Safety and Behavior of Implantable Electronic Devices During Cremation.

BACKGROUND: The current standard of practice for cremating patients with cardiac implantable electronic devices (CIEDs) is surgical explantation prior to cremation to mitigate the risk of device explosion. This surgery may conflict with patient or family beliefs, whereas cremation of CIEDs may create occupational hazards. OBJECTIVES: This study sought to establish an ex-vivo model for screening CIED behavior during cremation. METHODS: Seven CIED underwent testing including projectile/sound testing, impact testing, and gas analysis. In the projectile test, devices were heated until thermal failure (explosion) and filmed with a high-speed camera and microphone. For impact testing, brick structures were built to assess damage after explosion. Gas chromatography-mass spectrometry identified released gases. Findings were compared with occupational health standards, where available. RESULTS: The implantable loop recorder and leadless pacemaker produced minimal kinetic energy and impact risk with thermal failure. The remaining devices demonstrated explosive disintegration at thermal temperatures <500°C. The pacemakers and implantable cardiac defibrillators produced sound levels >120 dB and resulted in damage to brick structures. Small quantities of benzene and hydrogren fluoride were produced but at quantities within acceptable occupational exposure limits in a cremation chamber. CONCLUSIONS: All tested CIEDs experienced explosion at temperatures below crematorium standards. The smallest devices produced minimal risk of damage or injury suggesting they may safely remain in situ during cremation, while the larger devices produced more kinetic energy, testing chamber damage, and louder explosions suggesting potential risk with cremation. Cadaveric testing in full-sized cremation chambers is required to determine real-world risk.

Daratumumab, cyclophosphamide, bortezomib, and dexamethasone for transplant-ineligible myeloma: AMaRC 03-16.

ABSTRACT: In newly diagnosed transplant-ineligible patients with myeloma, daratumumab has improved outcomes when added to the standard-of-care regimens. In a randomized trial, we tested whether similar improvements would be observed when daratumumab was added to the bortezomib, cyclophosphamide, and dexamethasone (VCD) regimen. Transplant-ineligible patients with untreated myeloma were randomized to receive VCD or VCD plus daratumumab (VCDD). A total of 121 patients were randomized: 57 in the VCD arm and 64 in the VCDD arm. Baseline characteristics were balanced between the 2 arms. The median progression-free survival (PFS) was 16.8 months (95% confidence interval [CI], 15.3-21.7) and 25.8 months (95% CI, 19.9-33.5) in the VCD and VCDD arms, respectively (hazard ratio, 0.67; log-rank test P = .066). In a preplanned analysis, it was demonstrated that the daratumumab-containing arm showed a significant improvement in PFS from 18 months onward, based on estimates at fixed time points after randomization. The proportions of patients who were progression-free at the following time points were: 18 months, 48% vs 68% (P = .0002); 24 months, 36% vs 52% (P = .0001); and 30 months, 27% vs 41% (P < .0001) in the VCD and VCDD arms, respectively. The best overall response and very good partial response rate were significantly higher in the daratumumab arm compared with the VCD and VCDD arms, respectively (65% vs 86%, P = .007; and 28% vs 52%, P = .009). Seventy-two percent of the VCDD patients completed the 9 cycles of induction therapy with no grade 3 or 4 peripheral neuropathy adverse events. This study supports VCDD as an option for the initial treatment of transplant-ineligible patients with myeloma. This trial was registered at the Australian New Zealand Clinical Trials Registry (ACTRN12617000202369).

Teleophthalmology provides earlier eye care access for patients with newly-diagnosed diabetes.

Purpose: Timely diagnosis of diabetic retinopathy is important in preventing vision loss. This study aims to determine if remote retinal imaging enables earlier eye care access among newly-diagnosed diabetic patients. Design: Retrospective cohort study. Methods: Using the OptumLabs® Data Warehouse - a longitudinal, real-world dataset containing deidentified administrative claims and electronic health record (EHR) data, we included 968 846 adults with newly diagnosed type 2 diabetes and at least 1 year of continuous enrollment. We compared time from initial diabetes diagnosis to first eye exam by remote screening or in-person eye exam. Results: We found that at year 1 after diagnosis, 5459 (0.56%) patients underwent remote imaging and 208 023 (21.5%) underwent in-person exam. The mean (95% CI) time to eye exam was 3.48 (3.38-3.58) months for remote imaging and 4.22 (4.20-4.23) months for in-person visits (p < 0.0001). Interestingly, 27.5% of remote screenings were performed on the same day of diabetes diagnosis. Excluding same-day encounters, mean time to eye exam was 4.80 (4.68-4.91) months for remote imaging and 4.85 (4.83-4.86) months for in-person eyecare (p = 0.4). Conclusions: Thus, teleophthalmology may enable earlier eye care access among patients with newly-diagnosed diabetes, primarily with same-day screenings. Increased adoption of teleretinal screening may enable earlier detection of diabetic retinopathy and prevent vision loss.

An intronic RNA element modulates Factor VIII exon-16 splicing.

Pathogenic variants in the human Factor VIII (F8) gene cause Hemophilia A (HA). Here, we investigated the impact of 97 HA-causing single-nucleotide variants on the splicing of 11 exons from F8. For the majority of F8 exons, splicing was insensitive to the presence of HA-causing variants. However, splicing of several exons, including exon-16, was impacted by variants predicted to alter exonic splicing regulatory sequences. Using exon-16 as a model, we investigated the structure-function relationship of HA-causing variants on splicing. Intriguingly, RNA chemical probing analyses revealed a three-way junction structure at the 3'-end of intron-15 (TWJ-3-15) capable of sequestering the polypyrimidine tract. We discovered antisense oligonucleotides (ASOs) targeting TWJ-3-15 partially rescue splicing-deficient exon-16 variants by increasing accessibility of the polypyrimidine tract. The apical stem loop region of TWJ-3-15 also contains two hnRNPA1-dependent intronic splicing silencers (ISSs). ASOs blocking these ISSs also partially rescued splicing. When used in combination, ASOs targeting both the ISSs and the region sequestering the polypyrimidine tract, fully rescue pre-mRNA splicing of multiple HA-linked variants of exon-16. Together, our data reveal a putative RNA structure that sensitizes F8 exon-16 to aberrant splicing.

Complex motion of steerable vesicular robots filled with active colloidal rods.

While the collective motion of active particles has been studied extensively, effective strategies to navigate particle swarms without external guidance remain elusive. We introduce a method to control the trajectories of two-dimensional swarms of active rod-like particles by confining the particles to rigid bounding membranes (vesicles) with non-uniform curvature. We show that the propelling agents spontaneously form clusters at the membrane wall and collectively propel the vesicle, turning it into an active superstructure. To further guide the motion of the superstructure, we add discontinuous features to the rigid membrane boundary in the form of a kinked tip, which acts as a steering component to direct the motion of the vesicle. We report that the system's geometrical and material properties, such as the aspect ratio and Péclet number of the active rods as well as the kink angle and flexibility of the membrane, determine the stacking of active particles close to the kinked confinement and induce a diverse set of dynamical behaviors of the superstructure, including linear and circular motion both in the direction of, and opposite to, the kink. From a systematic study of these various behaviors, we design vesicles with switchable and reversible locomotions by tuning the confinement parameters. The observed phenomena suggest a promising mechanism for particle transportation and could be used as a basic element to navigate active matter through complex and tortuous environments.

Rescue of blood coagulation Factor VIII exon-16 mis-splicing by antisense oligonucleotides.

The human Factor VIII ( F8 ) protein is essential for the blood coagulation cascade and specific F8 mutations cause the rare bleeding disorder Hemophilia A (HA). Here, we investigated the impact of HA-causing single-nucleotide mutations on F8 pre-mRNA splicing. We found that 14/97 (∼14.4%) coding sequence mutations tested in our study induced exon skipping. Splicing patterns of 4/11 (∼36.4%) F8 exons tested were especially sensitive to the presence of common disease-causing mutations. RNA-chemical probing analyses revealed a three-way junction structure at the 3' end of intron 15 (TWJ-3-15). TWJ-3-15 sequesters the polypyrimidine tract, a key determinant of 3' splice site strength. Using exon-16 of the F8 gene as a model, we designed specific antisense oligonucleotides (ASOs) that target TWJ-3-15 and identified three that promote the splicing of F8 exon-16. Interaction of TWJ-3-15 with ASOs increases accessibility of the polypyrimidine tract and inhibits the binding of hnRNPA1-dependent splicing silencing factors. Moreover, ASOs targeting TWJ-3-15 rescue diverse splicing-sensitive HA-causing mutations, most of which are distal to the 3' splice site being impacted. The TWJ-3-15 structure and its effect on mRNA splicing provide a model for HA etiology in patients harboring specific F8 mutations and provide a framework for precision RNA-based HA therapies.

Comparative assessment of the effects of DREADDs and endogenously expressed GPCRs in hippocampal astrocytes on synaptic activity and memory.

Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) have proven themselves as one of the key in vivo techniques of modern neuroscience, allowing for unprecedented access to cellular manipulations in living animals. With respect to astrocyte research, DREADDs have become a popular method to examine the functional aspects of astrocyte activity, particularly G-protein coupled receptor (GPCR)-mediated intracellular calcium (Ca2+) and cyclic adenosine monophosphate (cAMP) dynamics. With this method it has become possible to directly link the physiological aspects of astrocytic function to cognitive processes such as memory. As a result, a multitude of studies have explored the impact of DREADD activation in astrocytes on synaptic activity and memory. However, the emergence of varying results prompts us to reconsider the degree to which DREADDs expressed in astrocytes accurately mimic endogenous GPCR activity. Here we compare the major downstream signaling mechanisms, synaptic, and behavioral effects of stimulating Gq-, Gs-, and Gi-DREADDs in hippocampal astrocytes of adult mice to those of endogenously expressed GPCRs.

Teleophthalmology Using Remote Retinal Imaging During the COVID-19 Pandemic.

Introduction: Lower insurance reimbursements have limited the financial sustainability of remote eye screening programs. Greater utilization and insurance coverage for teleophthalmology screening during the coronavirus disease 2019 (COVID-19) pandemic in 2020 may enhance awareness and expand remote retinal imaging services. This retrospective cross-sectional study evaluates utilization and insurance coverage for remote retinal imaging in the United States in 2020. Methods: We analyzed teleretinal imaging utilization and insurance payments from January 1 to December 31, 2020, using the Optum Labs Data Warehouse, a comprehensive national database of deidentified administrative claims for commercial and Medicare Advantage enrollees in the United States. We evaluated frequency of claims and insurance payment for services using the Current Procedural Terminology codes 92227 and 92228 for remote eye imaging by any provider, and 92250 for fundus photography by non-eye care providers. Results: The use of remote retinal imaging in the United States declined rapidly during the initial COVID-19 lockdown from 3,627 claims in February 2020 to 1,414 claims in April 2020, but returned to 3,133 claims by December 2020, similar to mean prepandemic levels in 2019 (2,841 ± 174.8 claims). The proportion of insurance payments for remote imaging increased temporarily from 47.4% in February to 56.7% in April, and then returned to 45.9% in December of 2020. Discussion: Utilization of remote retinal imaging declined steeply, while the insurance coverage increased during the initial COVID-19 lockdown in 2020, but returned to prepandemic levels by end of the year. Changes in utilization and relaxed restrictions on insurance reimbursements for teleophthalmology during the COVID-19 pandemic were not sustained.

Long-Term Retinal Vascular Changes in Age-Related Macular Degeneration Measured Using Optical Coherence Tomography Angiography.

BACKGROUND AND OBJECTIVE: To determine if age-related macular degeneration (AMD) status affects longitudinal retinal vessel changes. PATIENTS AND METHODS: Retrospective, cohort study of 125 eyes (75 patients) with AMD, following retinal vessel density (VD) and foveal avascular zone (FAZ) measurements using optical coherence tomography angiography (OCT-A) over 24 months. RESULTS: FAZ area (P < .001) and perimeter (P < .001) increased over 2 years, with no difference between nonexudative and exudative AMD (P = .134-.976). Eyes with geographic atrophy (GA) showed greater progressive VD loss (P = .023-.038), and greater increase in FAZ area (P = .044) and perimeter (P = .040) compared to eyes without GA. Neither baseline nor 2-year change in vascular parameters were associated with choroidal neovascularization (CNV) or GA incidence in nonexudative AMD, or anti-VEGF injection frequency in exudative AMD (P = .070-.952). CONCLUSION: AMD eyes with GA undergo more rapid loss of retinal vessel density and FAZ enlargement over 2 years, suggesting a relationship between the retinal vasculature and AMD pathophysiology. [Ophthalmic Surg Lasers Imaging Retina 2022;53:529-536.].

A Bayesian modelling framework to quantify multiple sources of spatial variation for disease mapping.

Spatial connectivity is an important consideration when modelling infectious disease data across a geographical region. Connectivity can arise for many reasons, including shared characteristics between regions and human or vector movement. Bayesian hierarchical models include structured random effects to account for spatial connectivity. However, conventional approaches require the spatial structure to be fully defined prior to model fitting. By applying penalized smoothing splines to coordinates, we create two-dimensional smooth surfaces describing the spatial structure of the data while making minimal assumptions about the structure. The result is a non-stationary surface which is setting specific. These surfaces can be incorporated into a hierarchical modelling framework and interpreted similarly to traditional random effects. Through simulation studies, we show that the splines can be applied to any symmetric continuous connectivity measure, including measures of human movement, and that the models can be extended to explore multiple sources of spatial structure in the data. Using Bayesian inference and simulation, the relative contribution of each spatial structure can be computed and used to generate hypotheses about the drivers of disease. These models were found to perform at least as well as existing modelling frameworks, while allowing for future extensions and multiple sources of spatial connectivity.

Pediatric paranasal sinuses-Development, growth, pathology, & functional endoscopic sinus surgery.

The paranasal sinuses (maxillary, frontal, ethmoid, and sphenoid sinuses) are complex anatomical structures. The development and growth of these have been investigated utilizing a number of different methods ranging from cadaveric analysis to modern cross sectional imaging with 3D modeling. An understanding of normal pediatric paranasal sinus embryology and development enables us to better determine when pathology may be affecting the normal developmental process. Cystic fibrosis, chronic sinusitis, deviated nasal septum and cleft lip and palate are some of the conditions which have been shown to effect paranasal sinus development to varying degrees. Functional endoscopic sinus surgery (FESS) is becoming increasingly common and an understanding of sinus anatomy together with when periods of rapid growth occur during childhood is important clinically. Although concerns have been raised regarding the impact of FESS on facial growth, there is limited evidence of this in regards to either changes in anthropomorphic measurements or clinical assessments of symmetry post operatively.

Integrative review of singing and music interventions for family carers of people living with dementia.

The majority of people living with dementia are cared for by their families. Family carers play a vital role in upholding the formal care system. Caring for a family member with dementia can be fulfilling. However, this role can have a considerable negative impact on family carers' mental and physical health and quality of life. Several empirical research studies have recently been conducted that explore the potential benefits of music interventions for family carers of people living with dementia. Singing has been the primary musical medium employed. This article presents the first review of this literature to date. It investigates the impact of music interventions on the health and well-being of family carers of people living with dementia, and how they experience and perceive these interventions. Whittemore and Knafl's five-stage integrative review framework was utilized: (i) problem identification; (ii) literature search; (iii) data evaluation; (iv) data analysis and synthesis; and (v) presentation of the findings. A total of 33 studies met the inclusion criteria. Analysis and synthesis resulted in three overarching themes: impact on family carers, carer perceptions of music interventions and null quantitative findings in small studies. The review found that singing and music interventions may improve family carers' social and emotional well-being, enhance their ability to cope and care and ameliorate the caring relationship, contributing to experiences of flourishing. However, it highlighted that this area is under-researched and pointed to the need for larger, more rigorous studies.

Ageing causes an aortic contractile dysfunction phenotype by targeting the expression of members of the extracellular signal-regulated kinase pathway.

The extracellular signal-regulated kinase (ERK) pathway is a well-known regulator of vascular smooth muscle cell proliferation, but it also serves as a regulator of caldesmon, which negatively regulates vascular contractility. This study examined whether aortic contractile function requires ERK activation and if this activation is regulated by ageing. Biomechanical experiments revealed that contractile responses to the alpha1-adrenergic agonist phenylephrine are attenuated specifically in aged mice, which is associated with downregulation of ERK phosphorylation. ERK inhibition attenuates phenylephrine-induced contractility, indicating that the contractile tone is at least partially ERK-dependent. To explore the mechanisms of this age-related downregulation of ERK phosphorylation, we transfected microRNAs, miR-34a and miR-137 we have previously shown to increase with ageing and demonstrated that in A7r5 cells, both miRs downregulate the expression of Src and paxillin, known regulators of ERK signalling, as well as ERK phosphorylation. Further studies in aortic tissues transfected with miRs show that miR-34a but not miR-137 has a negative effect on mRNA levels of Src and paxillin. Furthermore, ERK phosphorylation is decreased in aortic tissue treated with the Src inhibitor PP2. Increases in miR-34a and miR-137 with ageing downregulate the expression of Src and paxillin, leading to impaired ERK signalling and aortic contractile dysfunction.

Interaction between xylanase and a proton pump inhibitor on broiler chicken performance and gut function.

Three hundred thirty-six Ross 308 male broiler chicks were used in a 21-d study to explore performance and gut function when treated with a proton pump inhibitor (PPI; 0 or 89 mg/kg) in a 2 × 2 factorial arrangement with a xylanase (Xyl; 0 or 0.1 g/kg) to determine if the beneficial activity of arabinoxylan (AX) depolymerisation, through arabinoxylo-oligosaccharides (AXOS) production, starts in the upper gastrointestinal tract. Treatment with the PPI started from d 14, and by d 21 animal performance had deteriorated (P < 0.001). An interaction was observed between PPI and Xyl for feed conversion ratio (FCR) (P < 0.05), whereby the combination reduced the negative effect of PPI on FCR. Application of PPI raised digesta pH in the gizzard and caecum (P < 0.05), increased protein concentrations in the lower gut (P < 0.05) and reduced intake of digestible nutrients (P < 0.05). Caecal concentrations of indole, p-cresol, ammonia and the ratio of total volatile fatty acid (VFA) to butyric acid were increased with PPI (P < 0.05), indicating enhanced protein fermentation. Xylanase activity in the digesta were greatest in the caeca, especially when Xyl was supplemented (P < 0.001). The concentration of total soluble AX was greater in the gizzard and ileal digesta with Xyl supplementation (P < 0.05), supporting the depolymerisation action of xylanase even under acidic conditions. These data suggest xylanase may function in the gizzard even though pH is not optimal for activity and emphasises the importance of chlorohydric acid secretions in ensuring overall optimum gut function. AX depolymerisation benefits animal performance although it is still unknown how the AXOS produced with xylanase supplementation in the upper gastrointestinal tract influence the microbial populations and overall gut functionality.

SARS-CoV-2 vaccine responses following CD20-depletion treatment in patients with haematological and rheumatological disease: a West Midlands Research Consortium study.

B-cell-depleting agents are among the most commonly used drugs to treat haemato-oncological and autoimmune diseases. They rapidly induce a state of peripheral B-cell aplasia with the potential to interfere with nascent vaccine responses, particularly to novel antigens. We have examined the relationship between B-cell reconstitution and SARS-CoV-2 vaccine responses in two cohorts of patients previously exposed to B-cell-depleting agents: a cohort of patients treated for haematological B-cell malignancy and another treated for rheumatological disease. B-cell depletion severely impairs vaccine responsiveness in the first 6 months after administration: SARS-CoV-2 antibody seroprevalence was 42.2% and 33.3% in the haemato-oncological patients and rheumatology patients, respectively and 22.7% in patients vaccinated while actively receiving anti-lymphoma chemotherapy. After the first 6 months, vaccine responsiveness significantly improved during early B-cell reconstitution; however, the kinetics of reconstitution was significantly faster in haemato-oncology patients. The AstraZeneca ChAdOx1 nCoV-19 vaccine and the Pfizer BioNTech 162b vaccine induced equivalent vaccine responses; however, shorter intervals between vaccine doses (<1 m) improved the magnitude of the antibody response in haeamto-oncology patients. In a subgroup of haemato-oncology patients, with historic exposure to B-cell-depleting agents (>36 m previously), vaccine non-responsiveness was independent of peripheral B-cell reconstitution. The findings have important implications for primary vaccination and booster vaccination strategies in individuals clinically vulnerable to SARS-CoV-2.

Impaired neutralisation of SARS-CoV-2 delta variant in vaccinated patients with B cell chronic lymphocytic leukaemia.

BACKGROUND: Immune suppression is a clinical feature of chronic lymphocytic leukaemia (CLL), and patients show increased vulnerability to SARS-CoV-2 infection and suboptimal antibody responses. METHOD: We studied antibody responses in 500 patients following dual COVID-19 vaccination to assess the magnitude, correlates of response, stability and functional activity of the spike-specific antibody response with two different vaccine platforms. RESULTS: Spike-specific seroconversion post-vaccine was seen in 67% of patients compared to 100% of age-matched controls. Amongst responders, titres were 3.7 times lower than the control group. Antibody responses showed a 33% fall over the next 4 months. The use of an mRNA (n = 204) or adenovirus-based (n = 296) vaccine platform did not impact on antibody response. Male gender, BTKi therapy, prophylactic antibiotics use and low serum IgA/IgM were predictive of failure to respond. Antibody responses after CD20-targeted immunotherapy recovered 12 months post treatment. Post-vaccine sera from CLL patients with Spike-specific antibody response showed markedly reduced neutralisation of the SARS-CoV-2 delta variant compared to healthy controls. Patients with previous natural SARS-CoV-2 infection showed equivalent antibody levels and function as healthy donors after vaccination. CONCLUSIONS: These findings demonstrate impaired antibody responses following dual COVID-19 vaccination in patients with CLL and further define patient risk groups. Furthermore, humoural protection against the globally dominant delta variant is markedly impaired in CLL patients and indicates the need for further optimisation of immune protection in this patient cohort.

Ultrahigh-b diffusion-weighted imaging for quantitative evaluation of myelination in shiverer mouse spinal cord.

PURPOSE: To perform a quantitative evaluation of myelination on WT and myelin-deficient (shiverer) mouse spinal cords using ultrahigh-b diffusion-weighted imaging (UHb-DWI). METHODS: UHb-DWI of ex vivo on spinal cord specimens of two shiverer (C3HeB/FeJ-shiverer, homozygous genotype for MbPshi ) and six WT (Black Six, C3HeB/FeJ) mice were acquired using 3D multishot diffusion-weighted stimulated-echo EPI, a homemade RF coil, and a small-bore 7T MRI system. Imaging was performed in transaxial plane with 75 × 75 µm2 in-plane resolution, 1-mm-slice thickness, and radial DWI using bmax = 42,890 s/mm2 . Histological evaluation was performed on upper thoracic sections using optical and transmission electron microscopy. Numerical Monte Carlo simulations (MCSs) of water diffusion were performed to facilitate interpretation of UHb-DWI signal-b curves. RESULTS: The white matter ultrahigh-b radial DWI (UHb-rDWI) signal-b curves of WT mouse cords behaved biexponentially with high-b diffusion coefficient DH < 0.020 × 10-3 mm2 /s. However, as expected with less myelination, the signal-b of shiverer mouse cords behaved monoexponentially with significantly greater DH = 0.162 × 10-3 , 0.142 × 10-3 , and 0.164 × 10-3 mm2 /s at anterodorsal, posterodorsal, and lateral columns, respectively. The axial DWI signals of all mouse cords behaved monoexponentially with D = (0.718-1.124) × 10-3 mm2 /s. MCS suggests that these elevated DH are mainly induced by increased water exchange at the myelin sheath. Microscopic results were consistent with the UHb-rDWI findings. CONCLUSION: UHb-DWI provides quantitative differences in myelination of spinal cords from myelin-deficit shiverer and WT mice. UHb-DWI may become a powerful tool to evaluate myelination in demyelinating disease models that may translate to human diseases, including multiple sclerosis.

Promoting well-being among people with early-stage dementia and their family carers through community-based group singing: a phenomenological study.

BACKGROUND: Dementia can negatively impact the well-being of people living with dementia and their family carers. Research suggests that music psychosocial interventions are effective, safe alternatives to pharmacological interventions for the promotion of well-being . However, evidence is limited, and research gaps remain. This study explores how a community-based group singing intervention impacts the well-being of people with early-stage dementia and their family carers. METHODS: A phenomenological methodological approach was adopted. Participants engaged in a six-week group singing intervention facilitated by a music therapist in a community arts centre. Semi-structured interviews were conducted (n = 7). RESULTS: Interpretative Phenomenological Analysis revealed four superordinate themes: (1) Social Connection; (2) Happiness and Rejuvenation; (3) Reconnection with the Self; and (4) Supporting the Carer-Cared-for Relationship. CONCLUSIONS: Evidence of multidimensional enhancement of well-being, absence of adverse effects, and accessibility of this musical medium support the increased provision of community-based singing groups for these populations.

The impact of climate suitability, urbanisation, and connectivity on the expansion of dengue in 21st century Brazil.

Dengue is hyperendemic in Brazil, with outbreaks affecting all regions. Previous studies identified geographical barriers to dengue transmission in Brazil, beyond which certain areas, such as South Brazil and the Amazon rainforest, were relatively protected from outbreaks. Recent data shows these barriers are being eroded. In this study, we explore the drivers of this expansion and identify the current limits to the dengue transmission zone. We used a spatio-temporal additive model to explore the associations between dengue outbreaks and temperature suitability, urbanisation, and connectivity to the Brazilian urban network. The model was applied to a binary outbreak indicator, assuming the official threshold value of 300 cases per 100,000 residents, for Brazil's municipalities between 2001 and 2020. We found a nonlinear relationship between higher levels of connectivity to the Brazilian urban network and the odds of an outbreak, with lower odds in metropoles compared to regional capitals. The number of months per year with suitable temperature conditions for Aedes mosquitoes was positively associated with the dengue outbreak occurrence. Temperature suitability explained most interannual and spatial variation in South Brazil, confirming this geographical barrier is influenced by lower seasonal temperatures. Municipalities that had experienced an outbreak previously had double the odds of subsequent outbreaks. We identified geographical barriers to dengue transmission in South Brazil, western Amazon, and along the northern coast of Brazil. Although a southern barrier still exists, it has shifted south, and the Amazon no longer has a clear boundary. Few areas of Brazil remain protected from dengue outbreaks. Communities living on the edge of previous barriers are particularly susceptible to future outbreaks as they lack immunity. Control strategies should target regions at risk of future outbreaks as well as those currently within the dengue transmission zone.