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SERPINA6 and SERPINA1 were recently identified as the main genes associated with plasma cortisol concentration in humans. Although dysregulation in the Hypothalamus-Pituitary-Adrenal (HPA) axis has been observed in Attention Deficit/Hyperactivity Disorder (ADHD), the molecular mechanisms underlying this relationship are still unclear. Evaluation of the SERPINA6/SERPINA1 gene cluster in ADHD may provide relevant information to uncover them. We tested the association between the SERPINA6/SERPINA1 locus, including 95 single nucleotide polymorphisms (SNPs), and ADHD, using data from a Brazilian clinical sample of 259 ADHD probands and their parents. The single SNP association was tested using binary logistic regression, and we performed Classification and Regression Tree (CART) analysis to evaluate genotype combinations' effects on ADHD susceptibility. We assessed SNPs' regulatory effects through the Genotype-Tissue Expression (GTEx) v8 tool, and performed a complementary look-up analysis in the largest ADHD GWAS to date. There was a suggestive association between ADHD and eight variants located in the SERPINA6 region and one in the intergenic region between SERPINA6 and SERPINA1 after correction for multiple tests (p 0.032). CART analysis showed that the combined effects of genotype GG in rs2144833 and CC in rs10129500 were associated with ADHD (OR = 1.78; CI95% = 1.24-2.55). The GTEx assigned the SNPs as eQTLs for genes in different tissues, including SERPINA6, and the look-up analysis revealed two SNPs associated with ADHD. These results suggest a shared genetic component between cortisol levels and ADHD. HPA dysregulation/altered stress response in ADHD might be mediated by upregulation of corticosteroid binding globulin (CBG, encoded by SERPINA6) expression.

We estimated the associations between age at first marriage and recent intimate partner violence (IPV) among women young women aged 20–24 years using data from demographic and health surveys (DHS) conducted at 48 low- and middle-income countries (LMICs). We fitted a multilevel logistic regression model controlling for sociodemographic covariates. Our pooled analyses revealed that age at marriage is strongly associated with past year IPV in a non-linear way, with steep reductions in violence when young women marry after age 15 and a continued decline in IPV for every year marriage is delayed up to age 24. The risk of physical IPV was 3.3 times higher among women married at age 15 (24.4%, 95% CI 19.7; 29.2%) compared to young women married at age 24 (7.5%, 95% CI 5.8; 9.2%). For sexual IPV, girls married at 15 had 2.2 times higher risk compared to those married at 24 (7.5%, 95% CI 5.6; 9.5% vs. 3.4%, 95% CI 2.7; 4.2%, respectively). For psychological IPV, the relative risk was 3.4 for the same comparison (married at 15: 20.1%, 95% CI 14.6; married at 24: 25.5% vs. 6.0%, 95% CI 3.4; 8.6%). Country specific analyses showed that, age at marriage was negatively associated with physical and psychological IPV in nearly half of the countries (n/48) and with sexual IPV in ten countries. Our findings underscore the importance of integrating violence prevention and response interventions into efforts to prevent child marriage, as well as the health, educations and social services young women access.

Background The global milk formula market has ‘boomed’ in recent decades, raising serious concerns for breastfeeding, and child and maternal health. Despite these developments, few studies have investigated the global expansion of the baby food industry, nor the market and political practices corporations have used to grow and sustain their markets. In this paper, our aim is to understand the strategies used by the baby food industry to shape ‘first-foods systems’ across its diverse markets, and in doing so, drive milk formula consumption on a global scale. We used a theoretically guided synthesis review method, which integrated diverse qualitative and quantitative data sources. Results Global milk formula sales grew from ~US$1.5 billion in 1978 to US$55.6 billion in 2019. This remarkable expansion has occurred along two main historical axes. First, the widening geographical reach of the baby food industry and its marketing practices, both globally and within countries, as corporations have pursued new growth opportunities, especially in the Global South. Second, the broadening of product ranges beyond infant formula, to include an array of follow-up, toddler and specialized formulas for a wider range of age groups and conditions, thereby widening the scope of mother-child populations subject to commodification. Sophisticated marketing techniques have been used to grow and sustain milk formula consumption, including marketing through health systems, mass-media and digital advertising, and novel product innovations backed by corporate science. To enable and sustain this marketing, the industry has engaged in diverse political practices to foster favourable policy, regulatory and knowledge environments. This has included lobbying international and national policy-makers, generating and deploying favourable science, leveraging global trade rules and adopting corporate policies to counter regulatory action by governments. Conclusion The baby food industry uses integrated market and political strategies to shape first-foods systems in ways that drive and sustain milk formula market expansion, on a global scale. Such practices are a major impediment to global implementation of the International Code of Marketing of Breastmilk Substitutes, and other policy actions to protect, promote and support breastfeeding. New modalities of public health action are needed to negate the political practices of the industry in particular, and ultimately to constrain corporate power over the mother-child breastfeeding dyad.

Introduction Zero-dose prevalence refers to children who failed to receive any routine vaccination. Little is known about the “immunisation cascade” in low- and middle-income countries (LMICs), defined as how children move from zero dose to full immunisation. Methods Using data from national surveys carried out in 92 LMICs since 2010 and focusing on the four basic vaccines delivered in infancy (BCG, polio, DPT and MCV), we describe zero-dose prevalence and the immunisation cascade in children aged 12 to 23 months. We also describe the most frequent combinations of vaccines (or co-coverage) among children who are partially immunized. Analyses are stratified by country income groups, household wealth quintiles derived from asset indices, sex of the child and area of residence. Results were pooled across countries using child populations as weights. Results In the 92 countries, 7.7% were in the zero-dose group, and 3.3%, 3.4% and 14.6% received one, two or three vaccines, respectively; 70.9% received the four types and 59.9% of the total were fully immunised with all doses of the four vaccines. Three quarters (76.8%) of children who received the first vaccine received all four types. Among children with a single vaccine, polio was the most common in low- and lower-middle income countries, and BCG in upper-middle income countries. There were sharp inequalities according to household wealth, with zero-dose prevalence ranging from 12.5% in the poorest to 3.4% in the wealthiest quintile across all countries. The cascades were similar for boys and girls. In terms of dropout, 4% of children receiving BCG did not receive DPT1, 14% receiving DPT1 did not receive DPT3, and 9% receiving DPT3 did not progress to receive MCV. Interpretation. Focusing on zero-dose children is particularly important because those who are reached with the first vaccine are highly likely to also receive remaining vaccines.

To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women's empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys.We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women's empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women's empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries.In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level.Our country-level and individual-level analyses support the importance of women's empowerment for child vaccination, especially in countries with weaker routine immunisation programs.

SARS-CoV-2 infection depend on the binding of the viral Spike glycoprotein (S) to the human receptor Angiotensin Converting Enzyme 2 (ACE2) to induce virus-cell membrane fusion. S protein evolved diverse amino acid changes that are possibly linked to more efficient binding to human ACE2, which might explain part of the increase in frequency of SARS-CoV-2 Variants Of Concern (VOCs). In this work, we investigated the role of ACE2 protein variations that are naturally found in human populations and its binding affinity with S protein from SARS-CoV-2 representative genotypes, based on a series of

BackgroundThe Sustainable Development Goals (SDGs) recommend stratification of health indicators by ethnic group, yet there are few studies that have assessed if there are ethnic disparities in childhood immunisation in low- and middle-income countries (LMICs).MethodsWe identified 64 LMICs with standardized national surveys carried out since 2010, which provided information on ethnicity or a proxy variable and on vaccine coverage; 339 ethnic groups across the 64 countries were identified after excluding those with fewer than 50 children in the sample and countries with a single ethnic group. Lack of vaccination with diphtheria-pertussis-tetanus (DPT) vaccine – a proxy for no access to routine vaccination or ‘zero-dose’ status – was the outcome of interest. Differences among ethnic groups were assessed using a chi-squared test for heterogeneity. Additional analyses controlled for household wealth, maternal education and urban-rural residence.FindingsThe median gap between the highest and lowest zero-dose prevalence ethnic groups in all countries was equal to 10 percentage points (interquartile range 4-22; range 1 to 84) and the median ratio was 3.3 (interquartile range 1.8-6.7; range 1.1-30.4). In 35 of the 64 countries, there was significant heterogeneity in zero-dose prevalence among the ethnic groups. In most countries, adjustment for wealth, education and residence made little difference to the ethnic gaps, but in four countries (Angola, Benin, Nigeria, and Philippines) the high-low ethnic gap decreased by over 15 pp after adjustment. Children belonging to a majority group had 29% lower prevalence of zero-dose compared to the rest of the sample.InterpretationStatistically significant ethnic disparities in child immunisation were present in over half of the countries studied. Such inequalities have been seldom described in the published literature. Regular analyses of ethnic disparities are essential for monitoring trends, targeting resources and assessing the impact of health interventions to ensure zero-dose children are not left behind in the Sustainable Development Goals era.FundingBill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, Wellcome Trust, and Associação Brasileira de Saúde Coletiva.

Background With the rise of vaccine hesitancy, which is allegedly more frequent among rich families, we hypothesized that the classical pattern of a positive gradient in coverage with rising wealth may no longer be observable in low- and middle-income countries (LMICs). Methods We analysed DHS and MICS surveys conducted from 2010-2018 in 88 LMICs. We estimated inequality in measles vaccination coverage by wealth quintile for children aged 12-23 months using the Slope Index of Inequality (SII). Negative SII values indicate higher coverage among poor children. We correlated the SII with per capita Gross Domestic Product (GDP), using countries as the units. Results Pearson’s correlation coefficient between SII and log per capita GDP was -0.35 (p Conclusions Our results are consistent with lower vaccination coverage among the wealthy when compared to poor families in countries with higher per capita GDPs. Key messages Vaccine hesitancy was initially detected in high-income countries, but our analyses show that it is also present in upper-middle income countries.

Background Non-vaccinated children are a particularly vulnerable and understudied group. Machine learning algorithms, such as decision trees, might be useful for identifying subgroups with high prevalence of zero dose (neither BCG, polio, DPT nor measles vaccines received). Methods We developed Classification and Regression Tree models using data from DHS surveys of India 2015 and Chad 2014 in order to identify risk groups of zero dose. Results The first split variable for India was the child’s place of delivery, followed by the mother’s tetanus vaccination status for the higher-risk subgroup of children born in noninstitutional facilities. For Chad, administrative region was selected, and two high zero dose regions were defined. For those regions, children whose mother did not receive any dose of tetanus vaccine were also considered a higher-risk subgroup. Conclusions Two trees were created with only two splits each. Subgroups with zero dose prevalence higher than 40% were identified. Key messages Decision trees might be valuable tools for exploratory data analysis and risk groups identification in epidemiological research.

Reducing vaccination inequalities is a key goal of the Immunization Agenda 2030. Our main objective was to identify high-risk groups of children who received no vaccines (zero-dose children). A decision tree approach was used for 92 low- and middle-income countries using data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys, allowing the identification of groups of children aged 12–23 months at high risk of being zero dose (no doses of the four basic vaccines—BCG, polio, DPT and measles). Three high-risk groups were identified in the analysis combining all countries. The group with the highest zero-dose prevalence (42%) included 4% of all children, but almost one in every four zero-dose children in the sample. It included children whose mothers did not receive the tetanus vaccine during and before the pregnancy, who had no antenatal care visits and who did not deliver in a health facility. Separate analyses by country presented similar results. Children who have been missed by vaccination services were also left out by other primary health care interventions, especially those related to antenatal and delivery care. There is an opportunity for better integration among services in order to achieve high and equitable immunization coverage.

Background: Primary prevention strategies are needed to reduce high levels of intimate partner violence (IPV) in low- and middle-income countries (LMICs), and their effectiveness may be improved by targeting the most vulnerable populational groups and by focusing on context-specific risk factors. Methods: We selected the most recent Demographic and Health Survey carried out since 2010 and with available information on IPV. Exposure to IPV was defined as having experienced physical and/or sexual IPV in the past 12 months. We selected 15 recognized IPV risk factors (or proxies) which were available in the surveys and had a potential for tailoring and targeting interventions. To identify groups of women most vulnerable to IPV, we applied a decision tree approach, creating individual trees for each country and for all countries combined. Findings: We identified 48 countries with suitable data. In the pooled decision tree, witnessing IPV during childhood, a lower empowerment level (attitude to violence) and partner’s alcohol use were the strongest markers of IPV vulnerability. IPV prevalence among the most vulnerable women was 43% compared to 21% in the overall sample. This high-risk group concentrated 1 in every 4 women who experienced IPV in LMICs. Across the individual national trees, the subnational regions emerged as the most frequent markers of IPV occurrence. Interpretation: This study contributes evidence that can be used to plan and improve policies and programmes aimed at reducing population levels of IPV by reaching high-risk women and families with focused interventions in LMICs. By using a decision-tree approach - a simple-to-use yet powerful statistical tool we provide important insights about subpopulations of women where IPV have very high prevalence and to which interventions could be prioritised and tailored. Funding Information: Grant number: 101815/Z/13/Z and The Bill & Melinda Gates Foundation Health - Grant Number: INV-007594 / OPP1148933 Declaration of Interests: None to declare. Ethics Approval Statement: Ethical approval was obtained by the national agencies responsible for conducting each survey. All analyses relied on publicly available, anonymized databases for which permission to access was received through the DHS Program.

Monitoring indicators of breastfeeding practices is important to protect and evaluate the progress of breastfeeding promotion efforts. However, high‐income countries lack standardized methodology to monitor their indicators. We aimed to update and summarize nationally representative annual estimates of breastfeeding indicators in high‐income countries and to describe methodological issues pertaining to the data sources used. A review was conducted through population‐based surveys with nationally representative samples or health reports from nationally representative administrative data of electronic surveys or medical records. Methodological aspects and rates of all breastfeeding indicators available were summarized by country. The median and annual growth of breastfeeding in percentage points within countries with time‐series data were estimated. Data from 51 out of 82 high‐income countries were identified. The data were obtained through surveys (n = 32) or administrative data (n = 19). Seventy‐one percent of countries have updated their indicators since 2015. Ever breastfed was the indicator most frequently reported (n = 46), with a median of 91%. By 6 months of age, the median equals 18% for exclusive and 45% for any breastfeeding. At 12 months, the median of continued breastfeeding decreased to 29%. The annual growth rate for ever breastfed, exclusive and any breastfeeding at 6 months and continued at 12 months varied from 1.5 to −2.0, 3.5 to −3.1, 5.0 to −1.0 and 5.0 to −1.9, respectively, with positive changes for most countries. Stronger interventions are needed to promote breastfeeding in high‐income countries as a whole, and investments are required to monitor trends with standardized methodologies.

Additional file 1: Figure S1. Global dry milk powder production and trade dynamics in 2005 (top) and 2014 (bottom) – circles represent country production values (tonnes), and lines the value and direction of trade (US$). Notes: To simplify the figure, only countries with trade flow (export) values >US$10 million were represented; dry milk powder production values (tonnes) were sourced from FAOSTAT. Trade data were soured from UN Comtrade. Table S1. List of organizations in the baby food industries’ global influence network. Notes: * formerly the Grocery Manufacturers Association.

Background Ultra-processed food (UPF) and Ultra-processed beverage (UPB) consumption is associated with higher risks of numerous non-communicable diseases (NCDs). Yet global consumption of these products is rising due to profound changes in production, processing, manufacturing, marketing, retail, and consumption practices, alongside the growth of the resources and political influence of Big Food. Whilst the sales of UPFs and UPBs in high-income countries (HICs) are stagnating, sales are rapidly expanding in more populous middle-income countries (MICs). In this paper, we adopt a political economy of food systems approach to understand how growth of Big Food in MICs drives the NCD pandemic. Methods We conducted a mixed methods synthesis review. This involved quantitative data collection and development of descriptive statistics; a search for academic, market and grey literature on the expansion of UPF in MICs; and the development of themes, three illustrative case examples (South Africa, Colombia, and Indonesia), and synthesis of the enablers of successful campaigns in MICs into recommendations for public health campaigns. Results We project that the combined sales volume of UPFs in MICs will reach equivalency with HICs by 2024, and the total sales volume of UPBs in MICs is already significantly higher than in HICs. Similarly, annual growth in UPF sales is higher in MICs compared to HICs. We also show how Big Food has entrenched its presence within MICs through establishing global production and hyper-local distribution networks, scaling up its marketing, challenging government policies and scientific expertise, and co-opting civil society. We argue that public health can counter the influence of Big Food by developing an expanded global network of driven and passionate people with diverse skillsets, and advocating for increased government leadership. Conclusion The projected increase in sales of UPFs and UPBs in MICs raises major concerns about the global capacity to prevent and treat NCDs.

Objective:To investigate the prevalence and socio-economic inequalities in breast milk, breast milk substitutes (BMS) and other non-human milk consumption, by children under 2 years in low- and middle-income countries (LMIC).Design:We analysed the prevalence of continued breast-feeding at 1 and 2 years and frequency of formula and other non-human milk consumption by age in months. Indicators were estimated through 24-h dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socio-economic inequalities.Setting:Nationally representative surveys from 2010 onwards from eighty-six LMIC.Participants:394 977 children aged under 2 years.Results:Breast-feeding declined sharply as children became older in all LMIC, especially in upper-middle-income countries. BMS consumption peaked at 6 months of age in low/lower-middle-income countries and at around 12 months in upper-middle-income countries. Irrespective of country, BMS consumption was higher in children from wealthier families, and breast-feeding in children from poorer families. Multilevel linear regression analysis showed that BMS consumption was positively associated with absolute income, and breast-feeding negatively associated. Findings for other non-human milk consumption were less straightforward. Unmeasured factors at country level explained a substantial proportion of overall variability in BMS consumption and breast-feeding.Conclusions:Breast-feeding falls sharply as children become older, especially in wealthier families in upper-middle-income countries; this same group also consumes more BMS at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups, suggesting that BMS marketing at national level might be partly responsible for the observed differences.

Coronavirus disease-19 (COVID-19) can develop into a severe respiratory syndrome that results in up to 40% mortality. Acute lung inflammatory edema is a major pathological finding in autopsies explaining O2 diffusion failure and hypoxemia. Only dexamethasone has been shown to reduce mortality in severe cases, further supporting a role for inflammation in disease severity. SARS-CoV-2 enters cells employing angiotensin converting enzyme 2 (ACE2) as a receptor, which is highly expressed in lung alveolar cells. ACE2 is one of the components of the cellular machinery that inactivates the potent inflammatory agent bradykinin, and SARS-CoV-2 infection could interfere with the catalytic activity of ACE2, leading to accumulation of bradykinin. In this open-label, randomized clinical trial, we tested two pharmacological inhibitors of the kinin-kallikrein system that are currently approved for the treatment of hereditary angioedema, icatibant and inhibitor of C1 esterase/kallikrein, in a group of 30 patients with severe COVID-19. Neither icatibant nor inhibitor of C1 esterase/kallikrein resulted in significant changes in disease mortality and time to clinical improvement. However, both compounds promoted significant improvement of lung computed tomography scores and increased blood eosinophils, which has been reported as an indicator of disease recovery. In this small cohort, we found evidence for a beneficial role of pharmacological inhibition of the kinin-kallikrein system in two markers that indicate improved disease recovery.

BackgroundConsumption of breast milk substitutes (BMS) by children aged under six months in low and middle income countries (LMICs) is directly driven by country income and family wealth. Multi-country investigations on the consumption of BMS by older children (6–23 months) are lacking.MethodsUsing data from 86 nationally representative surveys carried out in LMICs from 2010 onwards, we analyzed the prevalence of continued breastfeeding at one and two years, and frequency of consumption of formula and other non-human milk by age in months. Indicators were estimated through 24-hour dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socioeconomic inequalities. Results were stratified by country income groups.FindingsBreastfeeding declined sharply as children became older in all LMICs, especially in upper-middle income countries. Formula consumption peaked at six months of age in low and lower-middle income countries, and at around 12 months in upper-middle income countries. Consumption of formula at any age higher in children from wealthier families in all countries, while breastfeeding was more common among poor children. Multilevel linear regression analysis showed that consumption of formula was positively associated while breastfeeding was negatively associated with absolute national income. Factors at country level explained a substantial proportion of overall variability in formula use and breastfeeding.InterpretationInfant and young child feeding practices vary strongly according to wealth, both within and between countries. Breastfeeding falls sharply as children become older, especially in wealthier families living in upper-middle income countries; this is also the group with highest formula consumption at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups in LMICs, suggesting that formula marketing at national level may be partly responsible for the observed differences.FundingThe Bill & Melinda Gates Foundation, through the WHO

BackgroundThe Sustainable Development Goals (SDGs) recommend stratification of health indicators by ethnic group, yet there are few studies that have assessed if there are ethnic disparities in childhood immunisation in low-income and middle-income countries (LMICs).MethodsWe identified 64 LMICs with standardised national surveys carried out since 2010, which provided information on ethnicity or a proxy variable and on vaccine coverage; 339 ethnic groups were identified after excluding those with fewer than 50 children in the sample and countries with a single ethnic group. Lack of vaccination with diphtheria–pertussis–tetanus vaccine—a proxy for no access to routine vaccination or ‘zero-dose’ status—was the outcome of interest. Differences among ethnic groups were assessed using a χ2 test for heterogeneity. Additional analyses controlled for household wealth, maternal education and urban–rural residence.FindingsThe median gap between the highest and lowest zero-dose prevalence ethnic groups in all countries was equal to 10 percentage points (pp) (IQR 4–22), and the median ratio was 3.3 (IQR 1.8–6.7). In 35 of the 64 countries, there was significant heterogeneity in zero-dose prevalence among the ethnic groups. In most countries, adjustment for wealth, education and residence made little difference to the ethnic gaps, but in four countries (Angola, Benin, Nigeria and Philippines), the high–low ethnic gap decreased by over 15 pp after adjustment. Children belonging to a majority group had 29% lower prevalence of zero-dose compared with the rest of the sample.InterpretationStatistically significant ethnic disparities in child immunisation were present in over half of the countries studied. Such inequalities have been seldom described in the published literature. Regular analyses of ethnic disparities are essential for monitoring trends, targeting resources and assessing the impact of health interventions to ensure zero-dose children are not left behind in the SDG era.

Um dos desafios causados pela pandemia da covid-19 foi o provimento de leitos hospitalares para enfrentamento da doença e para evitar sobrecarga do sistema de saúde. Este artigo tem como objetivo apresentar a plataforma de projeção de leitos hospitalares desenhada para auxiliar a prefeitura do município de Pelotas, Rio Grande do Sul, a definir o número máximo de leitos de UTI necessário no pico da epidemia no município. Empregou-se o modelo epidemiológico SEIR adaptado com processo estocástico para os parâmetros da dinâmica de transmissão. A plataforma foi construída dentro de uma Aplicação Shiny e permite ao usuário ajustar todos os parâmetros utilizados no modelo. No início de abril de 2020, estimou-se a necessidade de 100 leitos de UTI no pico da epidemia em Pelotas. Tanto os parâmetros do modelo quanto as previsões foram constantemente atualizadas conforme o avanço da epidemia e do conhecimento científico sobre a doença. A plataforma foi uma das ferramentas utilizadas pela Equipe Científica do Comitê Interno para Acompanhamento da Evolução da Pandemia pelo Coronavírus da UFPel para tomada de decisões e divulgação de notas técnicas à imprensa.

Lung ultrasound is an accurate and accessible tool to quantify lung edema. Furthermore, left ventricle filling pressures (LVFP) can be assessed with transthoracic echocardiography (TTE) by the E/e' ratio (E/e'). The present study aimed to assess the correlation between E/e' and lung edema quantified by a simplified lung ultrasound score (LUS) in newly admitted septic patients.In this prospective observational cohort, septic adult patients admitted at the emergency department of a tertiary hospital were included. LUS consisted of four different patterns of lung edema (from normal aeration to parenchymal consolidation). To compare lung edema with LVFP, E/e' was calculated immediately before or within 5min of fluid therapy.Fifty patients were enrolled in 3months. The LUS correlated with E/e' (r=0.58, P0.0001). The LUS also increased among E/e' quartiles (Q) (Q1: E/e'≤4.49; Q2: 4.49E/e'≤5.49; Q3: 5.49E/e'≤7.11; Q4:7.11; P=0.0003 for Q1 and 4; 2 and 4); and LUS was significantly higher in abnormal (≥8) vs. normal (8) values of E/e' (11.29 vs 8.49, P=0.007).In newly admitted septic patients, lung edema is positively correlated with LVFP prior to fluid therapy. This finding might help find future targets for fluid resuscitation in sepsis.

Background Unvaccinated children may live in households with limited access to other primary health care (PHC) services, and routine vaccination services may provide the opportunity to bring caregivers into contact with the health system. We aimed to investigate the overlap between not being vaccinated and failing to receive other PHC services in low- and middle-income countries (LMICs). Methods Using Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) data between 2010-2019 from 92 LMICs, we analysed six vaccination indicators based on the bacille Calmette-Guerin (BCG), polio, diphtheria-pertussis-tetanus (DPT) and measles vaccines and their overlap with four other PHC indicators - at least four antenatal care (ANC) visits, institutional delivery, careseeking for common childhood illnesses or symptoms and place for handwashing in the home - in 211,141 children aged 12-23 months. Analyses were stratified according to wealth quintiles and World Bank income levels. Findings Unvaccinated children and their mothers were systematically less likely to receive the other PHC interventions. These associations were particularly marked for 4+ ANC visits and institutional delivery and modest for careseeking behaviour. Our stratified analyses confirm a systematic disadvantage of unvaccinated children and their families with respect to obtaining other health services in all levels of household wealth and country income. Interpretation We suggested that lack of vaccination goes hand in hand with missing out on other health interventions. This represents an opportunity for integrated delivery strategies that may more efficiently reduce inequalities in health service coverage. Funding Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, The Wellcome Trust, Associacao Brasileira de Saude Coletiva and Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior.

Background\ud Primary prevention strategies are needed to reduce high rates of intimate partner violence (IPV) in low- and middle-income countries (LMICs). The effectiveness of population-based approaches may be improved by adding initiatives targeted at the most vulnerable groups and tailored to context-specificities.\ud \ud Methods\ud We applied a decision-tree approach to identify subgroups of women at higher risk of IPV in 48 LMICs and in all countries combined. Data from the most recent Demographic and Health Survey carried out between 2010 and 2019 with available information on IPV and sociodemographic indicators was used. To create the trees, we selected 15 recognized risk factors for IPV in the literature which had a potential for targeting interventions. Exposure to IPV was defined as having experienced physical and/or sexual IPV in the past 12 months.\ud \ud Findings\ud In the pooled decision tree, witnessing IPV during childhood, a low or medium empowerment level and alcohol use by the partner were the strongest markers of IPV vulnerability. IPV prevalence amongst the most vulnerable women was 43% compared to 21% in the overall sample. This high-risk group included women who witnessed IPV during childhood and had lower empowerment levels. These were 12% of the population and 1 in 4 women who experienced IPV in the selected LMICs. Across the individual national trees, subnational regions emerged as the most frequent markers of IPV occurrence.\ud \ud Interpretation\ud Starting with well-known predictors of IPV, the decision-tree approach provides important insights about subpopulations of women where IPV prevalence is high. This information can help designing targeted interventions. For a large proportion of women who experienced IPV, however, no particular risk factors were identified, emphasizing the need for population wide approaches conducted in parallel, including changing social norms, strengthening laws and policies supporting gender equality and women´s rights as well as guaranteeing women´s access to justice systems and comprehensive health services.\ud \ud Funding\ud Bill and Melinda Gates Foundation (Grant INV-010051/OPP1199234), Wellcome Trust (Grant Number: 101815/Z/13/Z ) and Associação Brasileira de Saúde Coletiva (ABRASCO).

Coverage of health interventions usually shows social gradients with higher levels among wealthy than among poor individuals. Owing to the upsurge of vaccine hesitancy in high-income countries, the authors hypothesized that the social gradient may also be changing over time in the low- and middle-income countries and set out to test this hypothesis.In January 2020, surveys conducted from 2010 to 2018 in 86 low- and middle-income countries were analyzed to assess full immunization coverage in children aged 12-23 months. The authors calculated full immunization coverage point estimates and 95% CIs for each country and wealth quintile. To explore wealth-related inequalities, the authors estimated the slope index of inequality and calculated the Pearson correlation coefficient between these values and per capita gross domestic product. Time trends were analyzed in 10 countries with recent evidence of hesitancy.Pro-poor patterns were defined as significant slope index of inequality values with higher coverage among poor children, and pro-rich patterns were defined as the reverse pattern. A total of 11 countries showed pro-poor patterns in the most recent survey, accounting for 20% of upper middle- and 7% of low-income countries. The correlation between the slope index of inequality and log per capita gross domestic product was -0.38 (p0.001). Among the 10 countries with recent evidence of hesitancy, 5 showed full immunization coverage declines over time in the wealthiest quintiles, and 4 switched from pro-rich to pro-poor patterns throughout the years.Lower full immunization coverage was found among the wealthy than among the poor in 10 countries, especially in the upper middle-income group, consistent with the emergence of vaccine hesitancy.This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Stroke following scorpion stings is rare. We report a fatal envenomation involving multiple, extensive brain infarcts in a patient with a previous diagnosis of essential thrombocythemia (ET) who was stung by Tityus serrulatus (T. serrulatus).A 44-year-old woman with a diagnosis of low-risk ET (platelets1,000,000/mmSeveral mechanisms have been proposed to explain stroke following scorpion stings, such as sympathetic stimulation, myocardial dysfunction, hypotension/shock, arrhythmias and coagulopathy. Ischemic stroke is one of the most serious complications of ET. The risk factors for thrombotic/ischemic events in patients with ET include age (≥60 years) and previous vascular events. Severe scorpion envenomation resulting in myocardial dysfunction and systemic inflammatory response syndrome may increase the overall risk of arterial thrombosis in this patient.

BACKGROUND: Lung ultrasound (US) is an excellent tool to assess lung edema in a myriad of different clinical situations. We hypothesized that lung US might also be a good prognostic and management instrument in septic patients, regardless of disease severity.METHODS: This was a prospective observational cohort study at an urban academic emergency department (ED). Inclusion criteria were as follows: septic patients, at least 18 years old, admitted at the ED of a tertiary hospital. A simplified lung edema scoring system (SLESS) was developed, and 6 thoracic regions were evaluated. Four different lung US patterns were considered, from normal aeration to total consolidation. To evaluate disease severity, the SLESS was compared with the Mortality in Emergency Department Sepsis Score and the third version of the Simplified Acute Physiology Score scoring systems. Aiming to assess the effect of the lung edema in the gas exchange, the SLESS was compared with the Pao2/fraction of inspired oxygen ratio.RESULTS: Sixty-one patients were enrolled in a 3-month period. The SLESS had a good correlation with the Mortality in Emergency Department Sepsis Score and Simplified Acute Physiology Score (r = 0.53 and r = 0.55, respectively; P < .001 for both) and a negative correlation with the Pao2/fraction of inspired oxygen ratio (r = -0.62; P < .001). The SLESS also showed correlation with the respiratory rate (r = 0.45; P = .0003). The odds ratio for death related to the SLESS was 1.370 (95% confidence interval, 1.109-1.691; P = .0035).CONCLUSION: The SLESS is an easy and practical scoring system. It might be a useful tool to predict severity of disease in sepsis patients. The SLESS might also be able to be correlated with the oxygen exchange.

Management of Sepsis would greatly benefit from the incorporation of simple and informative new biomarkers in clinical practice. Ideally, a sepsis biomarker should segregate infected from non-infected patients, provide information about prognosis and organ-specific damage and be accessible to most healthcare services. The immature platelet fraction (IPF) and immature reticulocyte fraction (IRF) are new analytical parameters of the complete blood count, that have been studied as biomarkers of several inflammatory conditions. Recently, a study performed in critically-ill patients suggested that IPF could be a more accurate sepsis biomarker than C-reactive protein (CRP) and procalcitonin. In this retrospective study we evaluated the performance of IPF and IRF as biomarkers of sepsis diagnosis and severity. 41 patients admitted to two intensive care units were evaluated, 12 of which with severe sepsis or septic shock and 11 with non-complicated sepsis. Significantly higher IPF levels were observed in patients with severe sepsis/septic shock. IPF correlated with sepsis severity scores and presented the highest diagnostic accuracy for the presence of sepsis of all studied clinical and laboratory parameters. No significant differences were observed in IRF levels. Our results suggest that IPF levels could be used as a biomarker of sepsis diagnosis and severity.

In face of the diversified individual and collective requirements of Web applications, we argue that the Web interfaces should be flexible enough to adapt or to be adapted to each usage context. We draw on the idea of Tailoring to design for flexibility. However, due to the additional effort to provide flexibility, usually the construction of a tailorable application results on higher costs and complex solutions. The objective of this work is to provide developers and designers with a framework to support the development of tailorable Web applications. This framework is based on a normative approach to describe the volatile requirements including social and pragmatics aspects of the system usage. In the paper we discuss the theoretical basis, describe the framework, and provide short examples of how to use it.