ABSTRACT
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
Subject(s)
Atrial Fibrillation , Catheter Ablation , Humans , Atrial Fibrillation/diagnosis , Atrial Fibrillation/surgery , Latin America , Treatment Outcome , Catheters , Asia , Catheter Ablation/adverse effects , Catheter Ablation/methodsABSTRACT
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Consensus , Societies, Medical , Atrial Fibrillation/surgery , Catheter Ablation/methods , Humans , Europe , Latin America , AsiaABSTRACT
Hypertrophic cardiomyopathy (HCM) is a form of genetically caused heart muscle disease, characterized by the thickening of the ventricular walls. Diagnosis requires detection through imaging methods (Echocardiogram or Cardiac Magnetic Resonance) showing any segment of the left ventricular wall with a thickness > 15 mm, without any other probable cause. Genetic analysis allows the identification of mutations in genes encoding different structures of the sarcomere responsible for the development of HCM in about 60% of cases, enabling screening of family members and genetic counseling, as an important part of patient and family management. Several concepts about HCM have recently been reviewed, including its prevalence of 1 in 250 individuals, hence not a rare but rather underdiagnosed disease. The vast majority of patients are asymptomatic. In symptomatic cases, obstruction of the left ventricular outflow tract (LVOT) is the primary disorder responsible for symptoms, and its presence should be investigated in all cases. In those where resting echocardiogram or Valsalva maneuver does not detect significant intraventricular gradient (> 30 mmHg), they should undergo stress echocardiography to detect LVOT obstruction. Patients with limiting symptoms and severe LVOT obstruction, refractory to beta-blockers and verapamil, should receive septal reduction therapies or use new drugs inhibiting cardiac myosin. Finally, appropriately identified patients at increased risk of sudden death may receive prophylactic measure with implantable cardioverter-defibrillator (ICD) implantation.
La miocardiopatía hipertrófica (MCH) es una forma de enfermedad cardíaca de origen genético, caracterizada por el engrosamiento de las paredes ventriculares. El diagnóstico requiere la detección mediante métodos de imagen (Ecocardiograma o Resonancia Magnética Cardíaca) que muestren algún segmento de la pared ventricular izquierda con un grosor > 15 mm, sin otra causa probable. El análisis genético permite identificar mutaciones en genes que codifican diferentes estructuras del sarcómero responsables del desarrollo de la MCH en aproximadamente el 60% de los casos, lo que permite el tamizaje de familiares y el asesoramiento genético, como parte importante del manejo de pacientes y familiares. Varios conceptos sobre la MCH han sido revisados recientemente, incluida su prevalencia de 1 entre 250 individuos, por lo tanto, no es una enfermedad rara, sino subdiagnosticada. La gran mayoría de los pacientes son asintomáticos. En los casos sintomáticos, la obstrucción del tracto de salida ventricular izquierdo (TSVI) es el trastorno principal responsable de los síntomas, y su presencia debe investigarse en todos los casos. En aquellos en los que el ecocardiograma en reposo o la maniobra de Valsalva no detecta un gradiente intraventricular significativo (> 30 mmHg), deben someterse a ecocardiografía de esfuerzo para detectar la obstrucción del TSVI. Los pacientes con síntomas limitantes y obstrucción grave del TSVI, refractarios al uso de betabloqueantes y verapamilo, deben recibir terapias de reducción septal o usar nuevos medicamentos inhibidores de la miosina cardíaca. Finalmente, los pacientes adecuadamente identificados con un riesgo aumentado de muerte súbita pueden recibir medidas profilácticas con el implante de un cardioversor-desfibrilador implantable (CDI).
A cardiomiopatia hipertrófica (CMH) é uma forma de doença do músculo cardíaco de causa genética, caracterizada pela hipertrofia das paredes ventriculares. O diagnóstico requer detecção por métodos de imagem (Ecocardiograma ou Ressonância Magnética Cardíaca) de qualquer segmento da parede do ventrículo esquerdo com espessura > 15 mm, sem outra causa provável. A análise genética permite identificar mutações de genes codificantes de diferentes estruturas do sarcômero responsáveis pelo desenvolvimento da CMH em cerca de 60% dos casos, permitindo o rastreio de familiares e aconselhamento genético, como parte importante do manejo dos pacientes e familiares. Vários conceitos sobre a CMH foram recentemente revistos, incluindo sua prevalência de 1 em 250 indivíduos, não sendo, portanto, uma doença rara, mas subdiagnosticada. A vasta maioria dos pacientes é assintomática. Naqueles sintomáticos, a obstrução do trato de saída do ventrículo esquerdo (OTSVE) é o principal distúrbio responsável pelos sintomas, devendo-se investigar a sua presença em todos os casos. Naqueles em que o ecocardiograma em repouso ou com Manobra de Valsalva não detecta gradiente intraventricular significativo (> 30 mmHg), devem ser submetidos à ecocardiografia com esforço físico para detecção da OTSVE. Pacientes com sintomas limitantes e grave OTSVE, refratários ao uso de betabloqueadores e verapamil, devem receber terapias de redução septal ou uso de novas drogas inibidoras da miosina cardíaca. Por fim, os pacientes adequadamente identificados com risco aumentado de morta súbita podem receber medida profilática com implante de cardiodesfibrilador implantável (CDI).
ABSTRACT
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
ABSTRACT
BACKGROUND: It is estimated that atrial fibrillation (AF) affects approximately 1.5 million people in Brazil; however, epidemiological data are limited. We sought to evaluate the characteristics, treatment patterns, and clinical outcomes in patients with AF in Brazil by creating the first nationwide prospective registry. METHODS: RECALL was a multicenter, prospective registry that included and followed for 1 year 4,585 patients with AF at 89 sites across Brazil from April 2012 to August 2019. Patient characteristics, concomitant medication use, and clinical outcomes were analyzed using descriptive statistics and multivariable models. RESULTS: Of 4,585 patients enrolled, the median age was 70 (61, 78) years, 46% were women, and 53.8% had permanent AF. Only 4.4% of patients had a history of previous AF ablation and 25.2% had a previous cardioversion. The mean (SD) CHA2DS2-VASc score was 3.2 (1.6); median HAS-BLED score was 2 (2, 3). At baseline, 22% were not on anticoagulants. Of those taking anticoagulants, 62.6% were taking vitamin K antagonists and 37.4% were taking direct oral anticoagulants. The primary reasons for not using an oral anticoagulant were physician judgment (24.6%) and difficulty in controlling (14.7%) or performing (9.9%) INR. Mean (SD) TTR for the study period was 49.5% (27.5). During follow-up, the use of anticoagulants and INR in the therapeutic range increased to 87.1% and 59.1%, respectively. The rates/100 patient-years of death, hospitalization due to AF, AF ablation, cardioversion, stroke, systemic embolism, and major bleeding were 5.76 (5.12-6.47), 15.8 (14.6-17.0), 5.0 (4.4-5.7), 1.8 (1.4-2.2), 2.77 (2.32-3.32), 1.01 (0.75-1.36), and 2.21 (1.81-2.70). Older age, permanent AF, New York Heart Association class III/IV, chronic kidney disease, peripheral arterial disease, stroke, chronic obstructive pulmonary disease, and dementia were independently associated with increased mortality while the use of anticoagulant was associated with lower risk of death. CONCLUSIONS: RECALL represents the largest prospective registry of patients with AF in Latin America. Our findings highlight important gaps in treatment, which can inform clinical practice and guide future interventions to improve the care of these patients.
Subject(s)
Atrial Fibrillation , Stroke , Humans , Female , Aged , Male , Atrial Fibrillation/epidemiology , Atrial Fibrillation/therapy , Atrial Fibrillation/complications , Brazil/epidemiology , Risk Factors , Stroke/epidemiology , Stroke/etiology , Stroke/prevention & control , Anticoagulants , Hemorrhage/chemically induced , RegistriesABSTRACT
Importance: Contact tracing is a core strategy for preventing the spread of many infectious diseases of public health concern. Better understanding of the outcomes of contact tracing for COVID-19 as well as the operational opportunities and challenges in establishing a program for a jurisdiction as large as New York City (NYC) is important for the evaluation of this strategy. Objective: To describe the establishment, scaling, and maintenance of Trace, NYC's contact tracing program, and share data on outcomes during its first 17 months. Design, Setting, and Participants: This cross-sectional study included people with laboratory test-confirmed and probable COVID-19 and their contacts in NYC between June 1, 2020, and October 31, 2021. Trace launched on June 1, 2020, and had a workforce of 4147 contact tracers, with the majority of the workforce performing their jobs completely remotely. Data were analyzed in March 2022. Main Outcomes and Measures: Number and proportion of persons with COVID-19 and contacts on whom investigations were attempted and completed; timeliness of interviews relative to symptom onset or exposure for symptomatic cases and contacts, respectively. Results: Case investigations were attempted for 941â¯035 persons. Of those, 840â¯922 (89.4%) were reached and 711â¯353 (75.6%) completed an intake interview (women and girls, 358â¯775 [50.4%]; 60â¯178 [8.5%] Asian, 110â¯636 [15.6%] Black, 210â¯489 [28.3%] Hispanic or Latino, 157â¯349 [22.1%] White). Interviews were attempted for 1â¯218â¯650 contacts. Of those, 904â¯927 (74.3%) were reached, and 590â¯333 (48.4%) completed intake (women and girls, 219â¯261 [37.2%]; 47â¯403 [8.0%] Asian, 98â¯916 [16.8%] Black, 177â¯600 [30.1%] Hispanic or Latino, 116â¯559 [19.7%] White). Completion rates were consistent over time and resistant to changes related to vaccination as well as isolation and quarantine guidance. Among symptomatic cases, median time from symptom onset to intake completion was 4.7 days; a median 1.4 contacts were identified per case. Median time from contacts' last date of exposure to intake completion was 2.3 days. Among contacts, 30.1% were tested within 14 days of notification. Among cases, 27.8% were known to Trace as contacts. The overall expense for Trace from May 6, 2020, through October 31, 2021, was approximately $600 million. Conclusions and Relevance: Despite the complexity of developing a contact tracing program in a diverse city with a population of over 8 million people, in this case study we were able to identify 1.4 contacts per case and offer resources to safely isolate and quarantine to over 1 million cases and contacts in this study period.
Subject(s)
COVID-19 , Contact Tracing , Female , Humans , COVID-19/epidemiology , COVID-19/prevention & control , New York City/epidemiology , Cross-Sectional Studies , QuarantineABSTRACT
BACKGROUND: The 2017-2018 yellow fever virus (YFV) outbreak in southeastern Brazil marked a reemergence of YFV in urban states that had been YFV-free for nearly a century. Unlike earlier urban YFV transmission, this epidemic was driven by forest mosquitoes. The objective of this study was to evaluate environmental drivers of this outbreak. METHODOLOGY/PRINCIPAL FINDINGS: Using surveillance data from the Brazilian Ministry of Health on human and non-human primate (NHP) cases of YFV, we traced the spatiotemporal progression of the outbreak. We then assessed the epidemic timing in relation to drought using a monthly Standardized Precipitation Evapotranspiration Index (SPEI) and evaluated demographic risk factors for rural or outdoor exposure amongst YFV cases. Finally, we developed a mechanistic framework to map the relationship between drought and YFV. Both human and NHP cases were first identified in a hot, dry, rural area in northern Minas Gerais before spreading southeast into the more cool, wet urban states. Outbreaks coincided with drought in all four southeastern states of Brazil and an extreme drought in Minas Gerais. Confirmed YFV cases had an increased odds of being male (OR 2.6; 95% CI 2.2-3.0), working age (OR: 1.8; 95% CI: 1.5-2.1), and reporting any recent travel (OR: 2.8; 95% CI: 2.3-3.3). Based on this data as well as mosquito and non-human primate biology, we created the "Mono-DrY" mechanistic framework showing how an unusual drought in this region could have amplified YFV transmission at the rural-urban interface and sparked the spread of this epidemic. CONCLUSIONS/SIGNIFICANCE: The 2017-2018 YFV epidemic in Brazil originated in hot, dry rural areas of Minas Gerais before expanding south into urban centers. An unusually severe drought in this region may have created environmental pressures that sparked the reemergence of YFV in Brazil's southeastern cities.
Subject(s)
Droughts , Mosquito Vectors , Yellow Fever/epidemiology , Yellow Fever/transmission , Animals , Brazil/epidemiology , Disease Outbreaks , Female , Humans , Male , Occupations , Primate Diseases/epidemiology , Primate Diseases/virology , Primates , Urban Population , Yellow Fever/veterinary , Yellow fever virusABSTRACT
INTRODUÇÃO: Resultados favoráveis foram relatados com estimulação direta do sistema de excito-condutor cardíaco, o que tem motivado a inclusão desta técnica em recomendações e diretrizes atuais. Entretanto, não há dados disponíveis dessa prática no Brasil. OBJETIVOS: Descrever as características demográficas, eletrocardiográficas e ecocardiográficas assim como os achados intra e peri-operatórios dos pacientes submetidos a estimulação fisiológica no Brasil. MÉTODOS: Trata-se de um registro multicêntrico realizado em 15 centros no Brasil. A técnica cirúrgica utilizada seguiu a rotina dos centros participantes. RESULTADOS: 180 pacientes (64,9% homens, 74,8±12,5 anos) foram incluídos na análise entre maio e setembro de 2021. Características clínicas: 82,7% eram hipertensos, 33,5% diabéticos, 51,9% tinham antecedente de sincope, 23,2% DAC e 0,7% doença de Chagas; 76,7% apresentavam-se em CF-NYHA I ou II. A cardiopatia subjacente e o motivo do implante estão ilustrados na figura 1. Em 13,5% dos pacientes, o CDI foi concomitantemente indicado. Quanto aos achados eletrocardiográficos, 89,2% dos pacientes apresentavam-se em ritmo sinusal e 10,8% em FA/flutter atrial. O QRS basal médio era de 131±32ms; 28,1% dos pacientes apresentavam BRE e 31,4% BRD. A FEVE média foi de 54,14±16,66%. Todos os centros reportaram sucesso do implante. O tempo médio de fluoroscopia foi de 17,6±14,5min e a duração média do procedimento 81,8±43,8. Dispositivo bicameral foi predominante na maior parte dos casos (figura 2). Em 75,1% dos casos, o eletrodo ventricular foi posicionado no RE/septo profundo (LVAT médio 77,7±10,7ms, potencial de RE reportado em 25,7%) enquanto o feixe de His foi a posição escolhida em 24,9% dos casos. Em 6,6% dos pacientes procedeu-se HOT/LOT-CRT. A onda R média foi 9,8mV e o limiar de captura 1,17V x 1,0ms. A duração média do QRS final foi 107,46 ± 18,6ms. As taxas de complicações foram baixas (figura 3). CONCLUSÕES: O implante de marcapasso fisiológico é factível e seguro. As características dos pacientes incluídos nesse registro brasileiro, a preferência quanto ao tipo de estimulação (RE) e os resultados intra e pós operatórios precoces estão alinhados com as publicações internacionais mais recentes.
Subject(s)
Cardiac Pacing, Artificial , Guidelines as Topic , Heart Conduction SystemABSTRACT
While the annual incidence of HIV diagnosis in pregnancy in Brazil remains relatively stable, rates of maternal syphilis increased over six-fold in the past decade. We hypothesized that maternal HIV and syphilis are two distinct epidemics. Data on all cases of maternal HIV or syphilis detected in pregnancy between January 1, 2010 to December 31, 2018 were requested from the Brazilian Ministry of Health. In order to evaluate how the epidemics evolved over the time period, ArcGIS software was used to generate spatiotemporal maps of annual rates of detection of maternal HIV and syphilis in 2010 and 2018. We utilized Euclidean-distance hot spot analysis to identify state-specific clusters in 2010 and 2018. From 2010 to 2018, there were 66,631 cases of maternal HIV, 225,451 cases of maternal syphilis, and 150,414 cases of congenital syphilis in Brazil. The state of Rio Grande do Sul had the highest rate of maternal HIV detection in both 2010 and 2018. Hot spots of maternal HIV were identified in the three most Southern states in both 2010 and 2018 (99% confidence, z-score >2.58, p <0.01). While syphilis incidence >30 per 1,000 live births in 2018 in four states, only the two coastal states of Rio de Janeiro and Espirito Santo in Southeastern Brazil were significant hot spots (90% confidence, z-score 1.65-1.95, p <0.10). Contrary to the general assumption, HIV and syphilis epidemics in Brazil are not syndemic in pregnant women. There is a spatial cluster of maternal HIV in the South, while syphilis is increasing throughout the country, more recently on the coast. Focusing on maternal HIV hot spots in the Southern states is insufficient to curtail the maternal and congenital syphilis epidemics throughout the country. New strategies, including ongoing hot spot analysis, are urgently needed to monitor, identify and treat maternal syphilis.
Subject(s)
HIV Infections/epidemiology , HIV/isolation & purification , Maternal Exposure/statistics & numerical data , Syphilis/epidemiology , Adult , Brazil/epidemiology , Female , HIV Infections/virology , Humans , Pregnancy , Syphilis/microbiology , Young AdultABSTRACT
Este proyecto trata dos temas históricos, la alquimia y el desarrollo del método científico, y se analiza cómo estos saberes están relacionados entre sí. El uso de biografías científicas es hoy una de las tendencias más innovadoras en educación de distintas disciplinas, el método biográfico se justifica porque los expertos en cada materia y contexto entienden que las biografías de personajes característicos pueden ser útiles para conocer un determinado proceso. Se estudiaron y comprendieron las teorías de diferentes científicos y alquimistas, como Paracelso. Nos dedicaremos a su historiografía, que aportan ideas sobre el método científico y, sobre todo, relacionado con la ciencia experimental.
This project deals with two historical themes, alchemy, and the development of the method scientific, and it is analyzed how these knowledges are related to each other. The use of Scientific biographies is today one of the most innovative trends in education of different disciplines, the biographical method is justified because the experts in each subject and context understand that biographies of characteristic characters can be useful to know a certain process. They studied and understood the theories of different scientists and alchemists, such as Paracelsus. Us We will dedicate to his historiography, which provide ideas about the scientific method and, above all, related to experimental science.
Subject(s)
Humans , Science/classification , Biography , Alchemy , MethodsABSTRACT
Catheter-based ultrasonography is a widely used tool in cardiac electrophysiology practice, and intracardiac echocardiography is supplanting other forms of imaging to become the dominant imaging modality. Given advances in pericardial access, intrapericardial echocardiography can be performed using ultrasound catheters as well. Intrapericardial echocardiography and echocardiography from the coronary sinus, also an epicardial structure, allows interventionalists to obtain unique views from virtually any vantage point, compared with other forms of echocardiography. Both intrapericardial echocardiography and coronary sinus echocardiography are safe and important alternatives that can be used during complex procedures in the electrophysiology laboratory.
Subject(s)
Coronary Sinus/diagnostic imaging , Echocardiography/methods , Pericardium/diagnostic imaging , Catheter Ablation , Electrophysiologic Techniques, Cardiac/methods , HumansABSTRACT
More than 20 years since its initial use, catheter ablation has become a routinely performed procedure for the treatment of patients with atrial fibrillation (AF). Initially based on the electrical isolation of pulmonary veins in patients with paroxysmal AF, subsequent advances in the understanding of pathophysiology led to additional techniques not only to achieve better results, but also to treat patients with persistent forms of arrhythmia, as well as patients with structural heart disease and heart failure.
Após mais de 20 anos desde sua utilização inicial, a ablação por cateter se tornou um procedimento rotineiramente realizado para tratamento de pacientes com fibrilação atrial (FA). Fundamentado inicialmente no isolamento elétrico das veias pulmonares em pacientes com FA paroxística, subsequentes avanços no entendimento da fisiopatologia levaram a técnicas adicionais não só para obter melhores resultados, mas também para tratar pacientes com formas persistentes de arritmia, assim como pacientes com cardiopatia estrutural e insuficiência cardíaca.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Pulmonary Veins , Atrial Fibrillation/surgery , Humans , Pulmonary Veins/surgery , Recurrence , Treatment OutcomeABSTRACT
Resumo Após mais de 20 anos desde sua utilização inicial, a ablação por cateter se tornou um procedimento rotineiramente realizado para tratamento de pacientes com fibrilação atrial (FA). Fundamentado inicialmente no isolamento elétrico das veias pulmonares em pacientes com FA paroxística, subsequentes avanços no entendimento da fisiopatologia levaram a técnicas adicionais não só para obter melhores resultados, mas também para tratar pacientes com formas persistentes de arritmia, assim como pacientes com cardiopatia estrutural e insuficiência cardíaca.
Abstract More than 20 years since its initial use, catheter ablation has become a routinely performed procedure for the treatment of patients with atrial fibrillation (AF). Initially based on the electrical isolation of pulmonary veins in patients with paroxysmal AF, subsequent advances in the understanding of pathophysiology led to additional techniques not only to achieve better results, but also to treat patients with persistent forms of arrhythmia, as well as patients with structural heart disease and heart failure.
Subject(s)
Humans , Pulmonary Veins/surgery , Atrial Fibrillation/surgery , Catheter Ablation , Recurrence , Treatment OutcomeABSTRACT
OBJECTIVES: Rates of maternal syphilis have increased five-fold in Brazil in the past decade. While penicillin remains the only appropriate treatment for maternal syphilis, we hypothesized that low non-treponemal titers (<1:16) may lead to reduced penicillin treatment in Brazil. METHODS: Using Brazilian Ministry of Health data on women diagnosed with maternal syphilis between January 1, 2010, and December 31, 2018, we conducted a random-effects logistic regression model with a cluster correction at the state level to evaluate predictive factors of penicillin treatment. RESULTS: We observed yearly increases in cases of pregnant women with syphilis from 2010 to 2018. There was significant variation by state: 52,451 cases were reported in São Paulo, followed by 26,838 in Rio de Janeiro. Among 215,937 cases of maternal syphilis, 91·3% received penicillin. In the random-effects model, a non-treponemal titer ≥1:16 was associated with 1·44 higher odds of receiving penicillin (95% confidence interval [CI]: 1·391·48), and prenatal care was associated with a 2·12 increased odds of receiving penicillin (95% CI: 2·022·21). Although there is an association between the absence of prenatal care and inadequate treatment for syphilis, 83·2% of women in this cohort who did not receive penicillin were engaged in prenatal care. CONCLUSIONS: Providers may inappropriately exclude low non-treponemal titers and thereby fail to use penicillin treatment in maternal syphilis. While the cause of the maternal syphilis epidemic in Brazil is multifactorial, we believe our findings can be used to develop targeted interventions throughout Brazil as well as shape public health initiatives globally.