Ecotoxicological assessment of UV filters benzophenone-3 and TiO2 nanoparticles, isolated and in a mixture, in developing zebrafish (Danio rerio).

The increasing use of UV filters, such as benzophenone-3 (BP-3) and titanium dioxide nanoparticles (TiO2 NPs), has raised concerns regarding their ecotoxicological effects on the aquatic environment. The aim of the present study was to examine the embryo-larval toxicity attributed to BP-3 or TiO2 NPs, either alone or in a mixture, utilizing zebrafish (Danio rerio) as a model after exposure to environmentally relevant concentrations of these compounds. Zebrafish embryos were exposed to BP-3 (10, 100, or 1000 ng/L) or TiO2 NPs (1000 ng/L) alone or in a mixture (BP-3 10, 100, or 1000 ng/L plus 1000 ng/L of TiO2 NPs) under static conditions for 144 hr. After exposure, BP-3 levels were determined by high-performance liquid chromatography (HPLC). BP-3 levels increased in the presence of TiO2 NPs, indicating that the BP-3 degradation decreased in the presence of the NPs. In addition, in the presence of zebrafish, BP-3 levels in water decreased, indicating that zebrafish embryos and larvae might absorb BP-3. Data demonstrated that, in general, environmentally relevant concentrations of BP-3 and TiO2 NPs, either alone or in a mixture, did not significantly induce changes in heart and spontaneous contractions frequencies, levels of reactive oxygen species (ROS), morphological and morphometric parameters as well as mortality rates during 144 hr exposure. However, the groups exposed to TiO2 NPs alone and in a mixture with BP-3 at 10 ng/L exhibited an earlier significant hatching rate than the controls. Altogether, the data indicates that a potential ecotoxicological impact on the aquatic environment exists.

The Impact of Time, Region, and Income Level on Stillbirth and Neonatal Mortality in Brazil, 2000-2019.

OBJECTIVE: To describe trends in perinatal loss across Brazil, a country that transitioned in 2006 from a lower-middle income to an upper-middle income country, from 2000 to 2019 and analyze the effect of municipal wealth status on perinatal outcomes. STUDY DESIGN: We conducted an ecological cohort study, based on publicly available data from the Brazilian Ministry of Health's data repository on live births and deaths. The Atlas of Human Development in Brazil was used to associate each region with a World Bank income classification. RESULTS: The national neonatal mortality rate (NMR) for infants born at ≥22 weeks of gestation decreased from 21.2 in 2000 to 12.4 in 2019. The stillbirth rate (SBR) decreased from 12.0 to 10.2 during this period. For infants born between 22 and 27 weeks of gestation, worsening perinatal outcomes were seen after 2012. In 2019, the median rates of neonatal mortality and stillbirth were both 4 points higher in lower- to middle-income municipalities compared with high-income municipalities (P < .01). CONCLUSION: Brazil has made significant progress in neonatal mortality and stillbirth from 2000 to 2019, yet inequity in perinatal outcomes remains and is correlated with municipal economic status. Nationally, ongoing improvement is needed for infants <28 weeks of gestation, and closer exploration is needed into why there are increasing rates of negative perinatal outcomes among infants born at 22-27 weeks of gestation after 2012.

"Half-Sandwich" Ruthenium Complexes with Alizarin as Anticancer Agents: In Vitro and In Vivo Studies.

Upon exploration of the chemistry of the combination of ruthenium/arene with anthraquinone alizarin (L), three new complexes with the general formulas [Ru(L)Cl(η6-p-cymene)] (C1), [Ru(L)(η6-p-cymene)(PPh3)]PF6 (C2), and [Ru(L)(η6-p-cymene)(PEt3)]PF6 (C3) were synthesized and characterized using spectroscopic techniques (mass, IR, and 1D and 2D NMR), molar conductivity, elemental analysis, and X-ray diffraction. Complex C1 exhibited fluorescence, such as free alizarin, while in C2 and C3, the emission was probably quenched by monophosphines and the crystallographic data showed that hydrophobic interactions are predominant in intermolecular contacts. The cytotoxicity of the complexes was evaluated in the MDA-MB-231 (triple-negative breast cancer), MCF-7 (breast cancer), and A549 (lung) tumor cell lines and MCF-10A (breast) and MRC-5 (lung) nontumor cell lines. Complexes C1 and C2 were more selective to the breast tumor cell lines, and C2 was the most cytotoxic (IC50 = 6.5 µM for MDA-MB-231). In addition, compound C1 performs a covalent interaction with DNA, while C2 and C3 present only weak interactions; however, internalization studies by flow cytometry and confocal microscopy showed that complex C1 does not accumulate in viable MDA-MB-231 cells and is detected in the cytoplasm only after cell permeabilization. Investigations of the mechanism of action of the complexes indicate that C2 promotes cell cycle arrest in the Sub-G1 phase in MDA-MB-231, inhibits its colony formation, and has a possible antimetastatic action, impeding cell migration in the wound-healing experiment (13% of wound healing in 24 h). The in vivo toxicological experiments with zebrafish indicate that C1 and C3 exhibit the most zebrafish embryo developmental toxicity (inhibition of spontaneous movements and heartbeats), while C2, the most promising anticancer drug in the in vitro preclinical tests, revealed the lowest toxicity in in vivo preclinical screening.

Abundance of Procamallanus (Spirocamallanus) inopinatus (Nematoda: Camallanidae) in Characiformes fish and associated factors in Midwest Brazil.

The success of Procamallanus (Spirocamallanus) inopinatus infection in fish involves a complexity of variables. This study aims to evaluate the relationship between abundance of P. (S.) inopinatus with biometric and somatic parameters, sex, relative condition factor (Kn) and hosts diet, as well as to evaluate length relationship of the parasites and the hosts. The fishes were collected by the mesh method and data, length, weight, sex, gonad and liver weight, Gonadosomatic index (GSI) and hepatosomatic index (HSI), Kn and stomach content were recorded. Twenty-seven specimens of P. (S.) inopinatus were collected in the intestine from Serrasalmus rhombeus and 52 from Leporinus friderici. In general, the prevalence, mean intensity and mean abundance of infection was higher in L. friderici. The total abundance was explained by the variables GSI, HSI total length, gonad and liver weight. Fish relative condition factor (kn) and sex were not influenced by the infection, being that the parasite infection did not impair the body condition of the hosts. There is no relationship between host length and parasite length in any of the evaluated fish species. On average, S. rhombeus parasites are 0.69 cm larger than L. friderici parasites.

Identification of phlebotomine sand fly (Diptera: Psychodidae) in Atlantic forest fragments and their dispersal to urban area.

The geographical distribution of sand flies in Brazil has been the subject of some studies, yet there is no information about the phlebotomine fauna in João Pessoa, State of Paraíba, Brazil. The aim of this work is to evaluate the occurrence and distribution of sand flies in the Atlantic forest fragments and to evaluate a possible dispersion in 06 nearby districts. Light traps were used during three consecutive nights, supplemented by an aspirator during the dry period and rainy season. A total of 222 sand flies were found, 143 (130 males and 13 females) in the Atlantic forest, and 79 in urban areas. During the entire dry season, three species of phlebotomine sand flies were recorded in 11 forest fragments, Lutzomyia longipalpis, Lu. migonei and Lu. whitmani. During the rainy season, only Lu. longipalpis was found. This was the only species identified in the studied neighborhoods during both seasons. The differences in diversity of sand flies encountered between natural habitats and urban areas may thus be correlated mostly with adaptations to particular habitats and availability of food. One species (Lu. longipalpis) appears to be rapidly adapting to urban areas because of deforestation.

Snakebite envenoming in Brazilian children: clinical aspects, management and outcomes.

Snakebite envenoming is currently considered a neglected tropical disease, which affects over 5 million people worldwide, and causes almost 150 000 deaths every year, as well as severe injuries, amputations and other sequelae. Snakebite envenoming in children, although proportionally less frequent, is generally more severe, and represents an important challenge for pediatric medicine, since they often result in worse outcomes. In Brazil, given its ecological, geographic and socioeconomic characteristics, snakebites are considered an important health problem, presenting approximately 30 000 victims per year, approximately 15% of them in children. Even with low snakebite incidence, children tend to have higher snakebite severity and complications due to the small body mass and same venom volume inoculated in comparison to adults, even though, due to the lack of epidemiological information about pediatric snakebites and induced injuries, it is difficult to measure the treatment effectiveness, outcomes and quality of emergency medical services for snakebites in children. In this review, we report how Brazilian children are affected by snakebites, describing the characteristics of this affected population, clinical aspects, management, outcomes and main challenges.

Longitudinal associations between adolescents' individualised risk for depression and inflammation in a UK cohort study.

Inflammation is associated with poor physical and mental health including major depressive disorder (MDD). Moreover, there is evidence that childhood adversity - a risk factor for MDD - becomes biologically embedded via elevated inflammation. However, the risk of developing MDD arises from multiple sources and yet there has been little investigation of the links between individuals' constellation of MDD risk and subsequent inflammation. We therefore examined associations between individual risk for MDD calculated in early adolescence and levels of inflammation six years later. We use data from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative UK birth cohort of 2,232 children followed to age 18 with 93% retention. Participants' individual risk for developing future MDD was calculated at age 12 using a recently developed prediction model comprising multiple psychosocial factors. Plasma levels of three inflammation biomarkers were measured at age 18: C-reactive protein (CRP), interleukin-6 (IL-6), and a newer biomarker, soluble urokinase plasminogen activator receptor (suPAR), which is thought to reflect the level of systemic chronic inflammation. MDD risk scores calculated at age 12 were positively associated with levels of suPAR (but not CRP or IL-6) at age 18 after adjusting for key covariates (b = 1.70, 95% CI = 0.46 - 2.95, p = 0.007). Adolescents at high risk of MDD (risk scores ≥ 90th centile) had significantly higher mean levels of suPAR six years later than adolescents who had been identified as low risk (risk scores ≤ 10th centile) (b = 0.41, 95% CI = 0.18 - 0.64, p < 0.001). Findings support the notion that childhood psychosocial risk for MDD leads to increased levels of low-grade inflammation. If replicated in studies with repeated assessments of inflammation biomarkers throughout childhood and adolescence, these findings would support targeted interventions to reduce inflammation, as measured by suPAR, for adolescents at high risk of MDD to potentially prevent development of depression and physical health problems related to chronic inflammation.

Impact of socioeconomic factors and health determinants on preterm birth in Brazil: a register-based study.

BACKGROUND: More than 15 million children are born preterm annually. While preterm survival rates have increased in high-income countries. Low- and middle-income countries, like Brazil, continue to battle high neonatal mortality rates due to a lack of adequate postnatal care. Globally, neonatal mortality is higher for preterm infants compared to those born at term. Our study aims to map and analyze the spatial, socioeconomic, and health coverage determinants related to preterm birth in Brazil in order to understand how spatial variations in demographics and access to primary care may affect preterm birth occurrences.  METHODS: Using publicly available national-level data from the Brazilian health system for 2008-2017, we conducted an ecological study to visualize the spatial distributions of preterm birth along with socioeconomic status, the structure of health services, and primary care work process, each consisting of multiple variables reduced via principal component analysis. Regression models were created to determine predictive effects of numeric and spatial variation of these scores on preterm birth rates. RESULTS: In Brazil, preterm birth rates increased from 2008-2017, with small and rural municipalities frequently exhibiting higher rates than urban areas. Scores in socioeconomic status and work process were significant predictors of preterm birth rates, without taking into account spatial adjustment, with more positive scores in socioeconomic status predicting higher preterm birth rates (coefficient 0.001145) and higher scores in work process predicting lower preterm birth rates (coefficient -0.002416). Geographically weighted regression showed socioeconomic status to be a more significant predictor in the North, with the work process indicators being most significant in the Northeast. CONCLUSIONS: Results support that primary care work process indicators are more significant in estimating preterm birth rates than physical structures available for care. These results emphasize the importance of ensuring the presence of the minimum human resources needed, especially in the most deprived areas of Brazil. The association between social determinants of health and preterm birth rates raises questions regarding the importance of policies dedicated to foster equity in the accessibility of healthcare services, and improve income as protective proxies for preterm birth.

Are Primary Health Care Features Associated with Reduced Late Neonatal Mortality in Brazil? An Ecological Study.

OBJECTIVE: To analyze the effect and efficiency of the characteristics of PHC facilities' structures and the work process of PHC teams on late neonatal mortality (LNM). METHODS: This ecological time-series study adopted 3.764 Brazilian municipalities as analysis units. The independent variables were sorted into three hierarchical levels and four blocks. The distal level consisted of economic and demographic variables; the intermediate level comprised health coverage and demand for services; and the proximal level included structure and work process. The dependent variable was LNM. A linear mixed-effects regression analysis with a hierarchical approach was performed, estimating the crude (ß) and adjusted (alpha = 5%) regression coefficients. Data involution analysis and municipalities were the decision-making unit according to their strata. RESULTS: LNM was directly associated with the number of live births and unemployment rate. LNM was inversely associated with the year, per capita income, the community health worker's strategy coverage, vaginal delivery, household visits, and available vaccines. In the 2002-2014 period, the number of municipalities efficient in reducing LNM dropped from 38 to 27. In 2014, a more significant investment occurred in the number of vaginal deliveries in almost all strata to make inefficient municipalities efficient. CONCLUSION FOR PRACTICE: The deaths of children aged 7-28 days are affected by the characteristics of the PHC structure and work process.

The influence of environmental factors on Clinostomum sp. (Digenea) infection in the fish Cichlasoma paranaense (Kullander, 1983) in Central Brazil.

This study analyzed the parasitism by Clinostomum sp. metacercariae of the neotropical fish Cichlasoma paranaense (Kullander 1983) and environmental variables' influence on their host-parasite relationship in Central Brazil. Fish were collected in five impoundments (I) from three towns: Itauçú (n = 2), Inhumas (n = 1), and Goiânia (n = 2), Goiás State, Brazil. Ninety-five fish were analyzed, weighted and length measured. Afterward, the presence of metacercariae in the gills, muscles, fins, and body cavities was investigated. The metacercariae were fixed in AFA solution, kept in 70% alcohol, and stained with carmine. The infection prevalence revealed that 0.64, 0.56 and 0.91% of fish was infected. The abundance was 4.14, 3.22 and 5.88, with a mean intensity of 6.44, 5.80 and 6.42 per impoundment (I 13, I 15 and I 16), respectively. The frequency of metacercariae was higher in fish collected in Goiânia. High frequency of parasites was observed in the gills, muscles, and fins. The limnological variables did not present direct interference in the parasitism. The fish' standard length influenced the number of metacercariae positively but did not differ to the relative condition coefficient.

Bolsa Família Program and deaths from oral cancer in Brazil: an ecological study.

Objective: To assess the effect of coverage of the Bolsa Família Program (BFP) on oral cancer mortality rates in Brazil between 2005 and 2017, adjusting for health care coverage and socioeconomic characteristics of the Brazilian federative units. Methods: This is an ecological study using annual data (2005-2017) from all the Brazilian federative units. The dependent variable for this study was the oral cancer mortality rate, standardized by gender and age using the direct standardization technique. BFP coverage was the main independent variable, calculated as the ratio of the number of BFP beneficiaries to those families that should potentially be entitled to this conditional cash transfer. Socioeconomic background and health care coverage were covariables. Choropleth maps were drawn, and space-time cube analysis was used to assess changes in the spatiotemporal distribution of BFP and oral cancer mortality rates. Mixed-effects linear regression analysis estimated the coefficients (ß) and 95% confidence intervals (CI) for the association between BFP coverage and oral cancer mortality rates. Results: BFP coverage trends increased and oral cancer mortality rate trends stabilized in Brazilian federative units, except for Maranhão, Goiás, and Minas Gerais, where the oral cancer mortality rates have increased. In the adjusted model, greater BFP coverage was associated with lower oral cancer mortality rates (ß -2.10; 95% CI [-3.291, -0.919]). Conclusions: Egalitarian strategies such as BFP can reduce the oral cancer mortality rate. We recommend the follow-up of families benefiting from conditional cash transfer program by oral health teams to reduce the oral cancer mortality rate.

[Factors associated with hospitalizations for primary care-sensitive conditions in Brazil: an ecological studyFactores asociados a las hospitalizaciones infantiles por afecciones que podrían tratarse en la atención primaria en Brasil: estudio ecológico]. / Fatores associados às internações infantis por condições sensíveis à atenção primária no Brasil: estudo ecológico.

Objective: To investigate whether structural aspects of primary care units (PCUs) and the work processes of primary care teams are associated with the rate of hospitalizations for primary care-sensitive conditions (HPCSC) in children younger than 5 years of age in Brazil. Method: For this longitudinal ecological study, secondary data were obtained from the Brazilian Hospital Information System and from three cycles of the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) (2012, 2014, 2017/2018). The analysis included 42 916 PCUs. A multilevel random intercept model with fixed slope was used. In the first level, the outcome (HPCSC rates) and explanatory variables (structure and process indicators) aggregated by PCU were analyzed. Social determinants (represented by a stratification criterion combining municipality population and health care management indicators) were entered in the second level. The t test with Bonferroni correction was used to compare indicator means between regions, and multilevel linear regression was used to estimate the correlation coefficients. Results: The HPCSC rate in children younger than 5 years was 62.78/100 thousand population per estimated PCU coverage area. A direct association with the outcome was observed for: participation in one or more PMAQ-AB cycles; team planning; special hours; dedicated pediatric care area; and availability of vaccines. Equipment, materials, supplies, and being a small or medium-size municipality were inversely associated with HPCSC. Conclusions: HPCSC rates in children below 5 years of age may potentially be reduced through improvements in PCU structure and process indicators and in municipal social determinants.

Objetivo: Determinar la asociación de la estructura de las unidades básicas de salud (UBS) y del proceso de trabajo de los equipos de atención primaria con los determinantes sociales y las tasas de hospitalización por afecciones que podrían tratarse en la atención primaria en menores de 5 años en Brasil. Métodos: Estudio longitudinal ecológico, con datos secundarios del Sistema de Informaciones Hospitalarias y los tres ciclos del Programa Nacional de Mejora del Acceso y de la Calidad de la Atención Básica (PMAQ-AB) (2012, 2014, 2017-2018). Se analizaron 42.916 UBS. Se aplicó un modelo multinivel con pendiente fija e intercepción aleatoria. En el primer nivel, se analizaron el desenlace (tasas de hospitalización por afecciones que podrían tratarse en los servicios de atención primaria) y las variables explicativas (indicadores estructurales y procedimentales) consolidados por UBS. En el segundo nivel, se incluyeron determinantes sociales municipales (representados por un criterio de estratificación que combina el tamaño del municipio con indicadores que influyen en la gestión de salud). Se utilizó la prueba de la t con la corrección de Bonferroni para comparar las medias de los indicadores entre las regiones y la regresión lineal multinivel para estimar los coeficientes de correlación. Resultados: La tasa de hospitalización por afecciones que podrían tratarse en los servicios de atención primaria en menores de 5 años fue de 62,78/100 mil habitantes por área estimada de cobertura de UBS. Los siguientes factores presentaron una asociación directa con el desenlace: participación en uno o más ciclos del PMAQ-AB; planificación del equipo; horario especial; dependencias de atención infantil en la unidad; y disponibilidad de vacunas. La variable relativa a equipos, materiales e insumos y la clasificación como municipio pequeño o mediano se asociaron inversamente con las hospitalizaciones por afecciones que podrían tratarse en los servicios de atención primaria. Conclusiones: Las hospitalizaciones de menores de 5 años por afecciones que podrían tratarse en los servicios de atención primaria pueden reducirse mejorando los indicadores estructurales y procedimentales de las UBS y los determinantes sociales municipales.

Surfactants, Biosurfactants, and Non-Catalytic Proteins as Key Molecules to Enhance Enzymatic Hydrolysis of Lignocellulosic Biomass.

Lignocellulosic biomass (LCB) has remained a latent alternative resource to be the main substitute for oil and its derivatives in a biorefinery concept. However, its complex structure and the underdeveloped technologies for its large-scale processing keep it in a state of constant study trying to establish a consolidated process. In intensive processes, enzymes have been shown to be important molecules for the fractionation and conversion of LCB into biofuels and high-value-added molecules. However, operational challenges must be overcome before enzyme technology can be the main resource for obtaining second-generation sugars. The use of additives is shown to be a suitable strategy to improve the saccharification process. This review describes the mechanisms, roles, and effects of using additives, such as surfactants, biosurfactants, and non-catalytic proteins, separately and integrated into the enzymatic hydrolysis process of lignocellulosic biomass. In doing so, it provides a technical background in which operational biomass processing hurdles such as solids and enzymatic loadings, pretreatment burdens, and the unproductive adsorption phenomenon can be addressed.

Lead toxicity in Lucilia cuprina and electrochemical analysis: a simple and low-cost alternative for forensic investigation.

Entomotoxicology allows the detection and analysis of substances such as poisons, drugs, and metals in necrophagous insects using analytical protocols. In a forensic situation related to death by gunshot, the gunshot residue (GSR) is dispersed at the crime scene and may be consumed by necrophagous insects. Lead (Pb) is the most abundant metal in GSR samples and it can be determined using non-portable methods. However, the toxicity effects of GSR samples on Lucilia cuprina (Diptera: Calliphoridae) and the detection of Pb via portable electrochemical methods have not been investigated. This study describes for the first time the toxicity analysis of Pb on immature L. cuprina through their survival rate and influence of Pb on immature development. In addition, the bioaccumulation of Pb in the larvae samples was determined based on square wave anodic stripping voltammetry (SWASV) measurements. The results revealed a low limit of detection to Pb (6.5 µg L-1) and the analytical performance was satisfactory because it measures Pb levels in larvae exposed to a diet containing 50 µg Pb g-1. Furthermore, the levels of Pb influenced the survival rate and development time of the immature L. cuprina. Larvae exposed to a high concentration of the metal (50 µg Pb g -1) showed statistically significant changes (p < 0.05). The presence of Pb in immature L. cuprina can be used to estimate the post-mortem interval; thus, the present study provides important information in forensic entomology.

Predicting the risk of depression among adolescents in Nepal using a model developed in Brazil: the IDEA Project.

The burden of adolescent depression is high in low- and middle-income countries (LMICs), yet research into prevention is lacking. Development and validation of models to predict individualized risk of depression among adolescents in LMICs is rare but crucial to ensure appropriate targeting of preventive interventions. We assessed the ability of a model developed in Brazil, a middle-income country, to predict depression in an existing culturally different adolescent cohort from Nepal, a low-income country with a large youth population with high rates of depression. Data were utilized from the longitudinal study of 258 former child soldiers matched with 258 war-affected civilian adolescents in Nepal. Prediction modelling techniques were employed to predict individualized risk of depression at age 18 or older in the Nepali cohort using a penalized logistic regression model. Following a priori exclusions for prior depression and age, 55 child soldiers and 71 war-affected civilians were included in the final analysis. The model was well calibrated, had good overall performance, and achieved good discrimination between depressed and non-depressed individuals with an area under the curve (AUC) of 0.73 (bootstrap-corrected 95% confidence interval 0.62-0.83). The Brazilian model comprising seven matching sociodemographic predictors, was able to stratify individualized risk of depression in a Nepali adolescent cohort. Further testing of the model's performance in larger socio-culturally diverse samples in other geographical regions should be attempted to test the model's wider generalizability.

Molluscicidal activity of Persea americana Mill. (Lauraceae) stem bark ethanolic extract against the snail Biomphalaria glabrata (Say, 1818): a novel plant-derived molluscicide?

Plant-derived molluscicides have been indicated as biodegradable and low-cost strategies for control of Biomphalaria spp., intermediate host for the Schistosoma. This study evaluated whether the crude ethanolic extract of the Persea americana stem bark has molluscicidal activity against embryos, newly-hatched and adults of Biomphalaria glabrata. The extract was obtained, characterized and its toxicity analyzed by snail embryotoxicity test (144 h) and acute toxicity test with newly-hatching and adult snails (96 h). Results showed the presence of flavonoids, anthraquinone heterosides, coumarins and tannins in the crude ethanolic extract, which showed molluscicidal activity against all life cycle stages of B. glabrata. The LC50 for embryos, newly-hatched and adults were 27.06, 30.60 and 55.55 ppm, respectively. Embryos exposed to the extract at 50 ppm showed hatching inhibition and at 6.2 and 25 ppm had the highest rates of morphological alterations, such as shell malformations and coagulation of the perivitelline substance. Adult snails exposed to the extract at 75 ppm showed a peak of behavioral changes, such as lethargy and shell reclusion, in addition to answers like hemolymph release in most concentrations. Further studies are required, prioritizing toxicity testing on non-target organisms and further elucidation of the active molecules.

Mortality associated with alternative policy options for primary care and the Mais Médicos (More Doctors) Program in Brazil: forecasting future scenarios.

OBJECTIVE: To forecast the impact of alternative scenarios of coverage changes in Brazil's Family Health Strategy (Estratégia Saúde da Família) (ESF)-due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)-on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030. METHODS: A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects. RESULTS: In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030. CONCLUSIONS: Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.

Is there a fair distribution of the structure of dental services in the capitals of the Brazilian Federative Units?

BACKGROUND: Brazilian Primary Care Facilities (PCF) provide primary care and must offer dental services for diagnosis, prevention, and treatment of diseases. According to a logic of promoting equity, PCF should be better structured in less developed places and with higher need for oral health services. OBJECTIVE: To analyze the structure of dental caries services in the capitals of the Brazilian Federative Units and identify whether socioeconomic factors and caries (need) are predictors of the oral health services structure. METHODS: This is an ecological study with variables retrieved from different secondary databases, clustered for the level of the federative capitals. Descriptive thematic maps were prepared, and structural equations were analyzed to identify oral health service structure's predictors (Alpha = 5%). Four models with different outcomes related to dental caries treatment were tested: 1) % of PCF with a fully equipped office; 2) % of PCF with sufficient instruments, and 3) % of PCF with sufficient supplies; 4) % of PCF with total structure. RESULTS: 21.6% of the PCF of the Brazilian capitals had a fully equipped office; 46.9% had sufficient instruments, and 30.0% had sufficient supplies for caries prevention and treatment. The four models evidenced proper fit indexes. A correlation between socioeconomic factors and the structure of oral health services was only noted in model 3. The worse the socioeconomic conditions, the lower the availability of dental supplies (standard factor loading: 0.92, P = 0.012). Estimates of total, direct and indirect effects showed that dental caries experience observed in the Brazilian population by SB-Brasil in 2010 did not affect the outcomes investigated. CONCLUSION: Material resources are not equitably distributed according to the socioeconomic conditions and oral health needs of the population of the Brazilian capitals, thus contributing to persistent oral health inequities in the country.

An evaluation of outcomes in patients with traumatic brain injury at a referral hospital in Tanzania: evidence from a survival analysis.

OBJECTIVE: The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury. METHODS: The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania. RESULTS: Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI. CONCLUSIONS: Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

Ecotoxicity of rare earths in the marine mussel Mytilus galloprovincialis and a preliminary approach to assess environmental risk.

The increasing use of rare earth elements (REEs) in diverse technological applications has augmented the demand and exploitation of these worldwide, leading to a higher input of REEs + Yttrium (Y) in the marine environment. The present study investigated the ecotoxicity of Lanthanum (La) and Y to Mytilus galloprovincialis developing embryos and juveniles. This was achieved by quantifying the embryogenesis success after 48 h, and survival of juveniles after 96 h of exposure to different concentrations of La and Y. Results show that both La and Y are more toxic to developing embryos and larvae than to juveniles of M. galloprovincialis. Predicted no-effect concentration (PNEC) values were also derived for the embryo development as a preliminary approach to assess the environmental risk for these compounds to marine organisms. Results revealed that La is more toxic than Y. The high sensitivity of the early developmental stages to these compounds highlight the relevance of including these stages when evaluating the toxicity of chemicals where little information is available. Although older life stages may be more tolerant to toxicants, the population survival will be compromised if new recruits are not viable, with implications to the whole ecosystem health and functioning of the impacted area. Information on the ecotoxicity of chemicals with expanded technological use and that may be released during deep-sea mining activities is urgent in order to help estimate environmental impacts.