Análise da internação e mortalidade por HIV no Brasil, 2016-2020 / Analysis of hospitalization and HIV mortality in Brazil, 2016-2020 / Análisis de la hospitalización y la mortalidad por VIH en Brasil, 2016-2020

Apesar dos avanços programáticos conquistados na atenção às pessoas que vivem com HIV no Brasil, os índices de morbimortalidade atribuídos à infecção ainda são altos e heterogêneos no território nacional. Destarte, entende-se que os aspectos epidemiológicos do HIV devam ser analisados em consonância com as características e delimitações geográficas. Este estudo objetivou analisar os coeficientes de internação hospitalar e de mortalidade por HIV, segundo regiões do Brasil, de 2016 a 2020. Tratou-se de um estudo ecológico das regiões brasileiras, com dados extraídos das plataformas públicas de informação, referentes ao período de 2016 a 2020. Procedeu-se a análise por meio de estatística descritiva e, baseado nos coeficientes regionais de internação hospitalar e mortalidade calculados, foram derivadas ilustrações geográficas por meio do software QGIS, a partir do mapa do Brasil, divisado por regiões. Os resultados apontaram que as internações por HIV apresentaram queda em todas as regiões ao longo do período, contudo, o Sudeste se manteve abaixo da média nacional. Com relação aos óbitos, a queda foi observada em todas as regiões, com menor variação no Nordeste e Norte. Ademais, as regiões Sul e Norte seguiram com os maiores coeficientes de mortalidade do país durante todo o período analisado, enquanto as demais ficaram abaixo da média nacional. Pontua-se a necessidade de novas investigações quanto às especificidades regionais de conformação e organização da rede de atenção no que se refere à oferta de ações e serviços de saúde, bem como das condições socioeconômicas e comportamentais que influem no curso da infecção pelo HIV.

A pesar de los avances programáticos alcanzados en la atención de las personas que viven con el VIH en Brasil, las tasas de morbilidad y mortalidad atribuidas a la infección aún son elevadas y heterogéneas en el territorio nacional. Así, se entiende que los aspectos epidemiológicos del VIH deben ser analizados de acuerdo con las características y límites geográficos. Este estudio tuvo como objetivo analizar los coeficientes de hospitalización y mortalidad por VIH, según regiones de Brasil, de 2016 a 2020. Se trata de un estudio ecológico de regiones brasileñas, con datos extraídos de plataformas de información pública, referentes al período de 2016 a 2020. El análisis se realizó mediante estadística descriptiva y, a partir de los coeficientes de ingreso hospitalario regional y mortalidad calculados, se derivaron ilustraciones geográficas utilizando el software QGIS, a partir del mapa de Brasil, dividido por regiones. Los resultados mostraron que las hospitalizaciones por VIH disminuyeron en todas las regiones en el período, sin embargo, el Sudeste se mantuvo por debajo del promedio nacional. En cuanto a las muertes, la caída se observó en todas las regiones, con menor variación en el Nordeste y Norte. Además, las regiones Sur y Norte continuaron presentando las tasas de mortalidad más altas del país durante todo el período analizado, mientras que las demás se ubicaron por debajo del promedio nacional. Existe la necesidad de mayores investigaciones sobre las especificidades regionales de conformación y organización de la red de atención en lo que se refiere a la provisión de acciones y servicios de salud, así como las condiciones socioeconómicas y conductuales que influyen en el curso de la infección por el VIH.

Despite the programmatic advances achieved in the care of people living with HIV in Brazil, the morbidity and mortality rates attributed to the infection are still high and heterogeneous in the national territory. Thus, it is understood that the epidemiological aspects of HIV should be analyzed in accordance with the characteristics and geographical boundaries. This study aimed to analyze the coefficients of hospitalization and mortality from HIV, according to regions of Brazil, from 2016 to 2020. This was an ecological study of Brazilian regions, with data extracted from public information platforms, referring to the period 2016 to 2020. The analysis was performed using descriptive statistics and, based on the calculated regional hospital admission and mortality coefficients, geographic illustrations were derived using the QGIS software, from the map of Brazil, divided by regions. The results showed that hospitalizations for HIV decreased in all regions over the period; however, the Southeast remained below the national average. Regarding deaths, the drop was observed in all regions, with less variation in the Northeast and North. Furthermore, the South and North regions continued to have the highest mortality rates in the country throughout the analyzed period, while the others were below the national average. There is a need for further investigations regarding the regional specificities of conformation and organization of the care network with regard to the provision of health actions and services, as well as the socioeconomic and behavioral conditions that influence the course of HIV infection.

Las Topográfias Médicas: una aportación de la Medicina Rural a la Salud Pública / Medical Topographies: A Contribution of Rural Medicine to Public Health

Las Topografías Médicas (TM) o Geografías Médicas, son un género de la literatura médica, cuyos orígenes pueden encontrarse en el tratado de Hipócrates, Sobre los aires, aguas y lugares. El objetivo básico de las TM fue simplemente describir la salud de la población de un lugar determinado, aunque pronto ampliaron su campo de acción, para investigar la influencia del entorno físico y social en las enfermedades que padece la población en zonas geográficas o localidades. El inicio de su desarrollo tiene lugar en el contexto de la Medicina de la Ilustración, y adquirirán su mayoría de edad durante el siglo xix y las primeras décadas del siglo xx, para finalizar su producción en los años setenta del pasado siglo. Las Reales Academias de Medicina tuvieron una importancia decisiva en el desarrollo de las TM, proponiendo una metodología y un contenido homogéneo para la redacción de las mismas y estableciendo premios anuales para las obras galardonadas, lo que permitió mejorar su calidad y homogeneidad. El texto de las TM incluía generalmente un esbozo histórico de la población, la geografía de la zona, la descripción de la flora y de la fauna, con frecuencia de forma muy detalladas, el estudio del clima, de las vías públicas y las viviendas, la descripción de las enfermedades más frecuentes y epidemias, así como la demografía y situación socioeconómica de la población, entre otros. ... En el presente artículo se describe la evolución histórica de las TM, sus contenidos principales, su distribución por autonomías y años, y algunos personajes ilustres relacionados con ellas; aportándose alguna iconografía y copias de los documentos más interesantes por su valor médico o artístico. (AU)

Medical Topographies (TM) or Medical Geographies, are a genre of medical literature, whose origins can be found in Hippocrates’ treatise, On Airs, Waters and Places. The initial objective of TM was simply to describe the health of the population of given place, although they soon expanded their field of action to investigate the influence of the physical and social environment on the diseases suffered by the population in geographical areas or localities. The beginning of their development took place in the context of Enlightenment Medicine, and they came of age during the 19th century and the first decades of the 20th century, ending their production in the seventies of the last century. The Royal Academies of Medicine had a decisive importance in the development of TM, proposing a methodology and homogeneous content for their writing and establishing annual prizes for the award-winning works, which allowed them to improve their quality and homogeneity. The text of the TM generally included a historical outline of the population, the geography of the area, the description of the flora and fauna, often in very detailed form, the study of the climate, public roads and homes, the description of the most frequent diseases and epidemics, as well as the demographics and socio-economic situation of the population, among others. ... This article describes the historical evolution of the TM, its main contents, its distribution by autonomies and years, and some illustrious people related to them, providing some iconography and copies of the most interesting documents due to their medical or artistic value. (AU)

Análisis de la ansiedad y la depresión durante la pandemia del COVID-19 mediante Google Trends / Analysis of anxiety and depression during the Covid-19 pandemic using Google Trends

Los trastornos de ansiedad y depresión tienen una alta prevalencia en la población, en algunas ocasiones generada por situaciones excepcionales como la pandemia del Covid-19. La prevalencia de estos trastornos mentales podría inferirse con Google Trends, una herramienta que analiza las tenencias de búsqueda en Internet por rangos de tiempo y localización geográfica. Con el objetivo de estudiar la relación entre las tendencias de búsqueda de los términos "Ansiedad" y "Depresión" y su prevalencia en España durante la pandemia del Covid-19, se realizó un análisis de búsqueda selectiva a partir de variables geográficas (Madrid, Andalucía, Cataluña) y temporales (semanas año 2020). Se tuvieron en cuenta las palabras "Ansiedad", "Depresión" y "Covid-19", para realizar las estimaciones de las tendencias de búsqueda en Google Trends. Los resultados mostraron diferencias significativas entre las comunidades autónomas en el interés por la búsqueda de información sobre depresión, así como una progresión temporal diferente, tanto en ansiedad como en depresión, que reflejaría las fluctuaciones en la evolución de los datos epidemiológicos en cada región geográfica. Herramientas como Google Trends permitirían a la comunidad sanitaria implementar estrategias de prevención ante la detección de picos de preocupación por determinados trastornos mentales en regiones y periodos temporales concretos. Esto resulta especialmente relevante si la prevalencia de estos trastornos en la población puede interferir negativamente con la eficacia de las políticas de prevención y contención sanitaria en situaciones de emergencia.(AU)

Anxiety and depression disorders have a high prevalence in the population, sometimes generated by exceptional situations such as the Covid-19 pandemic. The prevalence of these mental disorders could be inferred with Google Trends, a tool that analyzes Internet search holdings by time ranges and geographic location. In order to study the relationship between search trends for the terms "Anxiety" and "Depression" and their prevalence in Spain during the Covid-19 pandemic, a selective search analysis was carried out based on geographic variables (Madrid, Andalusia, Catalonia) and temporary (weeks in 2020). The words "Anxiety", "Depression" and "Covid-19" were taken into account to make the estimates of search trends in Google Trends. The results showed significant differences between the autonomous communities in their interest in searching for information on depression, as well as a different temporal progression, both in anxiety and depression, which would reflect the fluctuations in the evolution of epidemiological data in each geographic region. Tools such as Google Trends would allow the health community to implement prevention strategies in the event of the detection of peaks of concern for certain mental disorders in specific regions and time periods. This is especially relevant if the prevalence of these disorders in the population can negatively interfere with the effectiveness of prevention and health containment policies in emergency situations.(AU)

Spatiotemporal distribution of cutaneous leishmaniasis in Sri Lanka and future case burden estimates.

BACKGROUND: Leishmaniasis is a neglected tropical vector-borne disease, which is on the rise in Sri Lanka. Spatiotemporal and risk factor analyses are useful for understanding transmission dynamics, spatial clustering and predicting future disease distribution and trends to facilitate effective infection control. METHODS: The nationwide clinically confirmed cutaneous leishmaniasis and climatic data were collected from 2001 to 2019. Hierarchical clustering and spatiotemporal cross-correlation analysis were used to measure the region-wide and local (between neighboring districts) synchrony of transmission. A mixed spatiotemporal regression-autoregression model was built to study the effects of climatic, neighboring-district dispersal, and infection carryover variables on leishmaniasis dynamics and spatial distribution. Same model without climatic variables was used to predict the future distribution and trends of leishmaniasis cases in Sri Lanka. RESULTS: A total of 19,361 clinically confirmed leishmaniasis cases have been reported in Sri Lanka from 2001-2019. There were three phases identified: low-transmission phase (2001-2010), parasite population buildup phase (2011-2017), and outbreak phase (2018-2019). Spatially, the districts were divided into three groups based on similarity in temporal dynamics. The global mean correlation among district incidence dynamics was 0.30 (95% CI 0.25-0.35), and the localized mean correlation between neighboring districts was 0.58 (95% CI 0.42-0.73). Risk analysis for the seven districts with the highest incidence rates indicated that precipitation, neighboring-district effect, and infection carryover effect exhibited significant correlation with district-level incidence dynamics. Model-predicted incidence dynamics and case distribution matched well with observed results, except for the outbreak in 2018. The model-predicted 2020 case number is about 5,400 cases, with intensified transmission and expansion of high-transmission area. The predicted case number will be 9115 in 2022 and 19212 in 2025. CONCLUSIONS: The drastic upsurge in leishmaniasis cases in Sri Lanka in the last few year was unprecedented and it was strongly linked to precipitation, high burden of localized infections and inter-district dispersal. Targeted interventions are urgently needed to arrest an uncontrollable disease spread.

Local versus distant lung donor procurement does not influence short-term clinical outcomes.

OBJECTIVE: The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS: This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS: Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS: Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.

Key genetic elements, single and in clusters, underlying geographically dependent SARS-CoV-2 genetic adaptation and their impact on binding affinity for drugs and immune control.

OBJECTIVES: To define key genetic elements, single or in clusters, underlying SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) evolutionary diversification across continents, and their impact on drug-binding affinity and viral antigenicity. METHODS: A total of 12 150 SARS-CoV-2 sequences (publicly available) from 69 countries were analysed. Mutational clusters were assessed by hierarchical clustering. Structure-based virtual screening (SBVS) was used to select the best inhibitors of 3-chymotrypsin-like protease (3CL-Pr) and RNA-dependent RNA polymerase (RdRp) among the FDA-approved drugs and to evaluate the impact of mutations on binding affinity of these drugs. The impact of mutations on epitope recognition was predicted following Grifoni et al. (Cell Host Microbe 2020. 27: 671-80.). RESULTS: Thirty-five key mutations were identified (prevalence: ≥0.5%), residing in different viral proteins. Sixteen out of 35 formed tight clusters involving multiple SARS-CoV-2 proteins, highlighting intergenic co-evolution. Some clusters (including D614GSpike + P323LRdRp + R203KN + G204RN) occurred in all continents, while others showed a geographically restricted circulation (T1198KPL-Pr + P13LN + A97VRdRp in Asia, L84SORF-8 + S197LN in Europe, Y541CHel + H504CHel + L84SORF-8 in America and Oceania). SBVS identified 20 best RdRp inhibitors and 21 best 3CL-Pr inhibitors belonging to different drug classes. Notably, mutations in RdRp or 3CL-Pr modulate, positively or negatively, the binding affinity of these drugs. Among them, P323LRdRp (prevalence: 61.9%) reduced the binding affinity of specific compounds including remdesivir while it increased the binding affinity of the purine analogues penciclovir and tenofovir, suggesting potential hypersusceptibility. Finally, specific mutations (including Y541CHel + H504CHel) strongly hampered recognition of Class I/II epitopes, while D614GSpike profoundly altered the structural stability of a recently identified B cell epitope target of neutralizing antibodies (amino acids 592-620). CONCLUSIONS: Key genetic elements reflect geographically dependent SARS-CoV-2 genetic adaptation, and may play a potential role in modulating drug susceptibility and hampering viral antigenicity. Thus, a close monitoring of SARS-CoV-2 mutational patterns is crucial to ensure the effectiveness of treatments and vaccines worldwide.

Characterization and Validation of the Second-generation wPUM Topography Monitors.

INTRODUCTION: Little is known about the natural use behavior of new and emerging tobacco products due to the limited availability of reliable puff topography monitors suitable for ambulatory deployment. An understanding of use behavior is needed to assess the health impact of emerging tobacco products and inform realistic standardized topography profiles for emissions studies. The purpose of this study is to validate four monitors: the wPUM cigalike, vapepen, hookah, and cigarette monitors. AIMS AND METHODS: Each wPUM monitor was characterized and validated for range, accuracy, and resolution for puff flow rate, duration, volume, and interpuff gap in a controlled laboratory environment. Monitor repeatability was assessed for each wPUM monitor using four separate week-long natural environment monitoring studies including cigalike, vapepen, hookah, and cigarette users. RESULTS: The valid flow rate range was 10 to 100 mL/s for cigalike and cigarette monitors, 10 to 95 mL/s for vapepen monitors, and 50 to 400 mL/s hookah monitors. Flow rate accuracy was within ±2 mL/s for cigalike, vapepen, and cigarette monitors and ±6 mL/s for the hookah monitor. Durations and interpuff gaps as small as 0.2 s were measured to within ±0.07 s. Monitor calibrations changed by 4.7% (vapepen), 1.5% (cigarette), 0.5% (cigalike), and 0.1% (hookah) after 1 week of natural environment use. CONCLUSIONS: The wPUM topography monitors were demonstrated to be reliable when deployed in the natural environment for a range of emerging tobacco products. IMPLICATIONS: The current study addresses the lack of available techniques to reliably monitor topography in the natural environment, across multiple emerging tobacco products. Natural environment topography data will inform standardized puffing protocols for premarket tobacco product applications. The ability to quantify topography over extended periods of time will lead to a better understanding of use behavior and better-informed regulations to protect public health.

Enabling Real-Time Compensation in Fast Photochemical Oxidations of Proteins for the Determination of Protein Topography Changes.

Fast photochemical oxidation of proteins (FPOP) is a mass spectrometry-based structural biology technique that probes the solvent-accessible surface area of proteins. This technique relies on the reaction of amino acid side chains with hydroxyl radicals freely diffusing in solution. FPOP generates these radicals in situ by laser photolysis of hydrogen peroxide, creating a burst of hydroxyl radicals that is depleted on the order of a microsecond. When these hydroxyl radicals react with a solvent-accessible amino acid side chain, the reaction products exhibit a mass shift that can be measured and quantified by mass spectrometry. Since the rate of reaction of an amino acid depends in part on the average solvent accessible surface of that amino acid, measured changes in the amount of oxidation of a given region of a protein can be directly correlated to changes in the solvent accessibility of that region between different conformations (e.g., ligand-bound versus ligand-free, monomer vs. aggregate, etc.) FPOP has been applied in a number of problems in biology, including protein-protein interactions, protein conformational changes, and protein-ligand binding. As the available concentration of hydroxyl radicals varies based on many experimental conditions in the FPOP experiment, it is important to monitor the effective radical dose to which the protein analyte is exposed. This monitoring is efficiently achieved by incorporating an inline dosimeter to measure the signal from the FPOP reaction, with laser fluence adjusted in real-time to achieve the desired amount of oxidation. With this compensation, changes in protein topography reflecting conformational changes, ligand-binding surfaces, and/or protein-protein interaction interfaces can be determined in heterogeneous samples using relatively low sample amounts.

Socioeconomic and geographic implications from carbon, nitrogen, and sulfur isotope ratios in human hair from Mexico.

This article presents data on carbon (C), nitrogen (N), and sulfur (S) isotopic composition of human hair collected throughout Mexico. The recorded values ranged from -18.3‰ to -12.8‰ for δ13C, 6.8‰ to 10.8‰ for δ15N and from 2.7‰ to 8.0‰ for δ34S. The socioeconomic covariates explored in this study showed, in part strong correlations with the recorded isotope values. Furthermore, these three isotope systems provide records of the dietary preferences and practices and also showed some spatial variation. This study detected geospatial patterning in the δ13C values of hair samples from Mexico as well as significant correlations with socioeconomic factors. No geospatial variation was detected in the δ15N and δ34S values, however, socioeconomic correlations were found. A δ13C isoscape was generated using a GIS approach, which provides a tool to narrow down region-of-origin predictions (in combination with other isotope systems) and to document the travel history of unidentified individuals.

Improved Geocoding of Cancer Registry Addresses in Urban and Rural Oklahoma.

BACKGROUND: Between 1997 and 2013 (the included study years), approximately 23% of addresses in the Oklahoma Central Cancer Registry (OCCR) were not geocoded to the address level. Addresses in rural counties were geocoded with poorer quality, preventing the instructive geographic research that informs policymaking. METHODS: To improve the accuracy of the geocodes, we first utilized the United States Postal Service's LACSLink database to correct addresses; specifically, to convert old rural route-based addresses to modernized Enhanced 911 (E911) addresses. We created custom geocoders using regional E911 reference data sets and used existing national scope geocoders of NAVTEQ and the North American Association of Central Cancer Registries. We attempted to geocode 5,102 addresses, which are either regular street addresses or rural route addresses. In the process, we evaluated and tabulated performances of the address correction. Accordingly, we first tabulated how well each geocoder could geocode original and LACSLink corrected addresses. We then documented the overall performances of geocoders based on pairwise comparisons. RESULTS: We were able to geocode 1,945 addresses out of this data set using 5 distinct geocoders. We observed that the LACSLink correction and E911 data were useful in the specific purpose of geocoding rural addresses, as found in the literature. CONCLUSIONS: We conclude that both LACSLink correction and E911 data were useful for improving geocoding of cancer records, many of which were in rural areas. Future directions include further validation of the geocoding and plans to conduct spatial exploratory data analysis to generate hypotheses related to the distribution of cancer in Oklahoma.

Automated Noncontact Facial Topography Mapping, 3-Dimensional Printing, and Silicone Casting of Orbital Prosthesis.

PURPOSE: A proof-of-concept workflow study for the fabrication of custom orbital exenteration prostheses via automated noncontact scanning, 3D printing, and silicone casting. DESIGN: Noncomparative, interventional case series. METHODS: Setting: Single-center institutional study. StudyPopulation: Three patients who have discontinued wearing of the ocularist-made exenteration prosthesis due to altered fit, discoloration, or material degradation. InterventionProcedure: A digital representation of the exenteration socket and contralateral periocular region was captured through noncontact facial topography mapping. Digital construction of the anterior prosthesis surface was based on the mirrored image of the contralateral side, and the posterior surface contour was based on orbital cavity geometry. The anterior and posterior surface details were digitally merged. A 2-piece mold was designed and produced in a 3D printer. Colorimetry was used to create a custom blend of pigments for incorporation into the Shore 40 silicone elastomer to generate a prosthesis that approximates the patient's skin tone. MainOutcomeMeasures: Prosthesis symmetry, skin tone match, comfort of wear, and appearance. RESULTS: The first copy of every 3D-printed orbital prosthesis using this fabrication workflow produced good symmetry, color match, and prosthesis fit. In one case, the recontoured second copy with improved prosthesis edge-to-skin interface was made without the patient present. CONCLUSION: A noncontact 3D scanning, computer-aided design, 3D printing, and silicone casting for fabrication of orbital prosthesis was developed and validated. This production workflow has the potential to provide an efficient, standardized, reproducible exenteration prosthesis and to overcome the principal barriers to an affordable custom prosthesis worldwide: access and cost.

Regional variations in cardiovascular risk factors and access to care among US veterans with cardiovascular disease.

BACKGROUND: It remains unclear whether cardiovascular risk factors and access to healthcare for veterans with cardiovascular disease (CVD) vary among US regions. This study sought to determine the extent of regional variations in cardiovascular risk factors and access to medical care in a cohort of veterans with CVD in the USA. METHODS: The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veteran patients with CVD. Participants were classified based on four US regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. We compared demographic data, medical history, and access to care for veterans of each US region. The outcomes of interest included financial barriers to medical care and annual medical checkup. RESULTS: Among the 13 835 veterans, 18.3% were from the Northeast, while 23.5, 37.1, and 21.1% were from the Midwest, South, and West, respectively. Veterans of each region differed significantly with respect to demographic characteristics, prior medical history, and access to care. Rates of financial barriers to medical care were similar across the four regions (7.3 vs. 7.1 vs. 8.0 vs. 6.9%, P = 0.203). Veterans from the West had the lowest rates of medical checkup within the past year (91.7 vs. 89.5 vs. 91.4 vs. 86.6%). On multivariate analysis, the Midwest [odds ratio (OR) 0.69; 95% CI, 0.53-0.89] and West (OR 0.53; 95% CI 0.41-0.68) regions were independently associated with lower rates of medical checkup within the past year compared to the Northeast. CONCLUSIONS: In this observational study involving US veterans with CVD, cardiovascular risk factors and frequency of annual medical checkup differed amongst each US region. Further large-scale studies examining the prevalence of impaired access to care and quality of care in US veterans with CVD are warranted.

The estimated burden of scrub typhus in Thailand from national surveillance data (2003-2018).

BACKGROUND: Scrub typhus is a major cause of acute febrile illness in the tropics and is endemic over large areas of the Asia Pacific region. The national and global burden of scrub typhus remains unclear due to limited data and difficulties surrounding diagnosis. METHODOLOGY/PRINCIPAL FINDINGS: Scrub typhus reporting data from 2003-2018 were collected from the Thai national disease surveillance system. Additional information including the district, sub-district and village of residence, population, geographical, meteorological and satellite imagery data were also collected for Chiangrai, the province with the highest number of reported cases from 2003-2018. From 2003-2018, 103,345 cases of scrub typhus were reported with the number of reported cases increasing substantially over the observed period. There were more men than women, with agricultural workers the main occupational group affected. The majority of cases occurred in the 15-64 year old age group (72,144/99,543, 72%). Disease burden was greatest in the northern region, accounting for 53% of the total reported cases per year (mean). In the northern region, five provinces-Chiangrai, Chiangmai, Tak, Nan and Mae Hong Son-accounted for 84% (46,927/55,872) of the total cases from the northern region or 45% (46,927/103,345) of cases nationally. The majority of cases occurred from June to November but seasonality was less marked in the southern region. In Chiangrai province, elevation, rainfall, temperature, population size, habitat complexity and diversity of land cover contributed to scrub typhus incidence. INTERPRETATION: The burden of scrub typhus in Thailand is high with disease incidence rising significantly over the last two decades. However, disease burden is not uniform with northern provinces particularly affected. Agricultural activity along with geographical, meteorological and land cover factors are likely to contribute to disease incidence. Our report, along with existing epidemiological data, suggests that scrub typhus is the most clinically important rickettsial disease globally.

Identification of cholera hotspots in Zambia: A spatiotemporal analysis of cholera data from 2008 to 2017.

The global burden of cholera is increasing, with the majority (60%) of the cases occurring in sub-Saharan Africa. In Zambia, widespread cholera outbreaks have occurred since 1977, predominantly in the capital city of Lusaka. During both the 2016 and 2018 outbreaks, the Ministry of Health implemented cholera vaccination in addition to other preventative and control measures, to stop the spread and control the outbreak. Given the limitations in vaccine availability and the logistical support required for vaccination, oral cholera vaccine (OCV) is now recommended for use in the high risk areas ("hotspots") for cholera. Hence, the aim of this study was to identify areas with an increased risk of cholera in Zambia. Retrospective cholera case data from 2008 to 2017 was obtained from the Ministry of Health, Department of Public Health and Disease Surveillance. The Zambian Central Statistical Office provided district-level population data, socioeconomic and water, sanitation and hygiene (WaSH) indicators. To identify districts at high risk, we performed a discrete Poisson-based space-time scan statistic to account for variations in cholera risk across both space and time over a 10-year study period. A zero-inflated negative binomial regression model was employed to identify the district level risk factors for cholera. The risk map was generated by classifying the relative risk of cholera in each district, as obtained from the space-scan test statistic. In total, 34,950 cases of cholera were reported in Zambia between 2008 and 2017. Cholera cases varied spatially by year. During the study period, Lusaka District had the highest burden of cholera, with 29,080 reported cases. The space-time scan statistic identified 16 districts to be at a significantly higher risk of having cholera. The relative risk of having cholera in these districts was significantly higher and ranged from 1.25 to 78.87 times higher when compared to elsewhere in the country. Proximity to waterbodies was the only factor associated with the increased risk for cholera (P<0.05). This study provides a basis for the cholera elimination program in Zambia. Outside Lusaka, the majority of high risk districts identified were near the border with the DRC, Tanzania, Mozambique, and Zimbabwe. This suggests that cholera in Zambia may be linked to movement of people from neighboring areas of cholera endemicity. A collaborative intervention program implemented in concert with neighboring countries could be an effective strategy for elimination of cholera in Zambia, while also reducing rates at a regional level.

Evidence of the absence of human African trypanosomiasis in two northern districts of Uganda: Analyses of cattle, pigs and tsetse flies for the presence of Trypanosoma brucei gambiense.

BACKGROUND: Large-scale control of sleeping sickness has led to a decline in the number of cases of Gambian human African trypanosomiasis (g-HAT) to <2000/year. However, achieving complete and lasting interruption of transmission may be difficult because animals may act as reservoir hosts for T. b. gambiense. Our study aims to update our understanding of T. b. gambiense in local vectors and domestic animals of N.W. Uganda. METHODS: We collected blood from 2896 cattle and 400 pigs and In addition, 6664 tsetse underwent microscopical examination for the presence of trypanosomes. Trypanosoma species were identified in tsetse from a subsample of 2184 using PCR. Primers specific for T. brucei s.l. and for T. brucei sub-species were used to screen cattle, pig and tsetse samples. RESULTS: In total, 39/2,088 (1.9%; 95% CI = 1.9-2.5) cattle, 25/400 (6.3%; 95% CI = 4.1-9.1) pigs and 40/2,184 (1.8%; 95% CI = 1.3-2.5) tsetse, were positive for T. brucei s.l.. Of these samples 24 cattle (61.5%), 15 pig (60%) and 25 tsetse (62.5%) samples had sufficient DNA to be screened using the T. brucei sub-species PCR. Further analysis found no cattle or pigs positive for T. b. gambiense, however, 17/40 of the tsetse samples produced a band suggestive of T. b. gambiense. When three of these 17 PCR products were sequenced the sequences were markedly different to T. b. gambiense, indicating that these flies were not infected with T. b. gambiense. CONCLUSION: The lack of T. b. gambiense positives in cattle, pigs and tsetse accords with the low prevalence of g-HAT in the human population. We found no evidence that livestock are acting as reservoir hosts. However, this study highlights the limitations of current methods of detecting and identifying T. b. gambiense which relies on a single copy-gene to discriminate between the different sub-species of T. brucei s.l.

Potential distributions of Bacillus anthracis and Bacillus cereus biovar anthracis causing anthrax in Africa.

BACKGROUND: Bacillus cereus biovar anthracis (Bcbva) is an emergent bacterium closely related to Bacillus anthracis, the etiological agent of anthrax. The latter has a worldwide distribution and usually causes infectious disease in mammals associated with savanna ecosystems. Bcbva was identified in humid tropical forests of Côte d'Ivoire in 2001. Here, we characterize the potential geographic distributions of Bcbva in West Africa and B. anthracis in sub-Saharan Africa using an ecological niche modeling approach. METHODOLOGY/PRINCIPAL FINDINGS: Georeferenced occurrence data for B. anthracis and Bcbva were obtained from public data repositories and the scientific literature. Combinations of temperature, humidity, vegetation greenness, and soils values served as environmental variables in model calibrations. To predict the potential distribution of suitable environments for each pathogen across the study region, parameter values derived from the median of 10 replicates of the best-performing model for each pathogen were used. We found suitable environments predicted for B. anthracis across areas of confirmed and suspected anthrax activity in sub-Saharan Africa, including an east-west corridor from Ethiopia to Sierra Leone in the Sahel region and multiple areas in eastern, central, and southern Africa. The study area for Bcbva was restricted to West and Central Africa to reflect areas that have likely been accessible to Bcbva by dispersal. Model predicted values indicated potential suitable environments within humid forested environments. Background similarity tests in geographic space indicated statistical support to reject the null hypothesis of similarity when comparing environments associated with B. anthracis to those of Bcbva and when comparing humidity values and soils values individually. We failed to reject the null hypothesis of similarity when comparing environments associated with Bcbva to those of B. anthracis, suggesting that additional investigation is needed to provide a more robust characterization of the Bcbva niche. CONCLUSIONS/SIGNIFICANCE: This study represents the first time that the environmental and geographic distribution of Bcbva has been mapped. We document likely differences in ecological niche-and consequently in geographic distribution-between Bcbva and typical B. anthracis, and areas of possible co-occurrence between the two. We provide information crucial to guiding and improving monitoring efforts focused on these pathogens.

Projecting the future of dengue under climate change scenarios: Progress, uncertainties and research needs.

BACKGROUND: Dengue is a mosquito-borne viral disease and its transmission is closely linked to climate. We aimed to review available information on the projection of dengue in the future under climate change scenarios. METHODS: Using five databases (PubMed, ProQuest, ScienceDirect, Scopus and Web of Science), a systematic review was conducted to retrieve all articles from database inception to 30th June 2019 which projected the future of dengue under climate change scenarios. In this review, "the future of dengue" refers to disease burden of dengue, epidemic potential of dengue cases, geographical distribution of dengue cases, and population exposed to climatically suitable areas of dengue. RESULTS: Sixteen studies fulfilled the inclusion criteria, and five of them projected a global dengue future. Most studies reported an increase in disease burden, a wider spatial distribution of dengue cases or more people exposed to climatically suitable areas of dengue as climate change proceeds. The years 1961-1990 and 2050 were the most commonly used baseline and projection periods, respectively. Multiple climate change scenarios introduced by the Intergovernmental Panel on Climate Change (IPCC), including B1, A1B, and A2, as well as Representative Concentration Pathway 2.6 (RCP2.6), RCP4.5, RCP6.0 and RCP8.5, were most widely employed. Instead of projecting the future number of dengue cases, there is a growing consensus on using "population exposed to climatically suitable areas for dengue" or "epidemic potential of dengue cases" as the outcome variable. Future studies exploring non-climatic drivers which determine the presence/absence of dengue vectors, and identifying the pivotal factors triggering the transmission of dengue in those climatically suitable areas would help yield a more accurate projection for dengue in the future. CONCLUSIONS: Projecting the future of dengue requires a systematic consideration of assumptions and uncertainties, which will facilitate the development of tailored climate change adaptation strategies to manage dengue.

Descriptive and topographical analysis of the labyrinthine artery in human fetuses.

Hearing or/and balance impairments may be caused by disorders of the labyrinthine artery (LA) and their branches. Most findings regarding the LA anatomy have been acquired through investigation of the cerebellopontine angle (CPA) in animal or adult human specimens. Eighty-eight CPAs and LAs of human fetuses were investigated using angio-techniques and microdissections. We found 15 intricate forms of distribution of LA. The LA usually originated from the extra-meatus loop in the anterior inferior cerebellar artery (AICA). The distribution of its terminal branches was 53.42% uni-arterial, 44.31% bi-arterial, and 2.27% tri-arterial systems. In the uni-arterial system, the LA described an anterior superior path to the cochlear nerve (CN) and originated its terminal branches in the gap between CN and the inferior part of the vestibular nerve. In the bi-arterial system, the anterior LA was located anterior and superior to the CN while the posterior LA appeared posterosuperior to the superior part of the vestibular nerve. In the tri-arterial system, the terminal branches originated directly from the AICA loop. Our results provide anatomical support to explain how compressions in the LA branches inside the internal acoustic meatus, as evoked by Schwannomas in the VII and VIII nerves, can lead to hearing and balance loss. The zone of the posterior vestibular nerve appeared to be a "safe area" for invasive procedures in these specimens.

Malaria in China: a longitudinal population-based surveillance study.

This study aims to ascertain the long-term epidemic trends of malaria and evaluates the probability of achieving the eradication goal by 2020 in China. Data on malaria incidence and deaths were extracted from the China Information System for Disease Control and Prevention. The epidemic trends by sex, age and spatial distribution and predictions of malaria were estimated by using Joinpoint and Poisson regressions. From 1950 to 2016, 227 668 374 malaria cases were reported in China, with an annualised average incidence of 337.02 (336.98-337.07, 95% confidence interval (CI)) per 100 000 population. The incidence decreased with an average annual per cent change (AAPC) of -11.4% (-16.6 to -6.0). There were 36 085 malaria deaths, with an annualised average mortality of 0.534 (0.529-0.540) per 1 000 000 population. The mortality decreased with an AAPC of -8.7% (-13.7 to -3.4). The predicted number of malaria cases and deaths for 2020 is 2 562 and 10, respectively, and zero for indigenous cases. The disease burden of malaria dramatically decreased in China. Though, the goal of malaria elimination is realistic by 2020 in China, routine clinical and entomological surveillance should be continually conducted, especially for the cross-border areas and imported malaria cases.