERPROFISSIONAL NA PNEUMONIA ASSOCIADA À VENTILAÇÃO: IMPLEMENTAÇÃO DE BUNDLES EM UMA UNIDADE DE CUIDADOS INTENSIVOS

Enfermagem em Foco ◽

10.21675/2357-707x.2019.v10.n4.2262 ◽

2020 ◽

Vol 10 (4) ◽

Author(s):

Ariele Pinto Coelho ◽

Raquel Aparecida Monteiro e Vieira ◽

Monica Aparecida Leite ◽

Thabata Coaglio Lucas

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Direct Observation ◽

Statistical Significance ◽

A Priori ◽

Minas Gerais ◽

Interprofessional Learning ◽

Head Positioning ◽

Quasi Experimental ◽

The Impact

Objetivo: verificar o impacto dos bundles e o aprendizado interprofissional na prevenção de pneumonia associada à ventilação mecânica de uma unidade de terapia intensiva (UTI). Método: estudo quasi-experimental realizado em uma UTI de um hospital público de Diamantina, Minas Gerais. Foram incluídos neste estudo 56 profissionais que prestavam assistência direta a pacientes em ventilação mecânica. A coleta de dados ocorreu em três fases: pré-intervenção, que consistiu em observação direta e entrevista; intervenção, na qual o treinamento foi realizado por meio de simulações clínicas; e pós-intervenção, na qual foi avaliado o impacto das estratégias implementadas por observação direta. As diferenças entre os grupos pré- e pós-intervenção foram avaliadas pelo teste de McNemar. Foi utilizado um nível alfa de 0,05 definido a priori, e a correção de Bonferroni determinou significância estatística para o caso de comparações múltiplas. Resultados: após a intervenção, houve aumento da adesão à pressão endotraqueal do cuff (8,10%), interrupção diária da sedação (16,67%), e aspiração subglótica (18,75%). As associações entre categoria profissional versus ausência de aspiração, posicionamento da cabeceira da cama, frequência de higiene bucal, e tipo de higiene das mãos após a intervenção foram significativas (p < 0,0083). Conclusões: ainda existe uma lacuna a ser detectada na implementação do bundle e o impacto positivo gerado pelo conhecimento interprofissional, principalmente porque não é imediato, mas a longo prazo, para obter o feedback desejado.Palavras-chave: Pneumonia Associada a Ventilação; Bundles de Assistência ao Paciente; Controle de infecção; Melhoria da qualidade; Vigilância em saúde pública; Unidades de Terapia Intensiva.THE IMPACT OF THE INTERPROFESSIONAL LEARNING IN VENTILATOR-ASSOCIATED PNEUMONIA: BUNDLES IMPLEMENTATION IN AN INTENSIVE CARE UNITObjective: to verify the impact of the bundles and the interprofessional learning for the prevention of mechanical ventilation-associated pneumonia of an intensive care unit (ICU). Method: This was a quasi-experimental study performed in an ICU of a public hospital in Diamantina, Minas Gerais. Were included in this study 56 professionals who provided direct assistance to patients in mechanical ventilation. The data collection took place in three phases: pre-intervention, which consisted of direct observation and interview; intervention, in which training was performed through clinical simulations; and post-intervention, in which the impact of the strategies implemented through direct observation, was evaluated. Differences between pre and post groups were assessed using McNemar’s test. An alpha level of 0.05 set a priori was used, and a Bonferroni correction determined statistical significance for the case of multiple comparisons. Results: After the intervention, there was increased adherence to endotracheal cuff pressure (8.10%), daily interruption of sedation (16.67%) and subglottic aspiration (18.75%). It was significant (p < 0,0083) in the associations between the professional category versus non-aspiration, bed head positioning, oral hygiene frequency and the type of hand hygiene after intervention. Conclusions: There is still a gap to be detected in the bundle implementation and the positive impact generated by the inter-professional knowledge, mainly because it is not immediate but in the long term to obtain the desired feedback.Keywords: Pneumonia, Ventilator-Associated; Patient Care Bundles; Infection Control; Quality Improvement; Public health surveillance; Intensive Care Units.EL IMPACTO DEL APRENDIZAJE INTERPROFESIONAL EN LA NEUMONÍA ASOCIADA A VENTILADORES: APLICACIÓN DE PAQUETES EN UNA UNIDAD DE ATENCIÓN INTENSIVAObjetivo: verificar el impacto de los bundles y el aprendizaje interprofesional para la prevención de la neumonía asociada a la ventilación mecánica de una unidad de cuidados intensivos (UCI). Método: Este fue un estudio cuasi experimental realizado en una UCI de un hospital público en Diamantina, Minas Gerais. Se incluyeron en este estudio 56 profesionales que prestaron asistencia directa a los pacientes en ventilación mecánica. La recolección de datos se realizó en tres fases: pre-intervención, que consistió en observación directa y entrevista; intervención, en la cual se realizó entrenamiento por medio de simulaciones clínicas; y post-intervención, en que se evaluó el impacto de las estrategias de observación directa. Las diferencias entre los grupos pre y post se evaluaron mediante la prueba de McNemar. Se usó un nivel alfa de 0,05 a priori, y se usó una corrección de Bonferroni para determinar la significación estadística en el caso de comparaciones múltiples. Resultados: Después de la intervención, hubo aumento de la adhesión al monitoreo de la presión del cuff endotraqueal (8,10%), interrupción diaria de la sedación (16,67%) y aspiración subglótica (18,75%). Fue significativa (p < 0,0083) las asociaciones entre la categoría profesional frente a la no aspiración, la posición de la cabecera de la cama, la frecuencia de higiene oral y el tipo de higiene de las manos después de la intervención. Conclusiones: Aún existe una laguna a ser detectada en la implantación del bundle y el impacto positivo generado por el conocimiento interprofesional, principalmente por no ser inmediato, pero a largo plazo, para obtener el feedback deseado.Descriptores: Neumonía Asociada al Ventilador; Paquetes de Atención al Paciente; Control de Infecciones; Mejoramiento de la Calidad; Vigilancia en Salud Pública; Unidades de Cuidados Intensivos

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Critical country-level determinants of death rate during Covid-19 pandemic

International Journal of Disaster Risk Reduction ◽

10.1016/j.ijdrr.2021.102507 ◽

2021 ◽

pp. 102507

Author(s):

Arman Canatay ◽

Tochukwu J. Emegwa ◽

Md Farid Hossain Talukder

Keyword(s):

Death Rate ◽

Country Level

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Country-level Determinants of the Severity of the First Global Wave of the COVID-19 Pandemic: An Ecological Study

10.1101/2020.05.13.20100677 ◽

2020 ◽

Cited By ~ 1

Author(s):

Tiberiu A Pana ◽

Sohinee Bhattacharya ◽

David T Gamble ◽

Zahra Pasdar ◽

Weronika A Szlachetka ◽

...

Keyword(s):

Mortality Rate ◽

Study Design ◽

Vaccination Coverage ◽

Death Rate ◽

Ecological Study ◽

The Philippines ◽

International Travel ◽

Bcg Vaccination ◽

Country Level ◽

The Mean

ABSTRACTObjectiveWe aimed to identify the country-level determinants of the severity of the first wave of the COVID-19 pandemic.DesignAn ecological study design of publicly available data was employed. Countries reporting >25 COVID-related deaths until 08/06/2020 were included. The outcome was log mean mortality rate from COVID-19, an estimate of the country-level daily increase in reported deaths during the ascending phase of the epidemic curve. Potential determinants assessed were most recently published demographic parameters (population and population density, percentage population living in urban areas, median age, average body mass index, smoking prevalence), Economic parameters (Gross Domestic Product per capita); environmental parameters: pollution levels, mean temperature (January-May)), co-morbidities (prevalence of diabetes, hypertension and cancer), health system parameters (WHO Health Index and hospital beds per 10,000 population); international arrivals, the stringency index, as a measure of country-level response to COVID-19, BCG vaccination coverage, UV radiation exposure and testing capacity. Multivariable linear regression was used to analyse the data.Primary OutcomeCountry-level mean mortality rate: the mean slope of the COVID-19 mortality curve during its ascending phase.ParticipantsThirty-seven countries were included: Algeria, Argentina, Austria, Belgium, Brazil, Canada, Chile, Colombia, the Dominican Republic, Ecuador, Egypt, Finland, France, Germany, Hungary, India, Indonesia, Ireland, Italy, Japan, Mexico, the Netherlands, Peru, the Philippines, Poland, Portugal, Romania, the Russian Federation, Saudi Arabia, South Africa, Spain, Sweden, Switzerland, Turkey, Ukraine, the United Kingdom and the United States.ResultsOf all country-level predictors included in the multivariable model, total number of international arrivals (beta 0.033 (95% Confidence Interval 0.012,0.054)) and BCG vaccination coverage (−0.018 (−0.034,-0.002)), were significantly associated with the mean death rate.ConclusionsInternational travel was directly associated with the mortality slope and thus potentially the spread of COVID-19. Very early restrictions on international travel should be considered to control COVID outbreak and prevent related deaths.ARTICLE SUMMARYStrengths and limitationsA comparable and relevant outcome variable quantifying country-level increases in the COVID-19 death rate was derived which is largely independent of different testing policies adopted by each countryOur multivariable regression models accounted for public health and economic measures which were adopted by each country in response to the COVID-19 pandemic by adjusting for the Stringency IndexThe main limitation of the study stems from the ecological study design which does not allow for conclusions to be drawn for individual COVID-19 patientsOnly countries that had reported at least 25 daily deaths over the analysed period were included, which reduced our sample and consequently the power.

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