A human genome editing-based MLL::AF4 ALL model recapitulates key cellular and molecular leukemogenic features.

Cellular ontogeny and MLL breakpoint site influence the capacity of MLL-edited CD34+ hematopoietic cells to initiate and recapitulate infant patients' features in pro-B-cell acute lymphoblastic leukemia (B-ALL). We provide key insights into the leukemogenic determinants of MLL-AF4+ infant B-ALL.

Clostridium and Cryptosporidium outbreak linked to a splash pad.

BACKGROUND: . Splash pads for recreational purposes are widespread. Using these pads can pose a health risk if they lack installation regulation and water quality supervision. Our aim was to describe a waterborne disease outbreak caused by Clostridium perfringens and Cryptosporidium spp. in a Barcelona district and the measures taken for its control. METHODS: . On August 2018, 71 cases of acute gastroenteritis were detected, affecting people who used a splash pad or were in contact with a user. Microbiological and environmental investigations were carried out. A descriptive analysis of the sample and Poisson regression models adjusted for age and sex were performed, obtaining frequencies, median values, and adjusted prevalence ratios with their 95% confidence intervals. RESULTS: The median age of the cases was 6.7 years, 27 (38%) required medical care, and three (4.2%) were hospitalized. The greater the number of times a person entered the area, the greater the number of symptoms and their severity. Nineteen (76%) of the 25 stool samples collected from cases showed the presence of one or both pathogens. Environmental investigations showed deficiencies in the facilities and identified the presence of both species in the splash pad. Health education and hygiene measures were carried out, and 14 days after the closure of the facilities, no more cases related to the pad were recorded. CONCLUSIONS: . Specific regulations are needed on the use of splash pads for recreational purposes. Until these regulations are in place, these types of facility should comply with the regulations that apply to swimming pools and spas, including those related to the design of the tanks, water recirculation systems, and adequate disinfection systems.

Electrospray Ionization Tandem Mass Spectrometry With Collision Induced Dissociation of Uranyl Peroxide Nanoclusters Containing Various Uranyl Bridging Ligands.

Electrospray ionization tandem mass spectrometry with collision-induced dissociation (ESI-MS/MS) was utilized to study the gas phase fragmentation of uranyl peroxide nanoclusters with hydroxo, peroxo, oxalate, and pyrophosphate bridging ligands. These nanoclusters fragment into uranium monomers and dimers with mass-to-charge (m/z) ratios in the 280-380 region. The gas phase fragmentation of each cluster studied yields a distinct UO6 - anion attributed to the cleavage of a uranyl ion bound to 2 peroxide groups, along with other anions that can be attributed to the initial composition of the nanoclusters.

Electrochemistry of Uranyl Peroxide Solutions during Electrospray Ionization.

The ionization of uranyl triperoxide monomer, [(UO2)(O2)3]4- (UT), and uranyl peroxide cage cluster, [(UO2)28(O2)42 - x(OH)2x]28- (U28), was studied with electrospray ionization mass spectrometry (ESI-MS). Experiments including tandem mass spectrometry with collision-induced dissociation (MS/CID/MS), use of natural water and D2O as solvent, and use of N2 and SF6 as nebulizer gases, provide insight into the mechanisms of ionization. The U28 nanocluster under MS/CID/MS with collision energies ranging from 0 to 25 eV produced the monomeric units UOx- (x = 3-8) and UOxHy- (x = 4-8, y = 1, 2). UT under ESI conditions yielded the gas-phase ions UOx- (x = 4-6) and UOxHy- (x = 4-8, y = 1-3). Mechanisms that produce the observed anions in the UT and U28 systems are: (a) gas-phase combinations of uranyl monomers in the collision cell upon fragmentation of U28, (b) reduction-oxidation resulting from the electrospray process, and (c) ionization of surrounding analytes, creating reactive oxygen species that then coordinate to uranyl ions. The electronic structures of anions UOx- (x = 6-8) were investigated using density functional theory (DFT).

Solubility and Thermodynamic Investigation of Meta-Autunite Group Uranyl Arsenate Solids with Monovalent Cations Na and K.

We investigated the aqueous solubility and thermodynamic properties of two meta-autunite group uranyl arsenate solids (UAs). The measured solubility products (log Ksp) obtained in dissolution and precipitation experiments at equilibrium pH 2 and 3 for NaUAs and KUAs ranged from -23.50 to -22.96 and -23.87 to -23.38, respectively. The secondary phases (UO2)(H2AsO4)2(H2O)(s) and trögerite, (UO2)3(AsO4)2·12H2O(s), were identified by powder X-ray diffraction in the reacted solids of KUA precipitation experiments (pH 2) and NaUAs dissolution and precipitation experiments (pH 3), respectively. The identification of these secondary phases in reacted solids suggest that H3O+ co-occurring with Na or K in the interlayer region can influence the solubilities of uranyl arsenate solids. The standard-state enthalpy of formation from the elements (ΔHf-el) of NaUAs is -3025 ± 22 kJ mol-1 and for KUAs is -3000 ± 28 kJ mol-1 derived from measurements by drop solution calorimetry, consistent with values reported in other studies for uranyl phosphate solids. This work provides novel thermodynamic information for reactive transport models to interpret and predict the influence of uranyl arsenate solids on soluble concentrations of U and As in contaminated waters affected by mining legacy and other anthropogenic activities.

Kinetics of Na- and K- uranyl arsenate dissolution.

We integrated aqueous chemistry analyses with geochemical modeling to determine the kinetics of the dissolution of Na and K uranyl arsenate solids (UAs(s)) at acidic pH. Improving our understanding of how UAs(s) dissolve is essential to predict transport of U and As, such as in acid mine drainage. At pH 2, Na0.48H0.52(UO2)(AsO4)(H2O)2.5(s) (NaUAs(s)) and K0.9H0.1(UO2)(AsO4)(H2O)2.5(s) (KUAs(s)) both dissolve with a rate constant of 3.2 × 10-7 mol m-2 s-1, which is faster than analogous uranyl phosphate solids. At pH 3, NaUAs(s) (6.3 × 10-8 mol m-2 s-1) and KUAs(s) (2.0 × 10-8 mol m-2 s-1) have smaller rate constants. Steady-state aqueous concentrations of U and As are similarly reached within the first several hours of reaction progress. This study provides dissolution rate constants for UAs(s), which may be integrated into reactive transport models for risk assessment and remediation of U and As contaminated waters.

Decomposition of Growth Curves into Growth Rate and Acceleration: a Novel Procedure To Monitor Bacterial Growth and the Time-Dependent Effect of Antimicrobials.

In this paper, a simple numerical procedure is presented to monitor the growth of Streptococcus sanguinis over time in the absence and presence of propolis, a natural antimicrobial. In particular, it is shown that the real-time decomposition of growth curves obtained through optical density measurements into growth rate and acceleration can be a powerful tool to precisely assess a large range of key parameters (i.e., lag time [t0], starting growth rate [γ0], initial acceleration of the growth [a0], maximum growth rate [γmax], maximum acceleration [amax], and deceleration [amin] of the growth and the total number of cells at the beginning of the saturation phase [Ns]) that can be readily used to fully describe growth over time. Consequently, the procedure presented provides precise data of the time course of the different growth phases and features, which is expected to be relevant, for instance, to thoroughly evaluate the effect of new antimicrobial agents. It further provides insight into predictive microbiology, likely having important implications for assumptions adopted in mathematical models to predict the progress of bacterial growth. IMPORTANCE The new and simple numerical procedure presented in this paper to analyze bacterial growth will possibly allow the identification of true differences in efficacy among antimicrobial drugs for their applications in human health, food security, and the environment, among others. It further provides insight into predictive microbiology, likely helping in the development of proper mathematical models to predict the course of bacterial growth under diverse circumstances.

Ionothermal Synthesis of Uranyl Vanadate Nanoshell Heteropolyoxometalates.

Two uranyl vanadate heteropolyoxometalates (h-POMs) have been synthesized by ionothermal methods using the ionic liquid 1-ethyl-3-methylimidazolium diethyl phosphate (EMIm-Et2PO4). The hybrid actinide-transition metal shell structures have cores of (UO2)8(V6O22) and (UO2)6(V3O12), which we designate as {U8V6} and {U6V3}, respectively. The diethyl phosphate anions of the ionic liquids in some cases terminate the core structures to form actinyl oxide clusters, and in other cases the diethyl phosphate oxyanions link these cluster cores into extended structures. Three compounds exist for the {U8V6} cluster core: {U8V6}-monomer, {U8V6}-dimer, and {U8V6}-chain. Tungsten atoms can partially substitute for vanadium in the {U6V3} cluster, which results in a chain-based structure designated as {U6V3}-W. Each of these compounds contains charge-balancing EMIm cations from the ionic liquid. These compounds were characterized crystallographically, spectroscopically, and by mass spectrometry.

The Value of Prehospital Early Warning Scores to Predict in - Hospital Clinical Deterioration: A Multicenter, Observational Base-Ambulance Study.

OBJECTIVES: Early warning scores are clinical tools capable of identifying prehospital patients with high risk of deterioration. We sought here to contrast the validity of seven early warning scores in the prehospital setting and specifically, to evaluate the predictive value of each score to determine early deterioration-risk during the hospital stay, including mortality at one, two, three and seven- days since the index event. Methods: A prospective multicenter observational based-ambulance study of patients treated by six advanced life support emergency services and transferred to five Spanish hospitals between October 1, 2018 and December 31, 2019. We collected demographic, clinical, and laboratory variables. Seven risk score were constructed based on the analysis of prehospital variables associated with death within one, two, three and seven days since the index event. The area under the receiver operating characteristics was used to determine the discriminant validity of each early warning score. Results: A total of 3,273 participants with acute diseases were accurately linked. The median age was 69 years (IQR, 54-81 years), 1,348 (41.1%) were females. The overall mortality rate for patients in the study cohort ranged from 3.5% for first-day mortality (114 cases), to 7% for seven-day mortality (228 cases). The scores with the best performances for one-day mortality were Vitalpac Early Warning Score with an area under the receiver operating characteristic (AUROC) of 0.873 (95% CI: 0.81-0.9), for two-day mortality, Triage Early Warning Score with an AUROC of 0.868 (95% CI: 0.83-0.9), for three and seven-days mortality the Modified Rapid Emergency Medicine Score with an AUROC of 0.857 (0.82-0.89) and 0.833 (95% CI: 0.8-0.86). In general, there were no significant differences between the scores analyzed. Conclusions: All the analyzed scores have a good predictive capacity for early mortality, and no statistically significant differences between them were found. The National Early Warning Score 2, at the clinical level, has certain advantages. Early warning scores are clinical tools that can help in the complex decision-making processes during critical moments, so their use should be generalized in all emergency medical services.

Can capillary lactate improve early warning scores in emergency department? An observational, prospective, multicentre study.

AIMS: To determine the prognostic usefulness of the National Early Warning Score-2 (NEWS2) and quick Sepsis-related Organ Failure Assessment (qSOFA) scores, in isolation and combined with capillary lactate (CL), using the new NEWS2-L and qSOFA-L scores to predict the 30-day mortality risk. METHODS: Prospective, multicentre and observational study in patients across four EDs. We collected sets of vital signs and CL and subsequently calculated NEWS2, qSOFA, NEWS2-L and qSOFA-L scores when patients arrived at the ED. The main outcome measure was all-cause mortality 30 days from the index event. RESULTS: A total of 941 patients were included. Thirty-six patients (3.8%) died within 30 days of the index event. A high CL level has not been linked to a higher mortality. The NEWS2 presented AUROC of 0.72 (95% CI: 0.62-0.81), qSOFA of 0.66 (95% CI: 0.56-0.77) (P < .001 in both cases) and CL 0.55 (95% CI: 0.42-0.65; P = .229) to predict 30-day mortality. The addition of CL to the scores analysed does not improve the results of the scores used in isolation. CONCLUSION: NEWS2 and qSOFA scores are a very useful tool for assessing the status of patients who come to the ED in general for all types of patients in triage categories II and III and for detecting the 30-day mortality risk. CL determined systematically in the ED does not seem to provide information on the prognosis of the patients.

Human Monocytic Ehrlichiosis, Mexico City, Mexico.

Little information is available about human infections by the members of the genus Ehrlichia in Mexico. Only 2 species, Ehrlichia canis and E. chaffensis, are known to cause disease in this country. We report a fatal case of human monocytic ehrlichiosis in Mexico City in a man who was homeless.

Accuracy of prehospital point-of-care lactate in early in-hospital mortality.

BACKGROUND: Emergency medical services (EMS) routinely face complex scenarios where decisions should be taken with limited clinical information. The development of fast, reliable and easy to perform warning biomarkers could help in such decision-making processes. The present study aims at characterizing the validity of point-of-care lactate (pLA) during prehospital tasks for predicting in-hospital mortality within two days after the EMS assistance. MATERIALS AND METHODS: Prospective, multicentric, ambulance-based and controlled observational study without intervention, including six advanced life support and five hospitals. The pLA levels were recorded during EMS assistance of adult patients. The validity of pLA to determine the in-hospital mortality was assessed by the area under the curve (AUC) of the receiver operating curve (ROC). RESULTS: A total of 2997 patients were considered in the study, with a median of 69 years (IQR 54-81) and 41.4% of women. The median pLA value was 2.7 mmol/L (1.9-3.8) in survivors and 5.7 mmol/L (4.4-7.6) in nonsurvivors. The global discrimination level of pLA reached an AUC of 0.867, being 1.9 mmol/L and 4 mmol/L the cut-off point for low and high mortality. The discrimination value of pLA was not affected by sex, age or pathology. CONCLUSIONS: Our results highlight the clinical importance of prehospital pLA to determine the in-hospital risk of mortality. The incorporation of pLA into the EMS protocols could improve the early identification of risky patients, leading to a better care of such patients.

Frugivorous bats in the Colombian Caribbean region are reservoirs of the rabies virus.

BACKGROUND: Bats are an important ecological group within ecosystems. The rabies virus is a Lyssavirus, and haematophagous bats are the principal reservoir; however, the virus has also been detected in non-haematophagous bats. The objective was to determine the rabies virus in non-haematophagous bats in the Colombian Caribbean region. METHODS: In 2017, a cross-sectional study was carried out with a base-risk sampling in twelve geographic zones of the Colombian Caribbean area that included the main ecosystems of two departments. 286 bats were captured, which were euthanized with a pharmacological treatment following the ethical protocols of animal experimentation. The taxonomic identification was done with dichotomous keys. The necropsy was carried out at the capture site, and brain samples were kept in liquid nitrogen. The extraction of the RNA was carried out from the frozen brains with Trizol™; a fragment of 914 bp of the glycoprotein G of the rabies virus was amplified with RT-PCR. The amplicons were sequenced with the Sanger method. RESULTS: Twenty-three genera of bats were identified, and, in two frugivorous, Artibeus lituratus and Artibeus planirostris, amplicons were obtained and sequenced as the rabies virus. CONCLUSIONS: This is the first evidence of natural infection of the rabies virus in frugivorous bats in the Colombian Caribbean area; this result is important for the surveillance and control of rabies.

Prognosis of Clostridium difficile infection in adult oncohaematological patients: experience from a large prospective observational study.

The aim of the study is to evaluate demographics, epidemiology, clinical characteristics, treatment and outcomes of Clostridium difficile infection (CDI) in patients with and without concurrent cancer. This is a prospective cohort study of consecutive primary CDI episodes in adults (January 2006-December 2016). CDI was diagnosed on the presence of diarrhoea and positive stool testing for toxigenic C. difficile. Univariate analysis assessed differences between cancer and non-cancer patients. Risk factors of all-cause 30-day mortality were determinate using the logistic multivariable procedure. In total, 787 CDI episodes were recorded, 191 in cancer patients (median age 64, IQR 50-73). Of these, 120 (63%) had solid and 71 (37%) haematological malignancies (24 received a stem cell transplant). At the CDI diagnosis, 158 (82.7%) cancer patients had prior antibiotics and 150 (78.5%) were receiving proton pump inhibitors. Fifty-seven (80.3%) patients with haematological and 52 (43.3%) with solid malignancies were under chemotherapy at diagnosis; 25 (35.2%) with haematological and 11 (9.2%) with solid malignancies had an absolute neutrophil count < 1000/mm3. Overall, 30-day mortality was higher in cancer patients than in those without (19.2 vs. 8.6% respectively, p < 0.001); recurrence rates did not vary significantly (11.1 vs. 11%, p = 0.936). By type of neoplasm, 30-day mortality was higher in patients with haematological malignancies and solid tumours than in patients without cancer (respectively, 25.4 vs. 8.6%; p < 0.001 and 15 vs. 8.6%; p < 0.001). Our results suggest that the prognosis of CDI (30-day mortality) is poorer in patients with cancer than in those without although percentages of recurrent infection are similar in these two patient populations.

Secular trends in the epidemiology of Clostridium difficile infection (CDI) at a tertiary care hospital in Barcelona, 2006-2015: A prospective observational study.

OBJECTIVE: Describe secular trends in the epidemiology and outcome of Clostridium difficile infection (CDI) at a tertiary hospital. METHODS: All consecutive primary CDI episodes in adults (January 2006-December 2015) were included. CDI was diagnosed on the presence of diarrhoea and a positive stool test for C. difficile toxin A and/or B. To define trends, a time-series analysis was performed using yearly data on demographics, clinical characteristics, management, antimicrobial treatment, and outcome of CDI. Patients were followed-up for three months after the diagnosis. RESULTS: There were 724 CDI episodes. Over the period from 2006 to 2015, the incidence rose from 0.18 episodes/1000 admissions to 0.26 episodes (relative rate [RR] 1.43; 95%CI, 1.02-2.00; P = 0.035). Median Charlson comorbidity index increased from 2 (IQR 1-3) to 4 (IQR 2-4) (RR 1.65; 95%CI, 1.12-2.41; P = 0.005). Overall, 80.4% of patients received proton pump inhibitors (PPIs) prior to CDI, and the percentage of PPI discontinuations rose from 2.3% to 20.4% (RR 8.80; 95%CI 1.20-64.36; P = 0.006). Management of non-Clostridium antibiotics also changed: antibiotic withdrawals or switches increased from 4.2% to 29.2% (RR 7.00; 95%CI 1.68-29.15, P = 0.001). Regarding CDI treatment, the percentage of patients treated with metronidazole decreased (88.9% vs 52.6%) (RR 0.59 (0.48-0.73), P < 0.001), whereas the percentage receiving vancomycin increased (1.9% vs 32.6%) (RR 17.62 (2.47-125.49), P < 0.001). The percentages of cures, deaths, and first recurrences did not significantly change over the 10-year period. CONCLUSIONS: Changes in CDI management were associated with a stable prognosis (percentage of cures and first recurrences), even though affected patients had a greater number of comorbidities over time.

Value of Exhaled Nitric Oxide (FeNO) And Eosinophilia During the Exacerbations of Chronic Obstructive Pulmonary Disease Requiring Hospital Admission.

The aim of this study was to analyze whether FeNO levels in acute exacerbation of COPD (AECOPD) with hospital admission have better diagnostic value than eosinophilia in blood, and to evaluate its usefulness in predicting a better clinical response. An observational prospective study of patients with AECOPD was carried out. FeNO determinations were made on arrival at the emergency room (ER), at discharge and during stability 3-6 months after discharge. Co-morbidities, bronchodilators, inhaled (IGC) and systemic (SGC) glucocorticoids, eosinophils, systemic inflammation markers (procalcitonin, C-reactive protein), eosinophil cationic protein, and total IgE were collected. Fifty consecutive patients (92% men, mean age 75 ± 6 years) were included in this study. Phenotypes were 26% Asthma-COPD Overlap Syndrome (ACOS), 42% chronic bronchitis (CB) and 32% emphysema. ACOS patients showed significantly higher levels of FeNO (73 ppb) and eosinophils (508 cells/mm3) than the rest (CB: 23 ppb, 184 cells/mm3, emphysema: 27 ppb, 159 cells/mm3; p < 0.05). A significant correlation between FeNO levels measured in ER and eosinophils was observed (r = 0.7; p < 0.001), but not at discharge or in stable phase. No significant association was found with parameters of systemic inflammation and mean stay. In conclusion, the determination of FeNO in AECOPD does not offer advantages over the evaluation of eosinophilia. These parameters rise at arrival in ER, descend at discharge, and remain unchanged in the stable phase. Both present similar diagnostic utility and are able to better identify the ACOS phenotype, which helps select a population that could benefit from a glucocorticoids therapy.

ESBL-producing Salmonella enterica serovar Typhi in traveler returning from Guatemala to Spain.

We report a case of typhoid fever in a traveler returning to Spain from Guatemala that was caused by Salmonella enterica serovar Typhi which produced an extended-spectrum ß-lactamase (ESBL). This finding demonstrates the presence of ESBL-producing S. enterica ser. Typhi strains in the Americas. Enhanced surveillance is necessary to prevent further spread.

Circadian oscillatory transcriptional programs in grapevine ripening fruits.

BACKGROUND: Temperature and solar radiation influence Vitis vinifera L. berry ripening. Both environmental conditions fluctuate cyclically on a daily period basis and the strength of this fluctuation affects grape ripening too. Additionally, a molecular circadian clock regulates daily cyclic expression in a large proportion of the plant transcriptome modulating multiple developmental processes in diverse plant organs and developmental phases. Circadian cycling of fruit transcriptomes has not been characterized in detail despite their putative relevance in the final composition of the fruit. Thus, in this study, gene expression throughout 24 h periods in pre-ripe berries of Tempranillo and Verdejo grapevine cultivars was followed to determine whether different ripening transcriptional programs are activated during certain times of day in different grape tissues and genotypes. RESULTS: Microarray analyses identified oscillatory transcriptional profiles following circadian variations in the photocycle and the thermocycle. A higher number of expression oscillating transcripts were detected in samples carrying exocarp tissue including biotic stress-responsive transcripts activated around dawn. Thermotolerance-like responses and regulation of circadian clock-related genes were observed in all studied samples. Indeed, homologs of core clock genes were identified in the grapevine genome and, among them, VvREVEILLE1 (VvRVE1), showed a consistent circadian expression rhythm in every grape berry tissue analysed. Light signalling components and terpenoid biosynthetic transcripts were specifically induced during the daytime in Verdejo, a cultivar bearing white-skinned and aromatic berries, whereas transcripts involved in phenylpropanoid biosynthesis were more prominently regulated in Tempranillo, a cultivar bearing black-skinned berries. CONCLUSIONS: The transcriptome of ripening fruits varies in response to daily environmental changes, which might partially be under the control of circadian clock components. Certain cultivar and berry tissue features could rely on specific circadian oscillatory expression profiles. These findings may help to a better understanding of the progress of berry ripening in short term time scales.

Studying the influence of surface topography on bacterial adhesion using spatially organized microtopographic surface patterns.

The influence of surface topography on bacterial adhesion has been investigated using a range of spatially organized microtopographic surface patterns generated on polydimethylsiloxane (PDMS) and three unrelated bacterial strains. The results presented indicate that bacterial cells actively choose their position to settle, differentiating upper and lower areas in all the surface patterns evaluated. Such selective adhesion depends on the cells' size and shape relative to the dimensions of the surface topographical features and surface hydrophobicity/hydrophilicity. Moreover, it was found that all the topographies investigated provoke a significant reduction in bacterial adhesion (30-45%) relative to the smooth control samples regardless of surface hydrophobicity/hydrophilicity. This remarkable finding constitutes a general phenomenon, occurring in both Gram-positive and Gram-negative cells with spherical or rod shape, dictated by only surface topography. Collectively, the results presented in this study demonstrate that spatially organized microtopographic surface patterns represent a promising approach to controlling/inhibiting bacterial adhesion and biofilm formation.

Leptospirosis in pigs, dogs, rodents, humans, and water in an area of the Colombian tropics.

Leptospirosis is a reemerging zoonosis of global distribution and is one of the causes of hemorrhagic fevers in the tropics. We sought to determine seroprevalence in humans and animals and isolate Leptospira interrogans sensu lato in domestic animals, rodents, and water sources. The study was conducted in a tropical area of the middle Sinú in Cordoba, Colombia. In a prospective descriptive study, we collected blood and urine from pigs and dogs, sera from rural human workers, sera and kidney macerates of rodents, and water samples from environmental sources. We used microagglutination to screen for antibodies to 13 serovars. Strains were cultured on the Ellinghausen-McCullough-Johnson-Harris medium and confirmed by PCR amplifying lipL32 gene. Seroprevalence was 55.9% in pigs, 35.2% in dogs, and 75.8% in humans; no antibody was detected, and no Leptospira were isolated from kidney macerates of rodents. Seven L. interrogans sensu lato strains were isolated: three from pigs, two from dogs, and two from water. High seroprevalence in pigs, dogs, and humans, concomitant to isolation of strains, demonstrates that in Cordoba, transmission exists among animals, the environment, and humans, which warrants the implementation of public health intervention measures to reduce the epidemiological impact of leptospirosis in the region.