A scoping review on virtual autopsy: Main concepts, qualified professionals and future prospects.

The beginning of post-mortem evaluation studies through minimally invasive procedures began between 1800 and 1930. It started with Dr. Howard Kelly and was later followed by Décio Parreiras and Werneck Genofre, due to the yellow fever outbreak in Brazil. However, despite its early beginnings, the intensification of the research on this field occurred around 2010, when the publications about this subject became three times more frequent than before. There are basically two classifications for this procedure. The first one is virtual non-invasive autopsy, which is based only on imaging exams; the second is the minimally invasive autopsy, in which imaging exams are associated with other techniques such as biopsy and angiography. The main objective of the present study is to evaluate the existent data published about virtual autopsy from 2010, and highlight the key concepts related to this theme. A search was conducted in PUBMED, MEDLINE, and LILACS databases using the descriptors "virtual autopsy" and "minimally invasive autopsy", the review protocol has been registered on Open Science Framework (OSF), the total number of studies included were 28, and the data was presented through the PRISMA-ScR flowchart. Although, it is well known that this theme is recent in research fields and, because of that, there is still a lot to explore.

Air pollution aggravates renal ischaemia-reperfusion-induced acute kidney injury.

Chronic kidney disease (CKD) has emerged as a significant global public health concern. Recent epidemiological studies have highlighted the link between exposure to fine particulate matter (PM2.5) and a decline in renal function. PM2.5 exerts harmful effects on various organs through oxidative stress and inflammation. Acute kidney injury (AKI) resulting from ischaemia-reperfusion injury (IRI) involves biological processes similar to those involved in PM2.5 toxicity and is a known risk factor for CKD. The objective of this study was to investigate the impact of PM2.5 exposure on IRI-induced AKI. Through a unique environmentally controlled setup, mice were exposed to urban PM2.5 or filtered air for 12 weeks before IRI followed by euthanasia 48 h after surgery. Animals exposed to PM2.5 and IRI exhibited reduced glomerular filtration, impaired urine concentration ability, and significant tubular damage. Further, PM2.5 aggravated local innate immune responses and mitochondrial dysfunction, as well as enhancing cyclic GMP-AMP synthase-stimulator of interferon genes (cGAS-STING) pathway activation. This increased renal senescence and suppressed the anti-ageing protein klotho, leading to early fibrotic changes. In vitro studies using proximal tubular epithelial cells exposed to PM2.5 and hypoxia/reoxygenation revealed heightened activation of the STING pathway triggered by cytoplasmic mitochondrial DNA, resulting in increased tubular damage and a pro-inflammatory phenotype. In summary, our findings imply a role for PM2.5 in sensitising proximal tubular epithelial cells to IRI-induced damage, suggesting a plausible association between PM2.5 exposure and heightened susceptibility to CKD in individuals experiencing AKI. Strategies aimed at reducing PM2.5 concentrations and implementing preventive measures may improve outcomes for AKI patients and mitigate the progression from AKI to CKD. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Usefulness of minimally invasive autopsy in the diagnosis of arboviruses to increase the sensitivity of the Epidemiological Surveillance System in Ceará, Brazil.

OBJECTIVE: To create a protocol for performing minimally invasive autopsies (MIA) in detecting deaths from arboviruses and report preliminary data from its application in Ceará state, Brazil. METHODS: Training was provided to medical pathologists on MIA. RESULTS: A protocol was established for performing MIA, defining criteria for sample collection, storage methods, and diagnoses to be carried out according to the type of biological sample; 43 MIAs were performed in three months. Of these, 21 (48.8%) arrived at the Death Verification Service (SVO) with arboviruses as a diagnostic hypothesis, and seven (16.3%) were confirmed (six chikungunya cases and one dengue case); cases of COVID-19 (n = 9), tuberculosis (n = 5), meningitis (n = 4), cryptococcosis (n = 1), Creutzfeldt-Jakob disease (n = 1), breast cancer (n = 1), and human rabies (n = 1) were also confirmed. CONCLUSION: The protocol implemented enabled identification of a larger number of suspected arbovirus-related deaths, as well as confirmation of other diseases of interest for surveillance. MAIN RESULTS: A protocol was developed to perform minimally invasive autopsies (MIAs) in Death Verification Services (SVO), capable of expanding the system's capacity to identify a greater number of deaths suspected to be due to arboviruses. IMPLICATIONS FOR SERVICES: The experience suggests that in-service trained health professionals are able to perform MIA, and that use of this technique in SVOs has been shown to be capable of increasing the system's sensitivity in detecting deaths of interest to public health. PERSPECTIVES: Trained professionals will be able to collect biological material in hospitals, through MIA, in cases of interest for health surveillance and when family members do not allow a complete conventional autopsy to be performed.

Exposure to urban ambient particles (PM2.5) before pregnancy affects the expression of endometrial receptive markers to embryo implantation in mice: Preliminary results.

Air pollution (AP) is one of the main recent concerns in reproductive healthy due to its potential to promote negative outcomes during pregnancy and male and female fertility. Several studies have demonstrated that AP exposure has been linked to increased embryonic implantation failures, alterations in embryonic, fetal and placental development. For a well-succeeded implantation, both competent blastocyst and receptive endometrium are required. Based on the lack of data about the effect of AP in endometrial receptivity, this study aimed to evaluate he particulate matter (PM) exposure impact on uterine receptive markers in mice and associate the alterations to increased implantation failures due to AP. For this study, ten dams per group were exposed for 39 days to either filter (F) or polluted air (CAP). At fourth gestational day (GD4), females were euthanized. Morphological, ultrastructural, immunohistochemical and molecular analysis of uterine and ovarian samples were performed. CAP-exposed females presented a reduced number of corpus luteum; glands and epithelial cells were increased with pinopodes formation impairment. Immunohistochemistry analysis revealed decreased LIF protein levels. These preliminary data suggests that PM exposure may exert negative effects on endometrial receptivity by affecting crucial parameters to embryonic implantation as uterine morphological differentiation, corpus luteum quantity and LIF expression during implantation window.

Association of pulmonary black carbon accumulation with cardiac fibrosis in residents of Sao Paulo, Brazil.

Evidence suggests that myocardial interstitial fibrosis, resulting from cardiac remodeling, may possibly be influenced by mechanisms activated through the inhalation of airborne pollutants. However, limited studies have explored the relationship between lifetime exposure to carbon-based particles and cardiac fibrosis, specially using post-mortem samples. This study examined whether long-term exposure to air pollution (estimated by black carbon accumulated in the lungs) is associated with myocardial fibrosis in urban dwellers of megacity of Sao Paulo. Data collection included epidemiological and autopsy-based approaches. Information was obtained by interviewing the next of kin and through the pathologist's report. The individual index of exposure to carbon-based particles, which we designed as the fraction of black carbon (FBC), was estimated through quantification of particles on the macroscopic lung surface. Myocardium samples were collected for histopathological analysis to evaluate the fraction of cardiac fibrosis. The association between cardiac fibrosis and FBC, age, sex, smoking status and hypertension was assessed by means of multiple linear regression models. Our study demonstrated that the association of FBC with cardiac fibrosis is influenced by smoking status and hypertension. Among hypertensive individuals, the cardiac fibrosis fraction tended to increase with the increase of the FBC in both groups of smokers and non-smokers. In non-hypertensive individuals, the association between cardiac fibrosis fraction and FBC was observed primarily in smokers. Long-term exposure to tobacco smoke and environmental particles may contribute to the cardiac remodeling response in individuals with pre-existing hypertension. This highlights the importance of considering hypertension as an additional risk factor for the health effects of air pollution on the cardiovascular system. Moreover, the study endorses the role of autopsy to investigate the effects of urban environment and personal habits in determining human disease.

Effects of land cover and air pollution on the risk of preterm births / Efeitos da cobertura de solo e poluição do ar no risco de nascimentos prematuros

ABSTRACT OBJECTIVE To evaluate the association between gestational age and green areas, urban built areas, and the concentration of particulate matter 2.5 (PM2.5) in the city of São Paulo, analyzing the irregular distribution of these areas and pollution levels above the recommended level. METHODS The study population consisted of a cohort of live births from 2012, and data from the Live Birth Information System (Sinasc) of the city of São Paulo were used. Using satellite images and supervised classification, the distribution and quantity of green areas and built areas in the city of São Paulo was obtained, as well as the concentrations of PM2.5. Logistic regressions were used to obtain possible associations. RESULTS The results of the study show that a lower percentage of green areas is significantly associated with a higher chance of preterm births. A higher building density was positively associated with the odds ratio for preterm birth. We did not find any significant associations between air pollution (PM2.5) and preterm births. CONCLUSIONS The results of this study show that greener areas are less associated with preterm births when compared with less green areas.

RESUMO OBJETIVO Avaliar a associação entre a idade gestacional e as áreas verdes, áreas construídas urbanas e a concentração de material particulado 2,5 (MP2,5) em São Paulo, analisando a distribuição irregular dessas áreas e os níveis de poluição acima do recomendado. MÉTODOS A população utilizada no estudo foi a dos nascidos vivos no ano de 2012, com os dados do Sistema de Informações sobre Nascidos Vivo (Sinasc) na cidade de São Paulo. Por meio de imagens de satélites e realizando a classificação supervisionada, obtivemos a distribuição e quantidade de áreas verdes e de áreas construídas, na cidade de São Paulo, assim como as concentrações de MP2,5. Regressões logísticas foram utilizadas para obter possíveis associações. RESULTADOS Os resultados do estudo mostram que menor percentual de áreas verdes está associado significativamente com maior chance de prematuridade. Maior densidade de construção foi associada positivamente com a razão de chance de nascimento prematuro. Não encontramos resultados significativos entre a poluição do ar (MP2,5) e prematuridade. CONCLUSÕES Os resultados deste estudo demostraram que áreas mais verdes em relação às áreas menos verdes são menos associadas a nascimentos prematuros.

Usefulness of minimally invasive autopsy in the diagnosis of arboviruses to increase the sensitivity of the Epidemiological Surveillance System in Ceará, Brazil / Utilidad de la autopsia mínimamente invasiva en el diagnóstico de arbovirus para aumentar la sensibilidad del Sistema de Vigilancia Epidemiológica en Brasil: experiencia de Ceará, Brasil / Utilidade da autópsia minimamente invasiva no diagnóstico das arboviroses para ampliação da sensibilidade do Sistema de Vigilância Epidemiológica no Brasil: experiência do Ceará

Abstract Objective: To create a protocol for performing minimally invasive autopsies (MIA) in detecting deaths from arboviruses and report preliminary data from its application in Ceará state, Brazil. Methods: Training was provided to medical pathologists on MIA. Results: A protocol was established for performing MIA, defining criteria for sample collection, storage methods, and diagnoses to be carried out according to the type of biological sample; 43 MIAs were performed in three months. Of these, 21 (48.8%) arrived at the Death Verification Service (SVO) with arboviruses as a diagnostic hypothesis, and seven (16.3%) were confirmed (six chikungunya cases and one dengue case); cases of COVID-19 (n = 9), tuberculosis (n = 5), meningitis (n = 4), cryptococcosis (n = 1), Creutzfeldt-Jakob disease (n = 1), breast cancer (n = 1), and human rabies (n = 1) were also confirmed. Conclusion: The protocol implemented enabled identification of a larger number of suspected arbovirus-related deaths, as well as confirmation of other diseases of interest for surveillance.

Resumen Objetivo: Estabelecer un protocolo utilizado para la realización de autopsias mínimamente invasivas (AMI) para la detección de muertes por arbovirus y presentar datos preliminares de este protocolo en Ceará, Brasil. Métodos: Se llevó a cabo la capacitación de médicos patólogos en AMI. Resultados: Se estableció un protocolo para la realización de AMI, que define los criterios para la toma de muestras, métodos de almacenamiento y diagnóstico; en tres meses se realizaron 43 AMI; de estas, 21 (48,8%) llegaron al Servicio de Verificación de Óbito (SVO) con una hipótesis diagnóstica de alguna arbovirosis y siete (16,3%) fueron confirmadas (seis casos de chikungunya y uno de dengue); también se confirmaron casos de Covid-19 (n = 9), tuberculosis (n = 5), meningitis (n = 4), criptococosis (n = 1), enfermedad de Creutzfeldt-Jakob (n = 1), neoplasia de mama (n = 1) y rabia humana (n = 1). Conclusión: El protocolo implementado permitió la identificación de un mayor número de muertes sospechosas de arbovirus, además de la confirmación de otras patologías de interés.

Resumo Objetivo: Estabelecer protocolo para realização de autópsias minimamente invasivas (AMIs) na detecção de óbitos por arboviroses e relatar dados preliminares desse protocolo no Ceará, Brasil. Métodos: Médicos patologistas foram treinados em AMI. Resultados: Estabeleceu-se protocolo para AMI, definindo-se critérios para amostras a serem coletadas, suas formas de armazenamento e diagnóstico, segundo o tipo de amostra biológica; em três meses, foram realizadas 43 AMIs, das quais 21 (48,8%) chegaram ao Serviço de Verificação de Óbito (SVO) com hipótese diagnóstica de alguma arbovirose e sete (16,3%) foram confirmados (seis de chikungunya; uma de dengue); também foram confirmados casos de covid-19 (n = 9), tuberculose (n = 5), meningite (n = 4), criptococose (n = 1), doença de Creutzfeldt-Jakob (n = 1), neoplasia de mama (n = 1) e raiva humana (n = 1). Conclusão: O protocolo implantado permitiu a captação de um maior número de óbitos suspeitos de arboviroses, além da confirmação de outras patologias de interesse da vigilância.

The association of COVID-19 incidence with temperature, humidity, and UV radiation - A global multi-city analysis.

BACKGROUND AND AIM: The associations between COVID-19 transmission and meteorological factors are scientifically debated. Several studies have been conducted worldwide, with inconsistent findings. However, often these studies had methodological issues, e.g., did not exclude important confounding factors, or had limited geographic or temporal resolution. Our aim was to quantify associations between temporal variations in COVID-19 incidence and meteorological variables globally. METHODS: We analysed data from 455 cities across 20 countries from 3 February to 31 October 2020. We used a time-series analysis that assumes a quasi-Poisson distribution of the cases and incorporates distributed lag non-linear modelling for the exposure associations at the city-level while considering effects of autocorrelation, long-term trends, and day of the week. The confounding by governmental measures was accounted for by incorporating the Oxford Governmental Stringency Index. The effects of daily mean air temperature, relative and absolute humidity, and UV radiation were estimated by applying a meta-regression of local estimates with multi-level random effects for location, country, and climatic zone. RESULTS: We found that air temperature and absolute humidity influenced the spread of COVID-19 over a lag period of 15 days. Pooling the estimates globally showed that overall low temperatures (7.5 °C compared to 17.0 °C) and low absolute humidity (6.0 g/m3 compared to 11.0 g/m3) were associated with higher COVID-19 incidence (RR temp =1.33 with 95%CI: 1.08; 1.64 and RR AH =1.33 with 95%CI: 1.12; 1.57). RH revealed no significant trend and for UV some evidence of a positive association was found. These results were robust to sensitivity analysis. However, the study results also emphasise the heterogeneity of these associations in different countries. CONCLUSION: Globally, our results suggest that comparatively low temperatures and low absolute humidity were associated with increased risks of COVID-19 incidence. However, this study underlines regional heterogeneity of weather-related effects on COVID-19 transmission.

What else in times of COVID-19? The role of minimally invasive autopsy for the differential diagnosis of acute respiratory failure in a case of kala-azar

ABSTRACT Visceral leishmaniasis (VL) is a chronic vector-borne zoonotic disease caused by trypanosomatids, considered endemic in 98 countries, mainly associated with poverty. About 50,000-90,000 cases of VL occur annually worldwide, and Brazil has the second largest number of cases in the world. The clinical picture of VL is fever, hepatosplenomegaly, and pancytopenia, progressing to death in 90% of cases due to secondary infections and multi-organ failure, if left untreated. We describe the case of a 25-year-old female who lived in the metropolitan area of Sao Paulo, who had recently taken touristic trips to several rural areas in Southeastern Brazil and was diagnosed post-mortem. During the hospitalization in a hospital reference for the treatment of COVID-19, the patient developed acute respiratory failure, with chest radiographic changes, and died due to refractory shock. The ultrasound-guided minimally invasive autopsy diagnosed VL (macrophages containing amastigote forms of Leishmania in the spleen, liver and bone marrow), as well as pneumonia and bloodstream infection by gram-negative bacilli.

Linha do tempo do "tratamento precoce" para Covid-19 no Brasil: desinformação e comunicação do Ministério da Saúde / Timeline of Covid-19 "early treatment" in Brazil: disinformation and communications from the Ministry of Health / Línea del tiempo del "tratamiento precoz" para Covid-19 en Brasil: desinformación y comunicación del Ministerio de la Salud

Em fevereiro de 2020, a Organização Mundial da Saúde alertou sobre a gravidade da epidemia de Covid-19 e enfatizou que as iniciativas relacionadas ao seu combate têm sido acompanhadas por uma infodemia. O Ministério da Saúde do Brasil publicou diretrizes em relação ao manejo da doença com o "tratamento precoce". O objetivo deste artigo foi construir uma linha do tempo visual de janeiro de 2020 até abril de 2021 por meio de pesquisa bibliográfica, documental e análise de conteúdo. Sistematizaram-se as principais notícias veiculadas no website do Ministério da Saúde sobre o "tratamento precoce", as evidências científicas sobre os medicamentos relacionados a este e os dados das mortes e fatos relacionados à doença que aconteceram no Brasil. A linha do tempo evidencia a insistência da promoção do "tratamento precoce", no contexto da desinfodemia, pelo Ministério da Saúde na existência de evidências contrárias a essa intervenção.(AU)

In February 2020, the World Health Organisation warned about the gravity of the Covid-19 epidemic, emphasizing that initiatives to combat the problem had been accompanied by an "infodemic". Brazil's ministry of health published guidelines on the management of the disease using "early treatment". The aim of this study was to create a visual timeline from January 2020 to April 2021 based on the review of relevant literature and documents examined using document analysis. We synthesized the main items of news on early treatment published on the Ministry of Health website, scientific evidence on the medications used, and facts related to the disease in Brazil. The timeline evidenced the insistent promotion of early treatment by the Ministry of Health within the context of a "disinfodemic" despite the existence of evidence against this type of intervention.(AU)

En febrero de 2020, la Organización Mundial de la Salud alertó sobre la gravedad de la epidemia de Covid-19 y enfatizó que las iniciativas relacionadas con su combate habían sido acompañadas por una infodemia. El Ministerio de la Salud de Brasil publicó directrices con relación al manejo de la enfermedad con el "tratamiento precoz". El objetivo de este artículo fue construir una línea del tiempo visual desde enero de 2020 hasta abril de 2021 por medio de una investigación bibliográfica, documental y análisis de contenido. Se sistematizaron las principales noticias publicadas en la página web del Ministerio de la Salud sobre el "tratamiento precoz", las evidencias científicas sobre estos medicamentos y los datos de las muertes y hechos relacionados a la enfermedad en Brasil. La línea de tiempo dejará clara la insistencia de la promoción del "tratamiento precoz", en el contexto de la desinfodemia, por parte del Ministerio de la Salud con la existencia de evidencias contrarias a esta intervención.(AU)

Air Pollution's Impact on Cardiac Remodeling in an Experimental Model of Chagas Cardiomyopathy.

Background: Chagas disease is characterized by intense myocardial fibrosis stimulated by the exacerbated production of inflammatory cytokines, oxidative stress, and apoptosis. Air pollution is a serious public health problem and also follows this same path. Therefore, air pollution might amplify the inflammatory response of Chagas disease and increase myocardial fibrosis. Methods: We studied groups of Trypanosoma cruzi infected Sirius hamsters (Chagas=CH and Chagas exposed to pollution=CH+P) and 2 control groups (control healthy animals=CT and control exposed to pollution=CT+P). We evaluated acute phase (60 days post infection) and chronic phase (10 months). Echocardiograms were performed to assess left ventricular systolic and diastolic diameter, in addition to ejection fraction. Interstitial collagen was measured by morphometry in picrosirius red staining tissue. The evaluation of inflammation was performed by gene and protein expression of cytokines IL10, IFN-γ, and TNF; oxidative stress was quantified by gene expression of NOX1, MnSOD, and iNOS and by analysis of reactive oxygen species; and apoptosis was performed by gene expression of BCL2 and Capsase3, in addition to TUNEL analysis. Results: Chagas groups had increased collagen deposition mainly in the acute phase, but air pollution did not increase this deposition. Also, Chagas groups had lower ejection fraction in the acute phase (p = 0.002) and again air pollution did not worsen ventricular function or dilation. The analysis of the inflammation and oxidative stress pathways were also not amplified by air pollution. Apoptosis analysis showed increased expression of BCL2 and Caspase3 genes in chagasic groups in the acute phase, with a marginal p of 0.054 in BCL2 expression among infected groups, and TUNEL technique showed amplified of apoptotic cells by pollution among infected groups. Conclusions: A possible modulation of the apoptotic pathway was observed, inferring interference from air pollution in this pathway. However, it was not enough to promote a greater collagen deposition, or worsening ventricular function or dilation caused by air pollution in this model of Chagas cardiomyopathy.

Accumulation of trace element content in the lungs of Sao Paulo city residents and its correlation to lifetime exposure to air pollution.

Heavy metals are natural and essential elements of the environment and living beings, produced from natural (e.g. volcanic activity and cosmic ray-induced spallation) and anthropogenic processes (e.g. industrial and fossil fuel combustion). High-concentrations of heavy metals and radionuclides are also originated from anthropogenic activities in urban and industrial areas. In this preliminary study, we analyzed the levels of heavy metals and Polonium-210 (210Po) in lung tissues in autopsies from residents of the city of Sao Paulo, SP, Brazil. In order to identify the link among sources of the heavy metals in lungs, factor analysis was performed. Of the first four factors, which explain 66% of the total variability, three were associated with vehicular sources. The fitting of a regression model with 210Po as the response variable and with the four factors as explanatory variables, controlling for age, sex and tobacco, showed a significant association between the concentration of polonium and the first factor that is generated by catalysts and brakes (coefficient = 0.90, standard error = 0.33, p = 0.016). Our findings suggest an association between traffic-related trace metals and 210Po in lung autopsies.

Validation of physician certified verbal autopsy using conventional autopsy: a large study of adult non-external causes of death in a metropolitan area in Brazil.

BACKGROUND: Reliable mortality data are essential for the development of public health policies. In Brazil, although there is a well-consolidated universal system for mortality data, the quality of information on causes of death (CoD) is not even among Brazilian regions, with a high proportion of ill-defined CoD. Verbal autopsy (VA) is an alternative to improve mortality data. This study aimed to evaluate the performance of an adapted and reduced version of VA in identifying the underlying causes of non-forensic deaths, in São Paulo, Brazil. This is the first time that a version of the questionnaire has been validated considering the autopsy as the gold standard. METHODS: The performance of a physician-certified verbal autopsy (PCVA) was evaluated considering conventional autopsy (macroscopy plus microscopy) as gold standard, based on a sample of 2060 decedents that were sent to the Post-Mortem Verification Service (SVOC-USP). All CoD, from the underlying to the immediate, were listed by both parties, and ICD-10 attributed by a senior coder. For each cause, sensitivity and chance corrected concordance (CCC) were computed considering first the underlying causes attributed by the pathologist and PCVA, and then any CoD listed in the death certificate given by PCVA. Cause specific mortality fraction accuracy (CSMF-accuracy) and chance corrected CSMF-accuracy were computed to evaluate the PCVA performance at the populational level. RESULTS: There was substantial variability of the sensitivities and CCC across the causes. Well-known chronic diseases with accurate diagnoses that had been informed by physicians to family members, such as various cancers, had sensitivities above 40% or 50%. However, PCVA was not effective in attributing Pneumonia, Cardiomyopathy and Leukemia/Lymphoma as underlying CoD. At populational level, the PCVA estimated cause specific mortality fractions (CSMF) may be considered close to the fractions pointed by the gold standard. The CSMF-accuracy was 0.81 and the chance corrected CSMF-accuracy was 0.49. CONCLUSIONS: The PCVA was efficient in attributing some causes individually and proved effective in estimating the CSMF, which indicates that the method is useful to establish public health priorities.

LPS Response Is Impaired by Urban Fine Particulate Matter.

Fine particulate matter (PM2.5) is a complex mixture of components with diverse chemical and physical characteristics associated with increased respiratory and cardiovascular diseases mortality. Our study aimed to investigate the effects of exposure to concentrated PM2.5 on LPS-induced lung injury onset. BALB/c male mice were exposed to either filtered air or ambient fine PM2.5 in an ambient particle concentrator for 5 weeks. Then, an acute lung injury was induced with nebulized LPS. The animals were euthanized 24 h after the nebulization to either LPS or saline. Inflammatory cells and cytokines (IL-1ß, IL-4, IL-5, IL-6, IL-10, IL-17, TNF) were assessed in the blood, bronchoalveolar lavage fluid (BALF), and lung tissue. In addition, lung morphology was assessed by stereological methods. Our results showed that the PM+LPS group showed histological evidence of injury, leukocytosis with increased neutrophils and macrophages, and a mixed inflammatory response profile, with increased KC, IL-6, IL-1ß, IL-4, and IL-17. Our analysis shows that there is an interaction between the LPS nebulization and PM2.5 exposure, differently modulating the inflammatory response, with a distinct response pattern as compared to LPS or PM2.5 exposure alone. Further studies are required to explain the mechanism of immune modulation caused by PM2.5 exposure.

Validation of SmartVA using conventional autopsy: A study of adult deaths in Brazil.

Background: Accurate cause of death data are essential to guide health policy. However, mortality surveillance is limited in many low-income countries. In such settings, verbal autopsy (VA) is increasingly used to provide population-level cause of death data. VAs are now widely interpreted using the automated algorithms SmartVA and InterVA. Here we use conventional autopsy as the gold standard to validate SmartVA methodology. Methods: This study included adult deaths from natural causes in São Paulo and Recife for which conventional autopsy was indicated. VA was conducted with a relative of the deceased using an amended version of the SmartVA instrument to suit the local context. Causes of death from VA were produced using the SmartVA-Analyze program. Physician coded verbal autopsy (PCVA), conducted on the same questionnaires, and Global Burden of Disease Study data were used as additional comparators. Cause of death data were grouped into 10 broad causes for the validation due to the real-world utility of VA lying in identifying broad population cause of death patterns. Findings: The study included 2,060 deaths in São Paulo and 1,079 in Recife. The cause specific mortality fractions (CSMFs) estimated using SmartVA were broadly similar to conventional autopsy for: cardiovascular diseases (46.8% vs 54.0%, respectively), cancers (10.6% vs 11.4%), infections (7.0% vs 10.4%) and chronic respiratory disease (4.1% vs 3.7%), causes accounting for 76.1% of the autopsy dataset. The SmartVA CSMF estimates were lower than autopsy for "Other NCDs" (7.8% vs 14.6%) and higher for diabetes (13.0% vs 6.6%). CSMF accuracy of SmartVA compared to autopsy was 84.5%. CSMF accuracy for PCVA was 93.0%. Interpretation: The results suggest that SmartVA can, with reasonable accuracy, predict the broad cause of death groups important to assess a population's epidemiological transition. VA remains a useful tool for understanding causes of death where medical certification is not possible.

Ultrasound-Guided Minimally Invasive Tissue Sampling: A Minimally Invasive Autopsy Strategy During the COVID-19 Pandemic in Brazil, 2020.

BACKGROUND: Minimally invasive autopsies, also known as minimally invasive tissue sampling (MITS), have proven to be an alternative to complete diagnostic autopsies (CDAs) in places or situations where this procedure cannot be performed. During the coronavirus disease 2019 (COVID-19) pandemic, CDAs were suspended by March 2020 in Brazil to reduce biohazard. To contribute to the understanding of COVID-19 pathology, we have conducted ultrasound (US)-guided MITS as a strategy. METHODS: This case series study includes 80 autopsies performed in patients with COVID-19 confirmed by laboratorial tests. Different organs were sampled using a standardized MITS protocol. Tissues were submitted to histopathological analysis as well as immunohistochemical and molecular analysis and electron microscopy in selected cases. RESULTS: US-guided MITS proved to be a safe and highly accurate procedure; none of the personnel were infected, and accuracy ranged from 69.1% for kidney, up to 90.1% for lungs, and reaching 98.7% and 97.5% for liver and heart, respectively. US-guided MITS provided a systemic view of the disease, describing the most common pathological findings and identifying viral and other infectious agents using ancillary techniques, and also allowed COVID-19 diagnosis confirmation in 5% of the cases that were negative in premortem and postmortem nasopharyngeal/oropharyngeal swab real-time reverse-transcription polymerase chain reaction. CONCLUSIONS: Our data showed that US-guided MITS has the capacity similar to CDA not only to identify but also to characterize emergent diseases.

An autopsy study of the spectrum of severe COVID-19 in children: From SARS to different phenotypes of MIS-C.

BACKGROUND: COVID-19 in children is usually mild or asymptomatic, but severe and fatal paediatric cases have been described. The pathology of COVID-19 in children is not known; the proposed pathogenesis for severe cases includes immune-mediated mechanisms or the direct effect of SARS-CoV-2 on tissues. We describe the autopsy findings in five cases of paediatric COVID-19 and provide mechanistic insight into the mechanisms involved in the pathogenesis of the disease. METHODS: Children and adolescents who died with COVID-19 between March 18 and August 15, 2020 were autopsied with a minimally invasive method. Tissue samples from all vital organs were analysed by histology, electron microscopy (EM), reverse-transcription polymerase chain reaction (RT-PCR) and immunohistochemistry (IHC). FINDINGS: Five patients were included, one male and four female, aged 7 months to 15 years. Two patients had severe diseases before SARS-CoV-2 infection: adrenal carcinoma and Edwards syndrome. Three patients were previously healthy and had multisystem inflammatory syndrome in children (MIS-C) with distinct clinical presentations: myocarditis, colitis, and acute encephalopathy with status epilepticus. Autopsy findings varied amongst patients and included mild to severe COVID-19 pneumonia, pulmonary microthrombosis, cerebral oedema with reactive gliosis, myocarditis, intestinal inflammation, and haemophagocytosis. SARS-CoV-2 was detected in all patients in lungs, heart and kidneys by at least one method (RT-PCR, IHC or EM), and in endothelial cells from heart and brain in two patients with MIS-C (IHC). In addition, we show for the first time the presence of SARS-CoV-2 in the brain tissue of a child with MIS-C with acute encephalopathy, and in the intestinal tissue of a child with acute colitis. Interpretation: SARS-CoV-2 can infect several cell and tissue types in paediatric patients, and the target organ for the clinical manifestation varies amongst individuals. Two major patterns of severe COVID-19 were observed: a primarily pulmonary disease, with severe acute respiratory disease and diffuse alveolar damage, or a multisystem inflammatory syndrome with the involvement of several organs. The presence of SARS-CoV-2 in several organs, associated with cellular ultrastructural changes, reinforces the hypothesis that a direct effect of SARS-CoV-2 on tissues is involved in the pathogenesis of MIS-C. FUNDING: Fundação de Amparo à Pesquisa do Estado de São Paulo, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Bill and Melinda Gates Foundation.

Individual exposure to urban air pollution and its correlation with placental angiogenic markers in the first trimester of pregnancy, in São Paulo, Brazil.

Pollution of the atmosphere is known that may lead to adverse obstetric outcomes, including fetal growth restriction, gestational hypertension, and preeclampsia. Such disorders are correlated with imbalances in angiogenic factors, which may also be involved in the pathological mechanism as the pollutants impact placental and maternal physiology. In the first trimester of gestation, this study assessed the outcomes of personal maternal short period exposure to air pollution on soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PLGF) of pregnant women blood concentrations. This was a cross-sectional study, held in the city of São Paulo, Brazil, and conducted with low-risk pregnant women, who carried personal passive nitrogen dioxide (NO2) and ozone (O3) monitors for about a few days preceding the ultrasound evaluation, and on this day, the venous blood sample was collected to measure the angiogenic factors sFlt1 and PLGF and their ratio (sFlt1/PLGF) by enzyme-linked immunosorbent assay (ELISA). By means of multiple regression models, the effect of the studied pollutants on the log-transformed concentrations of the angiogenic factors was evaluated. One hundred thirty-one patients were included. The log of the sFlt1/PLGF ratio increased with rising NO2 levels (p = 0.021 and beta = 0.206), and the log of the PLGF concentration showed a negative correlation with NO2 (p = 0.008 and beta = - 0.234). NO2, an indicator of the levels of primary air pollutants, presented significant positive correlation with an increased sFlt1/PLGF ratio and diminished PLGF levels, which may reflect an antiangiogenic state generated by air pollution exposure.

Development and Assessment of a Brazilian Pilot Massive Open Online Course in Planetary Health Education: An Innovative Model for Primary Care Professionals and Community Training.

Introduction: Planetary health (PH) has emerged as a leading field for raising awareness, debating, and finding solutions for the health impacts of human-caused disruptions to Earth's natural systems. PH education addresses essential questions of how humanity inhabits Earth, and how humans affect, and are affected by, natural systems. A pilot massive open online course (MOOC) in PH was created in Brazil in 2020. This MOOC capitalized on the global online pivot, to make the course accessible to a broader audience. This study describes the process of course creation and development and assesses the impact evaluation data and student outcomes of the PH MOOC. Methods: The PH MOOC pilot was launched in Brazilian Portuguese, using the TelessaúdeRS-UFRGS platform on 4/27/2020 and concluded on 7/19/2020 with a total load of 80 h. It was composed of 8 content modules, pre and post-test, 10 topics in a forum discussion, and an optional action plan. This study analyzes the course database, profile of participants, answers to questionnaires, forum interaction, and action plans submitted. Results: Two thousand seven hundred seventy-seven participants enrolled in the course, of which 1,237 (44.54%) gave informed consent for this study. Of the 1,237 participants who agreed to participate in the research, 614 (49.8%) completed the course, and 569 (92.67%) were accredited by TelessaúdeRS-UFRGS. The majority of the participants were concerned with climate change, trained in the health area, and worked in primary health care in places that lacked ongoing sustainability programs. Two hundred forty-one action plans were submitted, major topics identified were food and nutrition, infectious diseases, and garbage and recycling. Discussion: The use of the PH lens and open perspective of the course centered the need to communicate planetary health topics to individuals. The local plans reflected the motto of "think global and act local." Brazil presents a context of an unprecedented social, political, and environmental crisis, with massive deforestation, extensive fires, and biomass burning altering the biomes, on top of an ongoing necropolitical infodemic and COVID-19 pandemic. In the face of these multiple challenges, this MOOC offers a timely resource for health professionals and communities, encouraging them to address planetary challenges as fundamental health determinants.