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Dengue is hyperendemic in Brazil, with outbreaks affecting all regions. Previous studies identified geographical barriers to dengue transmission in Brazil, beyond which certain areas, such as South Brazil and the Amazon rainforest, were relatively protected from outbreaks. Recent data shows these barriers are being eroded. In this study, we explore the drivers of this expansion and identify the current limits to the dengue transmission zone. We used a spatio-temporal additive model to explore the associations between dengue outbreaks and temperature suitability, urbanisation, and connectivity to the Brazilian urban network. The model was applied to a binary outbreak indicator, assuming the official threshold value of 300 cases per 100,000 residents, for Brazil’s municipalities between 2001 and 2020. We found a nonlinear relationship between higher levels of connectivity to the Brazilian urban network and the odds of an outbreak, with lower odds in metropoles compared to regional capitals. The number of months per year with suitable temperature conditions for Aedes mosquitoes was positively associated with the dengue outbreak occurrence. Temperature suitability explained most interannual and spatial variation in South Brazil, confirming this geographical barrier is influenced by lower seasonal temperatures. Municipalities that had experienced an outbreak previously had double the odds of subsequent outbreaks. We identified geographical barriers to dengue transmission in South Brazil, western Amazon, and along the northern coast of Brazil. Although a southern barrier still exists, it has shifted south, and the Amazon no longer has a clear boundary. Few areas of Brazil remain protected from dengue outbreaks. Communities living on the edge of previous barriers are particularly susceptible to future outbreaks as they lack immunity. Control strategies should target regions at risk of future outbreaks as well as those currently within the dengue transmission zone., Author summary Dengue is a mosquito-borne disease that has expanded rapidly around the world due to increased urbanisation, global mobility and climate change. In Brazil, geographical barriers to dengue transmission exist, beyond which certain areas including South Brazil and the Amazon rainforest are relatively protected from outbreaks. However, we found that the previous barrier in South Brazil has shifted further south as a result of increased temperature suitability. The previously identified barrier protecting the western Amazon no longer exists. This is particularly concerning as we found dengue outbreaks tend to become established in areas after introduction. Highly influential cities with many transport links had increased odds of an outbreak. However, the most influential cities had lower odds of an outbreak than cities connected regionally. This study highlights the importance of monitoring the expansion of dengue outbreaks and designing disease prevention strategies for areas at risk of future outbreaks as well as areas in the established dengue transmission zone.

Background Mobility restrictions and overloaded health services during the COVID-19 pandemic compromised services dedicated to the prevention and care of HIV and other sexually transmitted infections (STI). In this study, we present client’s responses to standardized questionnaires applied during the COVID-19 pandemic period as part of the strategy to measure impacts on social and sexual vulnerability, access to STI prevention services, and access to STI care. Methods: The questionnaires included variables on sociodemographics, behavior, risk perception, prevention attitudes, barriers to service-based HIV rapid test, reasons for taking an HIV self-test, and access to health services for STI diagnosis and treatment. We explored demographic variables associated with income reduction, reduced access to HIV/STI testing/treatment and increased vulnerability to HIV/STI. Results: 847 participants responded to the study questionnaire between May 2020 and January 2021. Most were young, cisgender male, and 63% self-reported as men who have sex with men. Income reductions were reported by 50%, with 30% reporting a decline over 50% of total income. An increase in heavy episodic drinking (>5 doses) was reported by 18%; 7% reported more sexual partners and 6% reported using condoms less often. Difficulties in obtaining HIV tests, tests for other STI and treatment for STI were reported by 5%, 6% and 6%, respectively. Lower schooling was significantly associated with income reduction (p = 0.004) and with reduced access to HIV/STI testing or STI treatment (p = 0.024); employment status was associated with income reduction (p < 0.001) and increased vulnerability to HIV/STI (p = 0.027). Having access to an expedite test result, avoiding physical attendance in health units during the pandemic, and undertaking the test with privacy with a trusted person were reported as motivators for HIV self-test. Conclusions: Our findings are relevant to promote service improvements tailored to subgroups more likely to struggle with detrimental effects during and after the COVID-19 pandemic.

Summary Background Temperature and rainfall patterns are known to influence seasonal patterns of dengue transmission. However, the effect of severe drought and extremely wet conditions on the timing and intensity of dengue epidemics is poorly understood. In this study, we aimed to quantify the non-linear and delayed effects of extreme hydrometeorological hazards on dengue risk by level of urbanisation in Brazil using a spatiotemporal model. Methods We combined distributed lag non-linear models with a spatiotemporal Bayesian hierarchical model framework to determine the exposure-lag-response association between the relative risk (RR) of dengue and a drought severity index. We fit the model to monthly dengue case data for the 558 microregions of Brazil between January, 2001, and January, 2019, accounting for unobserved confounding factors, spatial autocorrelation, seasonality, and interannual variability. We assessed the variation in RR by level of urbanisation through an interaction between the drought severity index and urbanisation. We also assessed the effect of hydrometeorological hazards on dengue risk in areas with a high frequency of water supply shortages. Findings The dataset included 12 895 293 dengue cases reported between 2001 and 2019 in Brazil. Overall, the risk of dengue increased between 0–3 months after extremely wet conditions (maximum RR at 1 month lag 1·56 [95% CI 1·41–1·73]) and 3–5 months after drought conditions (maximum RR at 4 months lag 1·43 [1·22–1·67]). Including a linear interaction between the drought severity index and level of urbanisation improved the model fit and showed the risk of dengue was higher in more rural areas than highly urbanised areas during extremely wet conditions (maximum RR 1·77 [1·32–2·37] at 0 months lag vs maximum RR 1·58 [1·39–1·81] at 2 months lag), but higher in highly urbanised areas than rural areas after extreme drought (maximum RR 1·60 [1·33–1·92] vs 1·15 [1·08–1·22], both at 4 months lag). We also found the dengue risk following extreme drought was higher in areas that had a higher frequency of water supply shortages. Interpretation Wet conditions and extreme drought can increase the risk of dengue with different delays. The risk associated with extremely wet conditions was higher in more rural areas and the risk associated with extreme drought was exacerbated in highly urbanised areas, which have water shortages and intermittent water supply during droughts. These findings have implications for targeting mosquito control activities in poorly serviced urban areas, not only during the wet and warm season, but also during drought periods. Funding Royal Society, Medical Research Council, Wellcome Trust, National Institutes of Health, Fundacao Carlos Chagas Filho de Amparo a Pesquisa do Estado do Rio de Janeiro, and Conselho Nacional de Desenvolvimento Cientifico e Tecnologico. Translation For the Portuguese translation of the abstract see Supplementary Materials section.

Made available in DSpace on 2021-06-25T11:10:15Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-01-01 Public health policies to contain the spread of COVID-19 rely mainly on non-pharmacological measures. Those measures, especially social distancing, are a challenge for developing countries, such as Brazil. In São Paulo, the most populous state in Brazil (45 million inhabitants), most COVID-19 cases up to April 18th were reported in the Capital and metropolitan area. However, the inner municipalities, where 20 million people live, are also at risk. As governmental authorities discuss the loosening of measures for restricting population mobility, it is urgent to analyze the routes of dispersion of COVID-19 in São Paulo territory. We hypothesize that urban hierarchy is the main responsible for the disease spreading, and we identify the hotspots and the main routes of virus movement from the metropolis to the inner state. In this ecological study, we use geographic models of population mobility to check for patterns for the spread of SARS-CoV-2 infection. We identify two patterns based on surveillance data: one by contiguous diffusion from the capital metropolitan area, and the other hierarchical with long-distance spread through major highways that connects São Paulo city with cities of regional relevance. This knowledge can provide real-time responses to support public health strategies, optimizing the use of resources in order to minimize disease impact on population and economy. Department of Infectious Diseases Botucatu Medical School São Paulo State University (UNESP) Department of Geography Faculty of Science and Technology São Paulo State University (UNESP) Department of Geography Federal University of Espírito Santo Institute of Biosciences São Paulo State University (UNESP) Institute of Mathematics Statistics and Scientific Computation University of Campinas (UNICAMP) Department of Infectious Diseases Botucatu Medical School São Paulo State University (UNESP) Department of Geography Faculty of Science and Technology São Paulo State University (UNESP) Institute of Biosciences São Paulo State University (UNESP)

Made available in DSpace on 2020-12-12T02:49:20Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-08-18 Different countries have adopted strategies for the early detection of SARS-CoV-2 since the declaration of community transmission by the World Health Organization (WHO) and timely diagnosis has been considered one of the major obstacles for surveillance and healthcare. Here, we report the increase of the number of laboratories to COVID-19 diagnosis in Brazil. Our results demonstrate an increase and decentralisation of certified laboratories, which does not match the much higher increase in the number of COVID-19 cases. Also, it becomes clear that laboratories are irregularly distributed over the country, with a concentration in the most developed state, São Paulo. School of Agriculture São Paulo State University (Unesp) Botucatu Medical School São Paulo State University (Unesp) Clinical Hospital of Botucatu Medical School (HCFMB) Institute of Biosciences São Paulo State University (Unesp) School of Technology and Sciences São Paulo State University (Unesp) Federal University of Espirito Santo (UFES) School of Agriculture São Paulo State University (Unesp) Botucatu Medical School São Paulo State University (Unesp) Clinical Hospital of Botucatu Medical School (HCFMB) Institute of Biosciences São Paulo State University (Unesp) School of Technology and Sciences São Paulo State University (Unesp)

The objective was to analyze the diffusion of cases of yellow fever in time and space in the epidemic of 2017 in the state of Espírito Santo, Brazil. An ecological observational study was performed with spatial analysis of yellow fever cases. Georeferencing of information and spatial analysis used the digital grid for the state of Espírito Santo, divided into 78 municipalities (counties), using the Arcgis software, 10.3. Geostatistical analysis was performed using the ordinary kriging function. The study found an incidence of 4.85/100,000 inhabitants of sylvatic yellow fever in Espírito Santo in 2017, with 29.74% case-fatality. Sylvatic yellow fever cases were distributed across 34 of the state's 78 municipalities, representing 43% of its territory. The temporal distribution of reported yellow fever cases in the current study occurred from the 1st to the 19th Epidemiological Weeks (EW). The geostatistical spatial analysis via ordinary kriging demonstrated spatial diffusion by yellow fever contagion among the municipalities in the state of Espírito Santo, with spatial continuity. The disease emerged in the state in the EW 1 through municipalities bordering on the state of Minas Gerais. Geoprocessing showed that yellow fever reached the state of Espírito Santo through the municipalities bordering on the state of Minas Gerais, moving eastward in the state and reaching the Atlantic coastline. There was a higher concentration of cases and persistence in the state's Central and Metropolitan regions, which have areas of Atlantic Forest, showing a pattern of diffusion continuity by contagion.O objetivo foi analisar a difusão dos casos de febre amarela no tempo e no espaço, na epidemia de 2017, no Estado do Espírito Santo, Brasil. Estudo observacional ecológico, com análise espacial da difusão dos casos de febre amarela. Para o georreferenciamento das informações e a análise espacial, utilizou-se a malha digital do Estado do Espírito Santo, dividida em 78 municípios, por meio do software ArcGIS 10.3. Realizou-se uma análise de geoestatística utilizando a função krigagem ordinária. Nosso estudo mostrou uma incidência de 4,85/100 mil habitantes de febre amarela silvestre no Espírito Santo, no período de 2017, perfazendo uma letalidade de 29,74%. Os casos de febre amarela silvestre estão distribuídos em 34 municípios dos 78 que compõem o estado, representando 43% do território. A distribuição temporal dos casos de febre amarela registrados no presente estudo encontrava-se entre a 1ª e a 19ª Semana Epidemiológica (SE). Por meio da análise espacial de geoestatística por krigagem ordinária, foi possível demonstrar a difusão espacial por contágio da doença amarílica entre os municípios no Estado do Espírito Santo, com uma continuidade espacial. A doença surgiu no estado na SE 1 pelos municípios que realizam divisa com o Estado de Minas Gerais. O geoprocessamento demonstrou que a doença amarílica chegou ao Espírito Santo pelos municípios vizinhos ao Estado de Minas Gerais, seguindo em direção leste do estado, atingindo o litoral. Apresentou uma maior concentração de casos e tempo de permanência nas regiões Central e Metropolitana, que possuem áreas de Mata Atlântica, mostrando um padrão de continuidade da difusão por contágio.El objetivo fue analizar la difusión de los casos de fiebre amarilla en el tiempo y espacio, en la epidemia de 2017 en el estado de Espírito Santo, Brasil. Estudio observacional ecológico, con análisis espacial de la difusión de los casos de fiebre amarilla. Para la georreferencia de la información y análisis espacial se utilizó la red digital del estado de Espírito Santo, dividida en 78 municipios, a través del software Arcgis 10.3. Se realizó un análisis de geoestadístico, utilizando la función krigagem ordinaria. Nuestro estudio mostró una incidencia de 4,85/100 mil habitantes de fiebre amarilla silvestre en Espírito Santo durante el período de 2017, ocasionando una letalidad de 29,74%. Los casos de fiebre amarilla silvestre están distribuidos en 34 municipios, de los 78 en los que se compone el estado, representando un 43% del territorio. La distribución temporal de los casos de febre amarela registrados en el presente estudio se encontraba entre la 1ª y la 19ª Semana Epidemiológica (SE). A través del análisis espacial de geoestadística por krigagem ordinaria fue posible demostrar la difusión espacial por contagio de la enfermedad amarílica entre los municipios en el estado de Espírito Santo, con una continuidad espacial. La enfermedad surgió en el estado en la SE 1, a través de los municipios que tienen frontera con el estado de Minas Gerais. El geoprocesamiento demostró que la enfermedad amarílica llegó al estado de Espírito Santo a través de los municipios vecinos al estado de Minas Gerais, siguiendo en dirección al este del estado, alcanzando el litoral. Presentó una mayor concentración de casos y tiempo de permanencia en las regiones Central y Metropolitana, que poseen areas de mata atlántica, presentando un patrón de continuidad de la difusión por contagio.

Objective To perform spatial distribution analysis of reported cases of Zika virus and congenital Zika syndrome (CZS) in the state of Espírito Santo, Brazil, by neighborhood, and relate the results to sociodemographic indicators and implications for the health process. Methods An ecological study using data from the 2016 National Notifiable Diseases Surveillance System, epidemiological records, and information on neighborhoods of families confirmed with CZS from qualitative field research. Results Sociodemographic indicators were analyzed in three distinct groups: general population with Zika virus, pregnant women with Zika virus, and cases of CZS visited. For the three groups, average literacy rates were 71.1%, 71.0%, and 68.3%; the average income per minimum wage was 1.4, 1.1, and 1.4; sanitary sewage coverage was 75.6%, 76.1%, and 71.4%; garbage coverage was 90.8%, 91.2%, and 89.2%; and water supply was 93.8%, 94.1% and 93.8%, respectively. Socioeconomic indicators showed no significant differences between groups, although they were above the national average. A nonsignificant variation of 68.3%–71.1% was seen in the average literacy level above 15 years of age. Conclusion Socioeconomic and demographic indicators of cases of Zika virus infection and CZS may indicate that the outbreak had different impacts according to class, social group, or gender, reflecting the persistence and social geography of inequality in Brazil., The sociodemographic profile of cases of Zika virus and congenital Zika virus syndrome reveals different impacts on social strata and reflects the social geography of inequality in Brazil.

Made available in DSpace on 2021-06-25T11:09:09Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-01-01 Two hundred days after the first confirmed case of COVID-19 in Brazil, the epidemic has rapidly spread in metropolitan areas and advanced throughout the countryside. We followed the temporal epidemic pattern at São Paulo State, the most populous of the country, the first to have a confirmed case of COVID-19, and the one with the most significant number of cases until now. We analyzed the number of new cases per day in each regional health department and calculated the effective reproduction number (Rt) over time. Social distance measures, along with improvement in testing and isolating positive cases, general population mask-wearing, and standard health security protocols for essential and non-essential activities, were adopted and impacted on slowing down epidemic velocity but were insufficient to stop transmission. Clinical Hospital of Botucatu Medical School (HCFMB) São Paulo State University (UNESP) Botucatu Medical School Department of Infectious Diseases São Paulo State University (UNESP) School of Agriculture São Paulo State University (UNESP) School of Technology and Sciences University of Campinas (UNICAMP) Institute of Mathematics Statistics and Scientific Computation Federal University of Abc (UFABC) Center for Mathematics Computation and Cognition Federal University of Espírito Santo (UFES) São Paulo State University (UNESP) Institute of Biosciences Clinical Hospital of Botucatu Medical School (HCFMB) São Paulo State University (UNESP) Botucatu Medical School Department of Infectious Diseases São Paulo State University (UNESP) School of Agriculture São Paulo State University (UNESP) School of Technology and Sciences São Paulo State University (UNESP) Institute of Biosciences

INTRODUCTION: Monitoring coronavirus disease (COVID-19)-related infections and deaths in Brazil is controversial, with increasing pressure to ease social distance measures. However, no evidence of a sustained, widespread fall in cases exists. METHODS We used segmented (joinpoint) regression analysis to describe the behavior of COVID-19 infections in Brazilian capital cities. RESULTS All capitals showed an exponential or a near-exponential increase in cases through May. A decline in reported cases was subsequently noted in 20 cities but was only significant for 8 (29.6%) and was followed in two by a renewed increase. CONCLUSIONS Caution is warranted when considering the relaxation of restrictions.

Objective to describe the completeness of data on yellow fever notification forms in the municipalities of the state of Espírito Santo, Brazil, in 2017. Methods this is a descriptive ecological study with data from the Notifiable Health Conditions Information System (SINAN); form completeness was categorized as poor (70.0%), regular (70-89.9%) or excellent (≥90.0%); thematic maps were prepared. Results 53.1% of the municipalities had poor or regular classification for many notification form variables, especially case Final Classification (57.1%), Confirmation/Dismissal Criterion (63.2%) and Closure Date (26.5%), which are required fields. Conclusion completeness was poor or regular for several variables, pointing to the need for a systematic assessment of information on yellow fever held on SINAN.

OBJECTIVE: to evaluate the outcome of abdominal wall integrity of both techniques. METHODS: a retrospective study was carried out at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, identifying the patients undergoing temporary abdominal closure (TAC) from January 2005 to December 2011. Data were collected through the review of clinical charts. Inclusion criteria were indication of TAC and survival to definitive abdominal closure. In the post-operative period only a group of three surgeons followed all patients and performed the reoperations. RESULTS: Twenty eightpatients were included. The difference in primary closure rates and mean time for fascial closure did not reach statistical significance (p=0.98 and p=0.23, respectively). CONCLUSION: VAC and Bogota Bag do not differ significantly regarding the outcome of abdominal wall integrity, due to the monitoring of a specific team and the adoption of progressive closure OBJETIVO: avaliar o resultado da integridade da parede abdominal após utilização do fechamento assistido a vácuo e da bolsa de Bogotá. MÉTODOS: um estudo retrospectivo foi realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), identificando os pacientes submetidos à técnica de fechamento abdominal temporário (FAT) entre janeiro de 2005 e dezembro de 2011. Os dados foram coletados por meio de revisão de prontuários. Os critérios de inclusão foram indicação de FAT e sobrevivência até o fechamento definitivo da parede abdominal. No período pós-operatório, apenas um grupo de três cirurgiões, seguiu todos os pacientes e realizou as reoperações. Além disso, independente da técnica de FAT utilizada, foi aplicada a tática de fechamento fascial progressivo durante as reoperações. RESULTADOS: Vinte e oito pacientes foram incluídos. Não houve diferença estatística nas taxas de fechamento primário e tempo médio de fechamento fascial. CONCLUSÃO: O fechamento assistido a vácuo e a bolsa de Bogotá não diferem significativamente em relação ao resultado da integridade da parede abdominal após as reoperações. Isso se deve ao acompanhamento de uma equipe específica e a adoção de técnica de fechamento fascial progressivo.

We report a patient with longstanding Behçet disease who presented sudden onset of headache and facial paresis. The magnetic resonance imaging (MRI) showed a mass in the right thalamus, extending to the lentiform nucleus, subthalamic area, right cerebral peduncle and deep subcortical white matter. Stereotactic brain biopsy disclosed gliosis with no signs of malignancy. The diagnosis of a pseudotumoral form of neuro-Behçet disease was done and she was treated with pulse methylpredinisolone and intravenous cyclophosphamide. After 8 weeks she had improved and a new MRI showed disappearance of the tumor-like lesion. The differential diagnosis, especially with central nervous system tumor is emphasized.

Pilonidal cysts and sinuses are described as dermoid cysts which contain follicles of hairs and sebaceous glands. They clinically present as a classic case of inflammation which comes with pain, local infection and redness. The origin of pilonidal disease remains controverse. There are many hypothesis as lack of hygiene on the affected area and a penetration and growth of a hair in the subcutaneus tissue caused by constant friction or direct trauma on the damaged area. The option for clinical treatment is very frequent. However, taking into consideration the incidence and the possibility of recidive, surgical treatment is presently recommended. Complications include cellulitis and abscess formation. Pilonidal cysts are mostly found on the sacral region. In the literature is found description of pilonidal cysts on the penis, interdigital region on the hands as well as on the cervical region. We present a case of pilonidal cyst located on the vault biparietal region, without malignant degeneration.

The group comprises episodic and chronic clus-ter headache, chronic and episodic paroxysmal hemicra-nia, and SUNCT syndrome. SUNA syndrome (short-lasting unilateral neuralgiform headache attacks with cranial au-tonomic symptoms), although not classified as a TAC, also shares some common characteristics with this group and may include the SUNCT definition. Despite their common elements, the TACs differ in response to therapy, frequen-cy and duration of attacks. They must be differentiated from secundary TACs because of the possible serious and treatable underlying causes, like mass lesions, subarach-noid hemorrhage, pathology in the base of the skull and others

To determine the diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) using fluorine-18-deoxyglucose ([18F]-FDG) for the evaluation of a solitary pulmonary nodule (SPN).Prospective analysis of 53 consecutive patients submitted to PET/CT between March 2005 and May 2007 for the evaluation of an SPN. Of those, 32 met the criteria for inclusion in the present study. The lesions were evaluated for location, size, radiotracer uptake and maximum standardized uptake value (SUV). The FDG-PET/TC results were correlated with other predictors of malignance (age, gender, smoking status, nodule size and nodule location). The definitive diagnosis was established through histopathology or through clinical/radiological follow-up for at least one year.Fourteen malignant SPNs were found. Through analysis of the ROC curve, we established an SUV of 2.5 as the most appropriate cut-off point, since it correctly identified 13 of the 14 malignant SPNs. The results below that point revealed one false positive for neoplasia out of a total of 14. The semiquantitative method presented a sensitivity of 92.9%, specificity of 72.2%, positive predictive value of 72.2%, negative predictive value of 92.9% and accuracy of 81.2%. The multivariate analysis showed a statistically significant association with SPN malignancy only for nodule location in the upper lobes (p = 0.048) and SUV (p = 0.07).The results obtained suggest that the SUV of [18F]-FDG is a useful predictor of neoplasia in SPN, with a high negative predictive value, which allows malignancy to be safely ruled out, showing its relevance in the diagnostic approach to pulmonary nodules.

There are few papers devoted to geriatric Guillain-Barré (GBS) and many related issues remain unanswered.To describe clinical, electrophysiological and therapeutic features in this age.Clinico-epidemiological data and therapy of GBS patients older than 60 years were reviewed. Hughes scores were used to quantify neurological deficit and define outcome.Among 18 patients (mean age 64.8 years), 9 had evident prodrome and 80% noticed initially sensory-motor deficit. Demyelinating GBS was found in 8 and axonal in 6 subjects. There was one Miller-Fisher and 3 unclassified cases. Plasmapheresis (PFX) was single therapy in 12 patients and intravenous immunoglobulin (IVIg) in 2. Disability scores just before therapy were similar in both groups, so as short and long term outcome.Axonal GBS seems to be more frequent in the elderly and this may have prognostic implications. PFX and IVIg were suitable options, but complications were noticed with PFX. Prospective studies are needed to better understand and manage GBS in the elderly.

Whipple's disease (WD) is an uncommon multisystem condition caused by the bacillus Tropheryma whipplei. Central nervous system involvement is a classical feature of the disease observed in 20 to 40% of the patients. We report the case of a 62 yeards old man with WD that developed neurological manifestations during its course, and discuss the most usual signs and symptoms focusing on recent diagnostic criteria and novel treatment regimens.