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Summary: Background: Latin America is one of the most unequal regions in the world, but evidence is lacking on the magnitude of health inequalities in urban areas of the region. Our objective was to examine inequalities in life expectancy in six large Latin American cities and its association with a measure of area-level socioeconomic status. Methods: In this ecological analysis, we used data from the Salud Urbana en America Latina (SALURBAL) study on six large cities in Latin America (Buenos Aires, Argentina; Belo Horizonte, Brazil; Santiago, Chile; San José, Costa Rica; Mexico City, Mexico; and Panama City, Panama), comprising 266 subcity units, for the period 2011–15 (expect for Panama city, which was for 2012–16). We calculated average life expectancy at birth by sex and subcity unit with life tables using age-specific mortality rates estimated from a Bayesian model, and calculated the difference between the ninth and first decile of life expectancy at birth (P90–P10 gap) across subcity units in cities. We also analysed the association between life expectancy at birth and socioeconomic status at the subcity-unit level, using education as a proxy for socioeconomic status, and whether any geographical patterns existed in cities between subcity units. Findings: We found large spatial differences in average life expectancy at birth in Latin American cities, with the largest P90–P10 gaps observed in Panama City (15·0 years for men and 14·7 years for women), Santiago (8·9 years for men and 17·7 years for women), and Mexico City (10·9 years for men and 9·4 years for women), and the narrowest in Buenos Aires (4·4 years for men and 5·8 years for women), Belo Horizonte (4·0 years for men and 6·5 years for women), and San José (3·9 years for men and 3·0 years for women). Higher area-level socioeconomic status was associated with higher life expectancy, especially in Santiago (change in life expectancy per P90–P10 change unit-level of educational attainment 8·0 years [95% CI 5·8–10·3] for men and 11·8 years [7·1–16·4] for women) and Panama City (7·3 years [2·6–12·1] for men and 9·0 years [2·4–15·5] for women). We saw an increase in life expectancy at birth from east to west in Panama City and from north to south in core Mexico City, and a core-periphery divide in Buenos Aires and Santiago. Whereas for San José the central part of the city had the lowest life expectancy and in Belo Horizonte the central part of the city had the highest life expectancy. Interpretation: Large spatial differences in life expectancy in Latin American cities and their association with social factors highlight the importance of area-based approaches and policies that address social inequalities in improving health in cities of the region. Funding: Wellcome Trust.

Summary: Background: Little is known about the effect of changes in mobility at the subcity level on subsequent COVID-19 incidence, which is particularly relevant in Latin America, where substantial barriers prevent COVID-19 vaccine access and non-pharmaceutical interventions are essential to mitigation efforts. We aimed to examine the longitudinal associations between population mobility and COVID-19 incidence at the subcity level across a large number of Latin American cities. Methods: In this longitudinal ecological study, we compiled aggregated mobile phone location data, daily confirmed COVID-19 cases, and features of urban and social environments to analyse population mobility and COVID-19 incidence at the subcity level among cities with more than 100 000 inhabitants in Argentina, Brazil, Colombia, Guatemala, and Mexico, from March 2 to Aug 29, 2020. Spatially aggregated mobile phone data were provided by the UN Development Programme in Latin America and the Caribbean and Grandata; confirmed COVID-19 cases were from national government reports and population and socioeconomic factors were from the latest national census in each country. We used mixed-effects negative binomial regression for a time-series analysis, to examine longitudinal associations between weekly mobility changes from baseline (prepandemic week of March 2–9, 2020) and subsequent COVID-19 incidence (lagged by 1–6 weeks) at the subcity level, adjusting for urban environmental and socioeconomic factors (time-invariant educational attainment, residential overcrowding, population density [all at the subcity level], and country). Findings: We included 1031 subcity areas, representing 314 Latin American cities, in Argentina (107 subcity areas), Brazil (416), Colombia (82), Guatemala (20), and Mexico (406). In the main adjusted model, we observed an incidence rate ratio (IRR) of 2·35 (95% CI 2·12–2·60) for COVID-19 incidence per log unit increase in the mobility ratio (vs baseline) during the previous week. Thus, 10% lower weekly mobility was associated with 8·6% (95% CI 7·6–9·6) lower incidence of COVID-19 in the following week. This association gradually weakened as the lag between mobility and COVID-19 incidence increased and was not different from null at a 6-week lag. Interpretation: Reduced population movement within a subcity area is associated with a subsequent decrease in COVID-19 incidence among residents of that subcity area. Policies that reduce population mobility at the subcity level might be an effective COVID-19 mitigation strategy, although they should be combined with strategies that mitigate any adverse social and economic consequences of reduced mobility for the most vulnerable groups. Funding: Wellcome Trust. Translation: For the Spanish translation of the abstract see Supplementary Materials section.

Background: Greenness has been found to be associated with reduced mortality and morbidity and improved wellbeing, with recent evidence further linking it to narrower health inequalities. However, results come mostly from high-income countries and thus might not be generalisable to other settings. In this preliminary analysis, we address this gap by examining whether education inequalities in life expectancy in Latin American cities vary by area-level greenness. Methods: We used data from the Salud Urbana en America Latina (SALURBAL) study. The analysis sample included 28 large cities in nine Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico, Panama, and El Salvador), comprising 671 sub-city units (>10 per city), for the period 2012–16. We used sub-city data on life expectancy, education (percentage of residents with high school or university education, as an indicator for socioeconomic status), and greenness (as calculated by the satellite image-derived normalised difference vegetation index). We used multilevel linear models of sub-cities nested within cities, with country fixed effects to predict life expectancy by education, greenness, and their interaction, while accounting for covariates at the city and sub-city levels. Findings: Higher education was associated with higher life expectancy in both sexes (men: standardised regression coefficient b=0·51 [95% CI 0·36–0·65]; women: 0·34 [0·23–0·45]), whereas increased area-level greenness was associated with higher life expectancy among men (0·39 [0·03–0·75]). The educational gradient in life expectancy was steeper in greener areas for both sexes (men: b for interaction=0·20 [0·08–0·32]; women: 0·15 [0·05–0·24]). Interpretation: Contrary to evidence from high-income countries, our initial results from Latin America suggest education disparities in life expectancy might increase with greater levels of green space. Given the already wide intra-urban inequalities in Latin American cities, and the sparse and unequal distribution of urban green spaces, greening policies need to make a concerted effort to ensure that unequal access to green spaces does not exacerbate existing health inequalities. Funding: Wellcome Trust (205177/Z/16/Z).

Background: Urban design features are often studied in relation to health and behavioural outcomes. They can also have major implications for environmental outcomes. However, the impact of these features on both health and environmental outcomes (co-benefits) is rarely examined. We investigated how urban landscape and street design profiles are related to jointly occurring health and environmental outcomes in Latin America cities. Methods: We used data from the Salud Urbana en América Latina (SALURBAL) project, which has compiled and harmonised data on built environment, environmental exposures, and health outcomes for 370 cities in 11 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Nicaragua, Panama, and Peru. Eight city profiles were identified using finite mixture models. Four urban-landscape profiles were defined measuring patch (contiguous area of urban development) fragmentation, shape, and isolation, and four street-design profiles were defined using street connectivity, length, and directness. Multilevel regression models were used to assess associations between the city profiles and several health and environmental outcomes. Findings: Our preliminary results show that compared with the urban-landscape profile labelled scattered pixels (comprising low fragmentation, compact shape, and high isolation), the proximate-stones profile (moderate fragmentation, irregular shape, and moderate isolation) had significantly higher levels of PM2·5 and nitrogen dioxide (NO2), and the proximate-inkblots profile (moderate-to-high fragmentation, complex shape, and moderate isolation) had significantly higher levels of violence-related deaths. Compared with the labyrinthine street design profile (low connectivity, moderate length, and moderate directness), the semi-hyperbolic grid (moderate connectivity, moderate length, and moderate directness) and spiderweb (high connectivity, low length, and moderate directness) profiles had significantly higher levels of PM2·5 and NO2, whereas the hyperbolic grid profile (moderate connectivity, high length, and low directness) had significantly higher levels of NO2 and lower levels of obesity. Interpretation: Identifying how city profiles are related to environment and health outcomes can shed light on the urban policies that could have the greatest environment and health co-benefits. Funding: The SALURBAL/Urban Health in Latin America project is funded by the Wellcome Trust (205177/Z/16/Z).

Newborn disease screening increases survival, improves quality of life and reduces treatment costs for healthcare systems. Mass spectrometry (MS) is an effective method for metabolic screening. However, conventional analytical methods require biofluid handling and cooling conditions during transport, making the logistics difficult and expensive, especially for remote regions. ’Paper-spray’ (PS) ionization generates a charged solvent spray from samples deposited on paper strips. Therefore, samples can be applied on a suitable matrix and shipped as dried spots to diagnostic laboratories with standard postal or messenger services. We built a robotic platform, the ’Open SprayBot’, to automatically analyze paper-deposited samples via PS-MS and increase the sample throughput. The system is operated via RUMBA32 and Arduino Mega boards. A commercial syringe pump and power supply provide solvent application and electrical current required for PS-MS. The usability of the Open SprayBot was demonstrated by quantifying palmitoyl-l-carnitine, a common biomarker in newborn screening.

Background: Appropriate programming of cardiovascular implantable electronic devices (CIED) is essential to ensure adequate function and avoid harmful effects. In underdeveloped countries, CIED monitoring and programming are often performed by physicians involved in their implantation. However, many of them often do not have sufficient training in CIED programming. Objective: We aimed to assess the differences in pacemaker programming between electrophysiology (EP) specialists and other physicians. Methods: We retrospectively reviewed changes in pacemaker programming performed by an EP specialist in patients who attended for pacemaker evaluation and reported previous follow-ups by a non-EP specialist. Results: Among 58 patients (26 males), 41 patients (71%) had programming errors and required setting modifications. The rate adaptative pacing function (R-mode) was incorrectly deactivated in 9 patients (15%) and improperly activated in 2 patients (3%). Unnecessary ventricular stimulation was detected in 23 patients (40%) with a pacing burden of 60% (32–95%). The lower rate limit was unnecessarily high in 12 patients (21%).Atrial or ventricular pacing output was inappropriate in 15 patients (26%) and was consequently modified (4 patients unnecessarily high, 9 patients below requirements). The auto-adapted pacing output was switched off in 17 of 18 patients (16 due to physician's preference, and 1 due to algorithm inaccuracy). The programmed sensitivity was inaccurate in 2 patients (3%). In 2 patients (3%) switching from DDDR to VVIR mode was required. Conclusion: We found a high prevalence of errors in pacemaker programming by non-EP specialists. An EP specialist should always be responsible for CIED follow-up.

Purpose: To conduct a genome-wide association study (GWAS) of individuals with neuropathic ocular pain (NOP) symptoms to identify genomic variants that may predispose to NOP development. Design: Prospective study of individuals with NOP. Participants: Three hundred twenty-nine patients recruited from the Miami Veterans Affairs eye clinic. Methods: The Neuropathic Pain Symptom Inventory modified for the eye (NPSI-Eye) was completed to calculate a NPSI-Eye-Sub-Score (summed ratings of burning and wind sensitivity) as an indicator of NOP severity. A GWAS was performed for the NPSI-Eye-Sub-Score with a significance threshold of P 0.8) within ENSG00000279046 coding for transcript ENST00000624288.1. The most significant genes from gene-based tests were matrix metalloproteinase-19 (MMP19) (P = 1.12 × 10−5), zinc finger RNA-binding motif and serine/arginine rich-1 (ZRSR1) (P = 1.48 × 10−4), CTC-487M23.8 (P = 1.79 × 10−4), receptor expression-enhancing protein-5 (REEP5) (P = 2.36 × 10−4), and signal recognition particle-19 (SRP19) (P = 2.56 × 10−4). From gene set enrichment analysis, the sensory perception (false discovery rate = 6.57 × 10−3) and olfactory signaling (false discovery rate = 1.63 × 10−2) pathways were enriched with the most significant genes. Conclusions: Our GWAS revealed genes with protein products that may impact sensory perception, lending biological plausibility to a role for SNPs identified by our GWAS in the development of NOP. A better understanding of the biological relevance of these genes and pathways in the pathophysiology associated with NOP may facilitate future novel mechanism-based treatments. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Green vegetation may protect against heat-related death by improving thermal comfort. Few studies have investigated associations of green vegetation with heat-related mortality in Latin America or whether associations are modified by the spatial configuration of green vegetation. We used data from 323 Latin American cities and meta-regression models to estimate associations between city-level greenness, quantified using population-weighted normalized difference vegetation index values and modeled as three-level categorical terms, and excess deaths from heat (heat excess death fractions [heat EDFs]). Models were adjusted for city-level fine particulate matter concentration (PM2.5), social environment, and country group. In addition to estimating overall associations, we derived estimates of association stratified by green space clustering by including an interaction term between a green space clustering measure (dichotomized at the median of the distribution) and the three-level greenness variable. We stratified analyses by climate zone (arid vs. temperate and tropical combined). Among the 79 arid climate zone cities, those with moderate and high greenness levels had modestly lower heat EDFs compared to cities with the lowest greenness, although protective associations were more substantial in cities with moderate versus high greenness levels and confidence intervals (CI) crossed the null (Beta: −0.41, 95% CI: −1.06, 0.25; Beta −0.23, 95% CI: −0.95, 0.49, respectively). In 244 non-arid climate zone cities, associations were approximately null. We did not observe evidence of effect modification by green space clustering. Our results suggest that greenness may offer modest protection against heat-related mortality in arid climate zone Latin American cities.

Background: Vertebral fractures, frequently resulting from high-impact trauma to the spine, are an increasingly relevant public health concern. Little is known about the long-term economic and demographic trends affecting patients undergoing surgery for such fractures. This study examines national economic and demographic trends in vertebral fracture surgery in the United States to improve value-based care and health care utilization. Methods: The National Inpatient Sample (NIS) was queried for patients who underwent surgical treatment of a vertebral fracture (ICD-9-CM-3.53) (excluding kyphoplasty and vertebroplasty) between 1993 and 2015. Demographic data included patient age, sex, income, insurance type, hospital size, and location. Economic data including aggregate charge, aggregate cost, hospital cost, and hospital charge were analyzed. Results: The number of vertebral fracture surgeries, excluding kyphoplasty and vertebroplasty, increased 461% from 3,331 in 1993 to 18,675 in 2014, while inpatient mortality increased from 1.9% to 2.5%.The mean age of patients undergoing vertebral fracture surgeries increased from 42 in 1993 to 53 in 2015. The aggregate cost of surgery increased from $189,164,625 in 2001 to $1,060,866,580 in 2014, a 461% increase. Conclusions: The significant increase in vertebral fracture surgeries between 1993 and 2014 may reflect an increased rate of fractures, more surgeons electing to treat fractures surgically, or a combination of both. The increasing rate of vertebral fracture surgery, coupled with increasing hospital costs and mortality, signifies that the treatment of vertebral fractures remains a challenging issue in healthcare. Further research is necessary to determine the underlying cause of both the increase in surgeries and the increasing mortality rate.

Background: The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known. Objectives: This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia. Methods: The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison. Results: Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020. Conclusions: The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Chagas disease, a worldwide public health concern, is a chronic infection caused by Trypanosoma cruzi. Considering T. cruzi chronic persistence correlates with CD4+ and CD8+ T cell dysfunction and the safety and efficacy profiles of Benznidazol and Nifurtimox, the two drugs currently used for its etiological treatment, are far from ideal, the search of new trypanocidal treatment options is a highly relevant issue. Therefore, the objective of this work was to evaluate the trypanocidal effect and cytokine production induction of three extracts (hexane, dichloromethane and hydroalcoholic) obtained from Clethra fimbriata, a plant traditionally used as a febrifuge in Colombia. Additionally, the extracts’ major components with the highest trypanocidal activity were determined. It was evidenced C. fimbriata hexane extract exhibited the highest activity capable of inhibiting the three parasite developmental stages with an IC50/EC50 of 153.9 ± 29.5 (epimastigotes), 39.3 ± 7.2 (trypomastigotes), and 45.6 ± 10.5 (amastigotes) μg/mL, presenting a low cytotoxicity in VERO cells with a selectivity index ranging from 6.49 to 25.4. Moreover, this extract induced trypomastigote apoptotic death and inhibited parasite cell infection. The extract also induced IFN-γ and TNF production in CD4+ and CD8+ T cells, as well as de novo production of the cytotoxic molecules granzyme B and perforin in CD8+ T cells from healthy donors. Fatty acids and terpenes represented C. fimbriata key compounds. Thus, the trypanocidal activity and cytokine production induction of the hexane extract may be associated with terpene presence, particularly, triterpenes.

Examples of how environmental susceptibility has a direct impact on the social vulnerability of a population, by affecting both the social and cultural life quality are discussed for the Northeast of Brazil, which is considered to be the poorest region of the country. Several direct and indirect mechanisms associated to soil degradation/desertification are addressed, mainly in relation to the impact they cause to the livelihood such as income, immigration/emigration rate, and mortality. Our purpose is to provide, based on a social vulnerability index, a spatial-temporal analysis of the population dynamics in response to the effects of degradation/desertification and extended periods of drought. The results of this study demonstrated that social vulnerability is mostly dictated by social factors but marginally by environmental factors. This conclusion has an impact on federal public policies designed to reduce social inequality in the region. Keywords: Desertification, Environmental susceptibility, Social vulnerability, Brazilian semi-arid, Public policies

Study region: The Tapajós Basin is an important Amazon tributary affected by human activities with great potential for water conflicts. The basin, as others within the Amazon region, is receiving a number of hydropower plants, among them the Teles Pires plant, projected to operate in 2015. Study focus: Hydrological impacts due to climate change affect human activities, such as hydroelectric generation, and should be carefully studied for better planning of water management. In this study, we assess climate change impacts by applying the MHD-INPE hydrological model using several climate models projections as inputs. The impact assessment consisted of statistical shifts of precipitation and discharge. Energy production in a projected hydropower plant was assessed through the development of annual power duration curves for each projection, also considering its design and structural limitations. New hydrological insights for the region: The high inter-model variability in the climate projections drives a high variability in the projected hydrological impacts. Results indicate an increase of basin's sensitivity to climate change and vulnerability of water exploitation. Uncertainties prevent the identification of a singular optimal solution for impacts assessment. However, exploratory analysis of the plant design robustness for hydropower generation show a reduction in the energy production even under projections of increased discharge, due to plant capacity limitations. This is valuable information for stakeholders to decide about energy production strategies.