Financial inclusion, whereby all adults have effective access to financial products, including insurance, has increasingly become a global priority, particularly in low and middle income economies. This study matches the measured development level of inclusive insurance in Chinese provinces with China Family Panel Studies (CFPS) data and evaluates the impact of inclusive insurance on income distribution and inclusive growth. The findings support that inclusive insurance has a positive impact on income distribution and inclusive growth. The effect is more pronounced in eastern areas, rural areas and low-income households. The policy shocks and instrumental variables introduced prove the robustness of the results. PSM-DID test indicate that the inclusive insurance policy has a significant positive effect on income distribution. Alternative measure of inclusive insurance and GMM test with instrumental variables indicate that the results are robust. Additionally, we also find that there is a threshold effect on the impact of the inclusive insurance on income. When the universal insurance index exceeds the threshold value, the promoting effect on income is enhanced. Non-banThe development of inclusive finance was a major strategic deployment made at the Third Plenary Session of the 18th CPC Central Committee in China. At present, the rapid development of inclusive insurance is playing an important role in medical and health care, social security, employment, small and microenterprise development, agricultural production and other aspects of guaranteeing the livelihood of people in China . In termIncome distribution and inclusive growth are also key issues emphasized in China's development. The Sixth Plenary Session of the 19th CPC Central Committee that was just held stressed “implementing the new development concept, building a new development pattern, promoting high-quality development, comprehensively deepening reform and opening up, promoting common prosperity, and insisting on safeguarding and improving people's livelihood in development.” The idea that “the income distribution system must be perfected” was mentioned in “Some Major Issues of the National Medium- and Long-Term Economic and Social Development Strategy of China” . It can In this context, it is particularly important to systematically explore the impact of inclusive insurance on income distribution and inclusive growth. The innovation of our research is reflected in the following: First, most studies on inclusive insurance have focused on its definition and index measurement and on the testing of its determinants. Based on the construction of an inclusive insurance index, we are the first to discuss and explore the effect of inclusive finance on income distribution and inclusive growth as well as the mechanism, providing theoretical support and practical guidance for the design of an inclusive insurance policy framework. Second, most existing studies have explained the economic effects of inclusive insurance at the theoretical level, and empirical analysis has focused on the provincial and municipal levels. However, the economic environment in China may lead to deviations, including deviations between the micro action mechanism and the macro expected effect. We combine the measured level of inclusive insurance development in each province of China with China Family Panel Studies (CFPS) data to examine the impact of inclusive financial development on residents' income and income growth at the micro level and to extend the micro mechanism of the economic effect of inclusive insurance. Third, we analyze the “growth effect” and “distribution effect” of inclusive insurance development on residents' income in the same framework and then explores whether the income-increasing effect of inclusive insurance is heterogeneous, how the mechanism of inclusive insurance affects income distribution and inclusive growth, and how inclusive insurance affects the income gap and income growth through the heterogeneity of health, human capital and social capital. It also provides corresponding theoretical support and an empirical basis for the development of inclusive insurance.Inclusive insurance encompass many different approaches to reaching the unserved, underserved, vulnerable, or low-income populations in emerging markets with appropriate and affordable insurance products. These range from microinsurance for people with very little disposable income to new products and services for an emerging middle class around the globe who have not been served by traditional insurance. The World Bank  estimateScholars' discussion of the economic effects of inclusive insurance mainly focuses on poverty reduction effects. Zhang and Jiang  found thIncome distribution has always been one of the economic and social issues of greatest concern to scholars. Some scholars have studied the impact of insurance on income distribution. Some scholars believe that the adjustment effect of insurance on the income gap is not obvious, and there is inequity in insurance. Jin et al.  found thDue to the economic development strategy and insurance system arrangement, the effective insurance supply  is insufficient. Some residents are excluded from the traditional insurance system due to their low income level, poor risk resistance ability, small scale of production and operation, lack of credit information and other reasons, and they cannot avoid life and production risks through the insurance system. Inclusive insurance can correct the resource mismatch, and microeconomic individuals can effectively use a more balanced resource allocation to achieve self-development. Even among people with very little disposable income, insurance can be an important tool for managing risk and helping them mitigate the stress of illness, crop failure, natural disasters or loss of income due to the death of the head of household . The rolTherefore, this study formulates Hypothesis 1: inclusive insurance contributes to the optimization of income distribution.Inclusive insurance contributes to inclusive growth by providing more equitable and broad-based insurance services in response to “market failures” in the development of insurance from the perspective of service equity.First, inclusive insurance, such as microguarantee insurance and medical insurance, can enable more effective risk management, mitigate the losses suffered by individuals and enterprises, protect affected families from major financial losses and help enterprises resume production in a timely manner, thus guaranteeing the continuity and stability of social reproduction. Inclusive insurance also contributes to the development of the rural economy and agriculture. By providing basic security for rural residents, it promotes the smooth progress of agricultural production and the stable development of the rural economy. Agricultural insurance and microcredit insurance establish rural financial risk compensation and decentralization mechanisms, which will help farmers expand their production scale, improve production efficiency and support the construction of modern agriculture.Second, the economic growth effect of insurance development is realized through two types of functions, risk transfer and financial intermediation , and incThird, inclusive insurance has a direct impact on rural social development. With the popularization of inclusive insurance in remote rural areas, on the one hand, hardware facilities in rural areas have been built, and the infrastructure represented by insurance infrastructure has been gradually improved. The production conditions, living conditions and life outlook of rural residents have been greatly improved. On the other hand, it can also microscopically improve the financial literacy and insurance awareness of rural residents, thus promoting inclusive development.Therefore, this study formulates Hypothesis 2: inclusive insurance is conducive to inclusive growth.Our research uses household and provincial data. The household data are from the China Family Panel Studies (CFPS) conducted by the Institute of Social Science Survey of Peking University. Twenty-five provinces, municipalities and autonomous regions are covered, and survey data from the base period of 2010 and tracking data from 2012, 2014, 2016, and 2018 are included. The provincial data are panel data on all provinces, municipalities and autonomous regions from 2010 to 2020, all of which come from the China Statistical Yearbook, the statistical yearbooks of each province, city and autonomous region, the China Insurance Yearbook, the China Economic Net and the WIND database. The data were processed as follows: firstly, Samples aged 18–60 years old were selected; Secondly, the adult questionnaire and household questionnaire were matched, and samples with “don't know” and “not applicable” were treated as missing values. The missing values of important variables were excluded, and linear interpolation or the mean value was used to supplement or replace individual missing values. Lastly, the continuous variables involved were subjected to a 1% tailing process. The final sample is composed of 75,737 samples from 16,640 households.2 km, representing the market scale, reflect the degree or proportion of consumers' exposure to insurance, which can measure the accessibility of insurance. Insurance density, insurance depth and the payout per capita can reflect the penetration level of insurance to a certain extent. The goal of insurance is protection; thus, the use efficiency of insurance is measured by the protection level and the payout level.China's Plan for Promoting the Development of Inclusive Finance 2016–2020) states that the inclusive finance indicator system should contain three dimensions: broad inclusiveness, the degree of specificity matching and commercial sustainability. Scholars have discussed the variables that should be included in inclusive finance –2020 sta, 60–64, 1, y2, …., yn); thus, the income inequality of household yi isIncome distribution is an important explanatory variable, and CFPS survey data have detailed information on income and are comparable. The relative deprivation index (Rel)  has beeny is the mean income of all samples, μyi is the mean income of households earning more than yi, yi, and the index is between 0 and 1.where μIn addition to inclusive insurance, other economic factors may have some impact on income distribution and inclusive growth. With reference to the existing literature –70, we cThe effect of inclusive insurance on income distribution was tested using a fixed effect model designed as follows.it is the relative deprivation index, IIit is the level of inclusive insurance coverage, Xkit is the set of control variables, and μit is a random disturbance term.where RelTo further explore whether inclusive insurance can lead to inclusive growth, drawing on the study by Zhang et al. , the lagit is the income of resident i in year t, α0 is the intercept term, ∅i is the individual fixed effect, φi is the time fixed effect, and μit is the sum of the two-way fixed effects and the error term.where Incomeit = 0, the value of the target variable isClearly, when IIit = 1, the value of the target variable isWhen IITo facilitate the analysis of the relationship between inclusive insurance and inclusive growth, the model is simplified as follows:it on yit can be divided into two parts: α1 measures the effect of inclusive insurance IIit on target variable yit when other conditions remain the same; α3yit−1 measures the heterogeneous influence of the income level in the previous period on the income level in the current period through the current period's inclusive insurance index: If α3 > 0, the higher the income level (the larger the yit−1), the more benefits from inclusive insurance; if α3 < 0, the lower the income level , the more benefits from inclusive insurance, indicating that the development of inclusive insurance in a region helps to raise the income level of low-income residents and alleviate income inequality.Based on the above equation, the influence of II1 + α3yit−1 > 0 and α3 < 0, we define that inclusive insurance improves the distribution of income and brings about inclusive growth. This is when inclusive insurance brings about growth in the target variable, on the one hand, and improves the distribution of the target variable, on the other hand. If only α1 + α3yit−1 > 0 but α3 > 0, then inclusive insurance leads to income growth, but it causes an increase in income inequality and therefore does not contribute to inclusive growth.Officially, when αPrincipal component analysis was used to synthesize multiple indicators of inclusive insurance into one index. All data were calculated based on the means, and the covariance matrix was used to reflect the differences in the degree of variation of each indicator, resulting in the eigenvalue, range of change, impact rate and cumulative impact rate of each indicator see .As shown in Based on the variance contribution of the table and the factor score coefficients in First, the benchmark model is used to test the impact of inclusive insurance on income distribution. As shown in To examine whether inclusive insurance promotes inclusive growth, we use Model (3) to test the relationship of inclusive insurance, income distribution and inclusive growth. The results show that with the inclusion of the interaction term, the model fit increases to some extent, and the sign and significance of the estimated coefficients of the explanatory variables are also improved. When the explanatory variable is income, the coefficient of the interaction term of the inclusive insurance index and the income lagged term is significantly negative, indicating that groups with lower income levels benefit more from inclusive insurance. Inclusive insurance improves the effect of income distribution among the individuals within the sample to some extent. The results of the model verify the positive effect of inclusive insurance on inclusive growth. When the explanatory variable is the deprivation index, the coefficient of the interaction term of the inclusive insurance index and the lagged term of the deprivation index is significantly positive, indicating that groups with lower income levels benefit more from inclusive insurance and that inclusive insurance reduces the deprivation index of the sample to a certain extent.Due to the differences in the development of inclusive insurance in different regions, urban and rural areas, as well as families of different income, sub sample analysis can better observe the heterogeneity of the impact of inclusive insurance on income distribution and inclusive growth.Some studies believe that agricultural insurance is generally beneficial for improving farmers' income , 75. HowComparing the results of the samples in the eastern, central and western regions , we see The empirical results of the urban-rural subsample test  show thaThe sample was divided into two groups based on income level, high-income and low-income groups, and the differences between the groups were separately tested.The results of In this section, we explore the robustness of our results to PSM-DID test, which is for reflecting the net effect of the inclusive insurance policy. We also use alternative measure of inclusive insurance by PKU-DFIIC and alternative estimation (GMM model) that handle the potential impact of outliers. Specifically, we construct panel threshold model to infer structural validity from coefficient robustness and plausibility.Considering that the development level of the central and western areas is lower than that of the eastern area, the Chinese state has adopted a differential central fiscal subsidy policy for agricultural insurance for the sake of balanced development between regions. Taking the “Measures for the administration of agricultural insurance premium subsidies from the Central Treasury” promulgated in 2016 as an example, it is observed that the central financial administration's subsidy ratio for agricultural insurance for planting in central and western provinces is 5% higher than that in eastern provinces; additionally, agricultural insurance for farming is 10% higher . The “Meit is the treatment variable. The “Measures for the administration of agricultural insurance premium subsidies from the Central Treasury” policy is used as the exogenous shock, and this variable takes the value of 1 when the year is ≥2016 and 0 otherwise. The coefficient α2 is the DID estimator, which portrays the causal impact of the policy on income distribution. Xkit is the set of control variables, andεit denotes the random disturbance term. The model test results are as follows.where TreatedThe results of the DID test are detailed in To test the robustness of the results, the Peking University Digital Financial Inclusion Index of ChinaThe endogeneity of inclusive insurance comes from several sources: first, reverse causality, where the level of household income affects the availability of insurance; second, omitted variables, where the development of inclusive insurance and household income may be influenced by other factors. Although the model incorporates a rich set of control variables to minimize the interference of omitted variables, there are still some variables that are unobservable. The third source is measurement error. The inclusive insurance index in this paper is a composite measure based on three dimensions and is generated by factor analysis, but there may still be bias. The use of alternative indicators also alleviates concerns about measurement error and reverse causality. To further test the robustness of the results, we test the causal relationship between inclusive insurance and income distribution and inclusive growth by introducing an instrumental variable approach.The instrumental variable selected is individual risk preferences. We construct the levelit is the relative deprivation index, IIit is the level of inclusive insurance coverage, IVit is an instrumental variable representing individual risk preferences, Xkit is the set of control variables, and μit is a random disturbance term.where RelTo test the validity of the instrumental variables, under identification, weak instrument, and over identification tests were performed on the instrumental variables.The results of the GMM model with the addition of instrumental variables  show thaResearch found that the impact of agricultural insurance on farmers' income is non-linear and that agricultural insurance has a significant positive impact on farmers' income only when their income level crosses the threshold value and is at a higher stage . To furtit is the relative deprivation index, IIit is the level of inclusive insurance coverage, Incomeit is household income, which is the threshold variable, γ is the threshold value to be estimated, Xkit is the set of control variables, and εit is a random disturbance term.where RelWe first conduct a preliminary test on whether there is a threshold effect between the two. Bootstrapping is used to obtain the significance level of the test statistics, which is the main basis for judging whether there is a threshold effect between the two. P = 0.036 in the single threshold model and P = 0.356 in the double threshold model, indicating that there is a threshold effect at the 1% significance level in the single threshold model. Therefore, we consider that there is a single threshold effect of the impact of the inclusive insurance index on income distribution, and the single threshold effect model is chosen to analyze the empirical model. The results are shown in The threshold value of the insurance index is 0.25 in the single threshold model, and the threshold value of the insurance index is 0.18 in the double threshold model. The threshold effect test The results show that for the threshold effect model, the elasticity coefficient of the effect of inclusive insurance development on income is −1.348 when II is below the threshold value of 0.250 and is significant at the 1% level. When inclusive insurance development is in this interval, inclusive insurance makes a significant contribution to income; when inclusive insurance development exceeds the threshold value, the elasticity coefficient becomes −1.524, indicating that the promoting effect of inclusive insurance on income increases at this time.We find that China's inclusive insurance developed rapidly from 2009 to 2020, showing regional differences, with regions such as Beijing and Shanghai experiencing faster insurance development but regions such as Tibet experiencing slower development. It can be observed that the gap in inclusive insurance between regions is narrowing over time, indicating that the universality of insurance has been greatly improved. The benchmark model show that the coefficient of the impact of the inclusive insurance index on income is positive and significant at the 10% level, indicating that inclusive insurance significantly raises the income level. Additionally, the coefficient of the impact of the inclusive insurance index on income deprivation is negative and significant at the 1% level, which means that inclusive insurance has a significant negative impact on income deprivation and reduces the relative deprivation index, thus having a positive impact on income distribution. We also show that groups with lower income levels benefit more from inclusive insurance and that inclusive insurance improves the effect of income distribution among individuals within the sample to a certain extent, verifying the positive effect of inclusive insurance on inclusive growth. The results of the subsample test indicate that the effect of inclusive insurance on income distribution gradually increases from east to west. The effect of inclusive insurance is greater in rural areas than in urban areas. Inclusive insurance significantly raises the income level of low-income households and has a more significant effect on the relative deprivation index of low-income households. The results of the PSM-DID test on the implementation of the “Measures for the administration of agricultural insurance premium subsidies from the Central Treasury” indicate that the inclusive insurance policy has a significant positive impact on income distribution. The robustness of the results is also demonstrated by using the Peking University Digital Financial Inclusion Index of China (PKU-DFIIC) as the alternative variable and the GMM model with instrumental variables. The results of the threshold effect model show that when the value of the inclusive insurance index is below the threshold value of 0.250, the elasticity coefficient of the effect of the development of inclusive insurance on income is −1.348 and is significant at the 1% level. Our results indicate that when the development of inclusive insurance is in this range, inclusive insurance makes a significant contribution to income. Additionally, when the value of the inclusive insurance index exceeds the threshold value, the elasticity coefficient becomes −1.524, indicating that inclusive insurance makes a significant contribution to income and the contribution of inclusive insurance to income increases.Based on the conclusions, we propose the following policy recommendations: First, there are great differences in the development of different regions in China; thus, we should adapt to regional characteristics, flexibly and reasonably design the inclusive insurance system, carry out inclusive insurance based on local conditions, reduce the cost of insurance service and expand the service radius in view of the unbalanced development of universal insurance between regions. Second, government should promote the development of inclusive insurance, improve the risk management ability of insurance institutions, reduce their operating costs, make inclusive insurance better serve the policy target groups, and effectively disperse and protect their production and life risks.There are still some expansions in our study: firstly, we only calculate the inclusive insurance index by provinces in China limited by the availability of data. If more data can be obtained in the future, we can calculate China's inclusive insurance index in cities or counties. Secondly, vigorously developing inclusive finance with the concept of inclusiveness is of great significance to improve income distribution and economic development, and more attention should be paid to regional balance and institutional conditions.Obviously, the development potential of inclusive insurance is greater in countries that do not have a developed financial industry or sophisticated products. Among countries where microinsurance is offered or being introduced, possibly only South Africa could be considered to be a mature conventional insurance market. A mature market may be defined as one that has passed both the emerging and growth phases of the industry. Earnings and sales grow tend to be slower in mature markets and there may be a lack of significant innovation. In contrast, most microinsurance markets are still emerging: microinsurance has expanded rapidly in India, and is growing or diversifying on the foundation of developing insurance mark in South America and Asia, whereas in Africa, microinsurance is relatively nascent. In the future, we can further explore the mechanisms through which inclusive insurance affects income distribution and inclusive growth, and study policy measures to achieve inclusiveness in these countries.http://www.isss.pku.edu.cn/cfps/.Publicly available datasets were analyzed in this study. This data can be found at: LZ: design of the paper, methodology, analysis of data, drafting the paper, review & editing, and responsible for ensuring that the descriptions accurate and agreed by YS. YS: collect the data, data curation, and translate. All authors contributed to the article and approved the submitted version.We gratefully acknowledge the financial support of the National Natural Science Foundation of China (Grant No. 71903209).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The economy of a country is exposed to disruptions caused by natural and man-made disasters. Here we present a set of probabilistic risk indicators, the Average Annual Loss (AAL) and the Loss Exceedance Curve (LEC), regarding to production, employment, Gross Domestic Product (GDP), Gross Regional Product (GRP), export volume, inflation, tariff revenue, among others, due to earthquakes. All indicators are computed using a systematic probabilistic approach, which integrates the seismic risk assessment with spatial computable general equilibrium models, both robust and well-known frameworks used worldwide in their respective fields. Our approach considers the induced damage and frequency of occurrence of a vast collection of events that collectively describe the entire seismic hazard of a country, giving us a better and more complete understanding of the full consequence of earthquakes. We illustrate this approach with an example developed for Chile. The integration of risk analysis and spatial CGE modeling frameworks allowed for measuring the direct and indirect consequences of extreme events via novel probabilistic risk indicators which incorporate elements of uncertainty and systemic effects We have witnessed recent catastrophic events that have made evident the economic implications and new features of disaster. The 2004 Indian Ocean earthquake and tsunami, hurricane Katrina in 2005, the 2010 Haiti earthquake, and the 2011 Japan earthquake and tsunami highlighted the importance of matters as disaster risk governance, reconstruction strategies, the vulnerability of the economy of developing countries, the multinational disaster aspects and how disasters can cascade. Accounting for indirect losses in risk is crucial and becomes more prominent as the supply-chain complexity increases in the age of globalization6. However, it is not easy to account for the economic consequences of earthquakes with historical information alone because these catastrophic events are infrequent, so that relevant information is scarce, and it is not always easy to distinguish between direct and indirect losses.There is evidence that economic production losses caused by disasters, on occasion called indirect losses, can sometimes be much more significant than those produced by physical damage10  Modeling of indirect losses, in comparison, lags far behind, mainly due to the difficulties in empirically translating property damage into indirect losses5 and due to the lack of adequate models that relate these two kinds of losses. Usually, indirect losses are estimated roughly as a percentage of physical losses, establishing this percent with empirical information obtained from a minimal historical database of events worldwide; this procedure is deficient and with very low reliability.Catastrophe modeling of physical damage caused by earthquakes is today a well-developed technique, to the point that it is possible to estimate, in a probabilistic manner, the seismic risk of individual assets11. On the one hand, efforts have been focused on improving and extending the quantitative models used for disaster impact analysis, such as cyber-attacks, extreme weather events, earthquakes, flooding, climate change, and terrorist attacks, amongst others17. In addition, new frameworks have been proposed to integrate models of transportation, critical supply chains, and community demand18. On the other hand, researchers have devised tools to directly estimate economic damages or losses based on some physical data of natural hazards20, or to evaluate, for instance, the changes in economic activities with a set of satellite data on annual differences in nighttime light intensity21. Furthermore, ESPON-TITAN23 provides evidence on the direct and indirect economic impacts of natural hazards, extreme events, and disasters, identifying trends and territorial vulnerability patterns across European regions and cities. This research project uses the multi-regional input-output models to assess the costs of extreme events on the supply chain. The European Commission24 and the World Bank25 also use the input-output models to assess direct and indirect economic impacts of disasters in Europe.However, there is a well-developed literature on the economic impact of natural and man-made disasters, whose most recent advances have been compiled by Okuyama and Rose30, without appropriate consideration of their frequency of occurrence. But the frequency of occurrence matters. Decisions and policy would be very different if one knew that the economic impacts of a specific size are to be expected, on average, once every 100 years or once every 1000 years. Further, it would seem that little attention has been given to linking physical damage to infrastructure or economic components with higher-order economic losses.Despite this large and rich analytical framework to study the impact of disasters on the economy, efforts have concentrated on analyzing individual events35 and the Computable General Equilibrium40 (CGE) modeling frameworks to the estimation of higher-order losses that take into account that: natural events—earthquakes in our case—take place as a stochastic process in time; that frequency of occurrence of events matters for measuring risk; and that there are links between the level of physical damage to economic components and the reduction of capital stock. We use a particular type of CGE model, known as spatial CGE models42, which can consider the geographic location of economic agents and endowments. The “Methods” section presents in detail the methodology proposed for the integration of the models. Besides successfully dealing with the estimation of indirect monetary losses, our approach allows for a better glance at the likely consequences of the earthquake occurrence in the whole economy by carrying out risk assessment for a vast set of events  and referred to different economic variables, such as employment, GDP, GRP, wages, tariff revenue, consumer price index (CPI), export volume, among others. In our hand-on case of study, we computed the annual average loss and loss exceedance curves for several components of the Chilean economy at the country, regional and sectoral level. The LECs allow us to estimate the expected losses associated with a wide range of return periods. Furthermore, we have observed the capacity of our model to catch positive economic impacts of earthquakes on specific sectors and regions through substitution effects. We believe that the results and the approach presented add value to current knowledge for disaster risk management, providing a set of complementary risk indicators in catastrophe modeling.Given this, here we present an approach to integrate, systematically, the probabilistic seismic riskAs we have mentioned before, this work proposes a robust, probabilistic, and systematic connection between entire seismic risk and large-scale economic models. The relation between the reductions of the capital stock and the direct losses in non-residential buildings are estimated from the probabilistic model for seismic risk assessment. The results obtained in this example are pretty reasonable and can be used to gauge the power of the approach. In what follows, we will present the main results of our example, highlighting some of the most interesting findings.Due to direct or indirect losses, we will express seismic risk results in terms of a few standard risk metrics. We will use the average annual loss , the production losses follow a positive proportional relation with the direct losses, which goes from almost zero up to a maximum value of 0.74ngs Fig. . We obseRisk metrics can be computed by economic sector or region of the country Figs. , 3 and 4We can also see that the regional distribution of the AAL of direct losses of Chile is similar to the regional distribution of the AAL of production losses Fig. . As expeAs mentioned before, our approach also allows us to obtain the LEC of production for whole regions or economic sectors of the country Fig. , being aIn addition to results aggregated at the national level, we can analyze what happens within the regional economics of the country by computing both the AAL of production losses and the production LEC of economic sectors into a specific region, as shown in Supplementary Fig. The richness of CGE modeling regarding the number of interesting output variables, each reflecting a different aspect of the economy, allows for the computation of many interesting and valuable risk measures. Besides calculating the risk measures in terms of production loss, it is possible to compute risk measures for losses of employment, GDP, GRP, tariff revenue, CPI, export volume, among others. These complementary indicators can be helpful for seismic risk management, as they provide a way to measure the losses in various aspects of an economy facing earthquake hazards.For instance, as presented in Table When an earthquake happens, economic losses usually occur; however, one or various economic sectors can face positive effects in certain regions. Using the same indicators, we can measure the positive effects in the same components of the economy for which we calculated the negative impacts. These probabilistic indicators of positive effects can also be helpful for better understanding and managing the seismic risk. Similar to economic losses, positive effects are captured for a vast collection of events that collectively describe the seismic hazard of the country. Our analysis confirms that, for specific events, there are gains, not losses, in some sectors and regions. For instance, the average annual gain of production computed for Chile was 18.32 million US dollars, that is, 0.0041% of its total yearly production. Figure CPI changes, production losses, and employment losses can also be probabilistically computed for any particular event coherent with the seismic hazard model. For instance, we present the direct losses, production losses, and GRP reductions estimated for simulations of three large earthquakes occurred in Chile in 1960, 1985, and 2010 .According to estimations of the Central Bank of Chile, The Maule 2010 Earthquake caused 3% of losses in the total net capital stock of the Chilean economy, 3.2% in the residential buildings, and 2.6% in non-residential infrastructureOur approach has shown how the CGE model and the probabilistic model for seismic risk assessment can work together, allowing for a robust and systematic probabilistic glance of the consequences of the earthquake disturbance into the whole economy. We were able to successfully deal with the production losses, exemplifying our methodology with the computation of the standard risk metrics concerning production losses, that is, the average annual production loss and the production loss exceedance curve, both at country and regional levels, and computed by considering a vast collection of earthquakes, with known annual occurrence frequencies, that collectively describe the entire seismic hazard of a country. We have also shown how our approach can go beyond production losses, harnessing the richness of the CGE modeling. We have computed the standard risk metrics for different economic variables, such as losses of employment, GDP, GRP, export volume, and CPI. We believe that these risk measures are useful and complement the usual risk indicators of physical damage and contribute to a better integral disaster risk management and design of financial hedging instruments for governments and the insurance industry. Our model captures the negative consequences of earthquakes and some positive effects on the economy, and we propose probabilistic measures of these gains. Our methodology is not exclusive to earthquakes and can be easily extended to other natural disasters like flooding, hurricanes, and droughts. The main results show that disaster management measures and damage prevention activities must consider intersectoral and interregional linkages in the economy. Supply-chain disruptions are propagation channels of the extreme event impacts, which is directly related to regional vulnerability to such events.The modeling approach is fully probabilistic on the earthquake occurrence side, but for now, it is deterministic on the CGE side; the reason for this is that, while earthquake risk modelling is a 50-year-old discipline, within which uncertainties have been thoroughly studied and characterized, we feel that characterization of uncertainties in CGE modelling is still a work in progress.24. However, regional modeling is essential as an exercise to measure the systemic effects of disruptions in supply chains, whether caused by natural hazards, extreme events, or disasters. The regional evaluation of the wider indirect economic impacts of natural disasters and climate change still requires new analytical tools. Therefore, as done in our analysis, mapping the economic impact of the natural disaster is essential for risk management and prevention since it provides tools for spatial planning decisions. In this context, our study can contribute to the literature by considering the economic impacts of natural hazards at the regional level using integrated modeling based on the probabilistic risk model and the spatial CGE model.The possibility to aggregate and transfer the macro-economic assessment of disaster impacts to regional levels of adaptation and analysis is limited45. Koks et al. (2016)46 compared natural disaster impacts using an input-output model and a CGE model. They showed that for a detailed assessment of disaster impacts on the economy, including the price effects and effects on employment, the CGE models are better suited. In addition, they highlight that the conventional multi-regional input-output models may largely overestimate the losses.We proposed to use spatial CGE models (SCGE), unlike some of the previous studies that assess the impact of natural disasters from interregional input-output models. CGE models go much further than input-output models, in which the principal focus is on links through sales of goods and services between industries and from industries to final users. In contrast, CGE modeling identifies behavior by individual agents and emphasizes links provided by competition for scarce resourcesAlthough our approach mainly uses SCGE models in a short-run environment, the type of CGE modeling proposed in our work allows us to easily change to a long-run economic scenario, including the labor migration effect. A wide range of aspects can be analyzed and studied using a long-run closure; however, we have limited ourselves to presenting the magnification effect that economic losses would have if no mitigation actions and recovery of the capital stocks destroyed by earthquakes took place over time. We compared some aggregated results regarding the annual average loss and loss exceedance curves of production in Chile obtained using short-run and long-run environments of economic modeling  caused by the change in relative prices captured in the CGE model. The change in relative prices causes a change in the interregional trade flows—that is, the interregional exports and imports. This change in trade flows, in turn, will have a negative/positive impact on Gross Regional Product. A subsequent increased economic activity because of spending on infrastructure and reconstruction can also partly offset the negative economic consequences of earthquakesEmpirical validation of catastrophe models is, by definition, a difficult task. Fortunately, catastrophes are relatively rare events, so observed values of losses are never a sample big enough to allow for empirical validation. Even if we had observed losses for a long time, cities change, construction materials change, so the loss information of events that took place more than a few decades ago is not very useful. In a way, the reason to start developing catastrophe models back in the 1990s was precisely the need to compensate for this data shortage. So direct validation of the models, in the sense of empirically establishing the exceedance frequency of losses of various sizes, is never possible.Nevertheless, efforts are made to carry out partial validations of different kinds. First, the rate of occurrence of earthquakes of various magnitudes, as well as their spatial distribution, is estimated from appropriate earthquake catalogs and knowledge of the regional tectonic setting; this guarantees that the model of future earthquake occurrences will not be introducing too many or too few events; this also guarantees that the spatial distribution of future, hypothetical events, will be coherent with the observed distribution of real earthquakes and coherent also with geological science.Additional validations are made regarding the relation between earthquake source characteristics  and the ground acceleration field produced by the event. This guarantees that, on average, the observed ground accelerations and the accelerations predicted for future events will be unbiased.In some cases, it is possible to compare the actual losses produced by an event with those computed with the model for a synthetic event of similar characteristics. We presented an example of this comparison with the Maule earthquake of 2010, finding that the modeled losses are coherent with those observed. In some cases, several loss-producing events can be used in this validation phase, but, in our case, the last big event before the Maule earthquake took place in 1985, which was considered to be too far away in the past.48. A better understanding of these spatial and economic dimensions of natural disasters is crucial to properly measure human and economic losses and direct efforts to prepare for and mitigate the losses. Disaster planning and preparedness become more effective when the total cost (direct and indirect) is calculated. Although direct impacts are usually higher than indirect impacts, the latter is increasingly important for total economic loss assessment; neglecting these spillover effects may lead to poor allocation of funds during recovery49. Policies should consider relief actions to mitigate both the impact on directly affected areas and indirectly affect neighboring regions50.Natural disasters in a given area affect assets located in the area. Nevertheless, losses can be transmitted to other areas through various channels, such as trade linkages, demand linkages, and interregional mobility of production factorsWe start generating a stochastic earthquake catalog that is coherent with a seismic hazard model for the region under study. We then simulate the occurrence of the first earthquake in the catalog and compute the physical damage (direct losses) produced to buildings, factories, and infrastructure using the conventional probabilistic seismic risk assessment techniques. Direct losses perturb the initial equilibrium of the CGE model, so we rerun it until it reaches a new equilibrium, but with different levels of outputs and prices, which allows for computation of the losses due to that particular event. The analysis is then repeated for each event belonging to the stochastic earthquake catalog. Finally, we compute various probabilistic risk metrics, including the effects of indirect losses, using the results obtained for all earthquakes. The remainder of this section will explain our approach and each of its components with some depth.55 that includes all assets at risk relevant to the analysis. In our case, the relevant assets are buildings, factories, infrastructure, and, in general, all assets that provide input of some kind to the economic model. In other words, all assets whose damage might have a potential impact on the economic flows. Each asset must be identified by its location, seismic vulnerability characteristics, and, particularly relevant for our present purposes, the economic sector to which it belongs.First, the seismic risk model contains an exposure databasehazard component59. This component provides a potentially very large event set, each associated with an annual frequency of occurrence and one or more intensity random fields. Therefore, the hazard component provides information about how frequently different kinds of earthquakes occur and gives probabilistic indications of the intensities it produces. In principle, the hazard component should contain information about occurrence frequencies and intensity distributions of all earthquakes that could take place in the future. In other words, the event set must be collectively exhaustive.At random instants, with all assets intact and following a Poisson process, the economic equilibrium is perturbed by the occurrence of an earthquake with known focal characteristics , which in turn will produce a spatial random field of intensities . In contemporary seismic risk models, this information is provided by its 60 provides tools to assess, in probabilistic terms, the level of direct losses suffered by each one of the assets contained in the exposure database; this part of the model is usually referred to as the loss component. The level of damage sustained by an asset depends on its location, the size of the intensity and its vulnerability characteristics. Thus, once a hypothetical event has taken place, we have means to determine the probability distribution of the losses sustained by each one of the assets at risk using special functions called vulnerability functions62 that we have used to characterize the seismic vulnerability of non-residential buildings belonging to the economic sectors of Chile. Supplementary Note Once a hypothetical earthquake has taken place, and its intensities are known—or, more precisely, the probability distributions of the intensities are known—,the seismic risk modelIn general, and given the lower geographical resolution of the CGE models compared to that of the seismic risk models, a loss aggregation is required in order to sum all the losses that correspond to the same economic sector at the same economic region. Since the losses at the various assets are not fixed numerical values but correlated random variables, the aggregation process is not trivial because of the correlation among losses for the same event. Supplementary Note Therefore, as it can be noticed, the seismic risk model is used in our approach to determine two essential pieces of information for each one of the members of the event set: (1) the probability distributions of the losses incurred by assets belonging to all economic sectors and regions, that is, the severity of the direct losses; and (2) the annual frequency with which that particular loss scenario takes place. We will see later how this information is used in the overall risk calculations.So far, the use of the seismic risk model is not at all different from its classic use in risk assessment. However, we will later see how these classic risk model results are used as inputs to the economic modeling.65 to incorporate the interregional economic structure. We use an absorption matrix as the basis to calibrate the CGE model, together with a set of elasticities borrowed from the econometric literature applied for Chile. This database allows capturing economy-wide effects through an intricate plot of input-output relations.We use the BMCH, the Chilean version of the B-MARIA model , a fully operational spatial CGE model for Chile. The model uses an approach similar to41. Supplementary Note The current version of the BMCH model recognizes the economic structures of the 15 Chilean regions. Results are based on a bottom-up approach—i.e., national results are obtained from the aggregation of regional results. The model identifies 12 production/investment sectors in each region producing 12 commodities, a representative household in each region, regional governments and a central government, and a single foreign area that trades with each domestic region. Two local primary factors are used in the production process, according to regional endowments . Particular groups of equations define government finances, accumulation relations, and regional labor markets. The BMCH model qualifies as a Johansen-type model in that the solutions are obtained by solving the system of linearized equations of the model, following the Australian tradition. A typical result shows the percentage change in the set of endogenous variables after a policy is carried out, compared to their values in the absence of such policy, in a given environment. Interregional linkages play an important role in the functioning mechanisms of the model. These linkages are driven by trade relations (commodity flows) and factor mobility . Interregional trade flows are incorporated; interregional input-output relations are required to calibrate the model, and interregional trade elasticities play an important roleWhen an earthquake occurs, it produces direct losses, whose probability distributions were determined with the seismic risk model described succinctly in the previous subsection. Once aggregated, the direct losses by sector and by region are entered into the CGE model as “shocks” to the capital stock component of the sector/region combination. These shocks are nothing more than exogenous capital stock reductions, usually calculated as the ratio between physical loss and the total cost of the capital stock. When entering the set of shocks to the CGE model, the equilibrium conditions of the model are lost, so we need to rerun the CGE model to reach a new equilibrium that reflects how the economy adjusts to the received shock. The new equilibrium condition is obtained with a new value-set of the endogenous variables, which are the model results.A CGE model can be made of hundreds or even thousands of variables (exogenous and endogenous); each can provide us with a different type of result, either of economic or social interest. The richness of the CGE model in terms of the number of results is extraordinary, allowing for the possibility of developing a broad range of analyses. Initially, we will focus on the variables that quantify the total production of the industries; later, however, we will analyze other non-economic types of losses.i in the spatial region j, Lpij, as the difference between the production before and after the earthquake for the same sector/region. In other words, as a consequence of the decreased capital stock in specific sectors and regions hit by the earthquake, the economy attains a new equilibrium in which the production at that sector/region is smaller (or higher) after the earthquake than before. We regard this difference as a production loss, and this will be our initial measure of indirect losses, although we will later explore the use of results related to other variables.We will define the production loss of sector At this initial phase of our research, the behavioral parameters and structural coefficients of the CGE model, the parameters and coefficients required to establish the relations between exogenous and endogenous economic variables, are considered deterministic. Despite this, the outputs of the CGE model— the indirect losses—are not fixed numerical values, but random variables, because some of the inputs were also random variables. The probability distributions of all relevant CGE model outputs, either at the sector/region level or for any required aggregation, are obtained during the modeling.At this point, we can compute, for each event of the event set, probabilistic direct and indirect losses. The following section will illustrate how the most common risk measures can be obtained with the results presented so far.The most common risk measures, both in the disaster risk management world and in the insurance sector, are: (1) the average annual loss; and (2) the loss exceedance curve, which indicates the average frequency with which given values of loss would be exceeded. We will focus only for illustration purposes on the total direct and indirect losses. The total losses are, of course, the sum of the losses for all assets, in the case of the direct losses, and for all sectors and regions, for the case of the indirect losses.k-th event of the event set produces probabilistic direct and indirect losses Ldk and Lpk, respectively. Then, the corresponding average annual losses, AALd, and AALp would be given by:Fk is the annual frequency of occurrence of event k. AALd is a quantity routinely computed in conventional risk analyses; AALp is introduced in this paper.For instance, the νd(.) and νp(.) of direct and indirect loss, respectively, are computed with the following expressions:Pr(Ldk> l) and Pr(Lpk> l) are, respectively, the probabilities of direct and indirect losses exceeding a given value, l. In this case, νp(.) is introduced in this paper.The loss exceedance curves, The procedure for the computation of the probabilistic risk measures regarding employment, GRP, CPI, export volume, and any other economic variable of the CGE model is the same but for the corresponding economic variable instead of that of production (indirect loss) one. In the case of positive economic effects, the procedure for the computation is again the same, with the difference that, in this case, we only account for the positive effects that each earthquake triggers in the CGE model.The risk calculations shown in this paper have been carried out with program DIRAS-2020, developed at the Instituto de Ingeniería, UNAM. This software has been specifically created to join and process the information coming from a conventional seismic risk model and a spatial CGE model.Further information on research design is available in the Supplementary informationReporting summaryPeer Review File


Immersive virtual therapy technology is a new method that uses head-mounted displays for rehabilitation purposes. It offers a realistic experience that puts the user in a virtual reality. This new type of therapy is used in the rehabilitation of stroke patients. Many patients after this disease have complications related to the upper extremities that limit independence in their everyday life, which affects the functioning of society. Conventional neurological rehabilitation can be supplemented by the use of immersive virtual therapy. The system allows patients with upper limb dysfunction to perform a motor and task-oriented training in virtual reality that is individually tailored to their performance. The complete immersion therapy itself is researched and evaluated by medical teams to determine the suitability for rehabilitation of the upper limb after a stroke. The purpose of this article is to provide an overview of the latest research (2019–2022) on immersive virtual reality with head-mounted displays using in rehabilitation of the upper extremities of stroke patients. In recent years, rehabilitation using virtual reality has become increasingly popular. VR technology offers capabilities based on human interaction in a simulated environment that receives continuous feedback on performance and efficiency . For effStroke is the second most common cause of death and the third cause of disability in the world. The recorded increase in the incidence of stroke is a serious public health problem, but also a problem of social and economic development of society . Stroke In the review, Guzsvincz, Szucs, and Sik-Lanyi divided reality into virtual, augmented, and mixed reality. Virtual reality is a synthetic environment in which interactions can take place. Augmented reality expands into our reality, as the name suggests, while mixed reality allows interaction with extended objects . The terImmersive VR enables a more comprehensive virtual reality experience in a three-dimensional environment. Computer equipment provides visual and acoustic visualization, which can also be reflected in the tactile interactions of the user. This makes it possible to experience the illusion of being in an imaginary environment that is not visible on the screen. Users who use this form of VR may need a special headband (HMD), but also can use haptic devices, motion trackers, data gloves, and wireless controllers . Visual-Neurological rehabilitation, consisting of platforms, cameras, and sensors used for virtual reality games, is well-tolerated by patients and arouses curiosity. Some studies show that conventional therapies appear monotonous and boring to patients ,25. ThisThe load on the neck and head when using the head-mounted display is an important criterion when choosing therapy for neurological patients having complications in the upper limbs and balance disorders. The use of an HMD causes changes in locomotion and postural control by manipulating optical flow . Neck stIn this review, we discussed rehabilitation using immersion therapy in post-stroke patients with upper limb complications, including: immersion therapy technology, clinical application and evidence of effective use in neurological rehabilitation, barriers that arise in the use of immersion therapy, and considerations for limitations and future use of immersion therapy among post-stroke patients with upper limb complications. This review provides an important contribution to insight into the effectiveness of immersive therapy rehabilitation in stroke patients. Immersion virtual reality therapy with the use of head-mounted displays gives the impression of the possibility of making rehabilitation more effective and engaging, due to the resulting motivation for a virtual reality with which patients interact . Many prImmersive therapy upper limb stroke;Rehabilitation after a VR stroke;HMD stroke rehabilitation;HMD rehabilitation of the upper limb;HMD stroke.The material gathered for this review was sourced from the following databases: PubMed, PubMed Central, Cochrane Library, Embase, Medline, Web of Science, and SCOPUS. The topics searched for included:In addition to the main issues, the abbreviations HMD and VR HMD were also searched. A total of 646 articles were analyzed. After removing the duplicates, 61 articles qualified as well as an additional 8 articles found by manually searching the reference lists. We excluded articles when: Head-mounted displays were not used for their rehabilitation; Rehabilitation was not used for the upper extremities; Rehabilitation was not for stroke patients; Rehabilitation with virtual reality was non-immersive or semi-immersive; Head-mounted displays were used for purposes other than rehabilitation of the upper extremities; Studies were published in a language other than English. Therefore, only 7 studies were approved to be studies included in our qualitative synthesis that met all requirements .Immerse VR is a relatively new form of neurological rehabilitation in patients with disorders in the upper limb after a stroke, which is why the number of studies in this area is limited. The research found from the last 5 years is presented in the tables below .The longest study involving patients lasted 12 weeks , the shoAll of the studies collected in the review used their own type of virtual games performed by patients to improve the indicators of the upper limb. Games that were used consisting of cooking, decorating trees with leaves and fruits, collecting vegetables, playing drums , climbinTwo studies conducted by Mekbib in 2020  and 2021The conducted studies presented their results as: an improvement in the function of the upper limbs ,48,49,50Of the seven studies, only one study conducted by Hsu et al. investigated the occurrence of adverse reactions to HMD. The authors did not record any adverse events such as dizziness, visual disturbances, or injuries to the upper extremity . This shNone of the seven articles addressed the head-mounted display, which could affect posture control and strain on the head and neck. These limitations may have been relevant to the results obtained by patients during rehabilitation.The purpose of this review was to look for studies with neurological rehabilitation of the upper limb for people after a stroke, in which immersion therapy with a head-mounted display (HMD) is used. This offers a broader view of a new and still rarely used technology that could have potential benefits in future rehabilitation. Virtual reality provides a rich and customized motor training, thanks to intensity modulation and sensory feedback ,52. The studies considered in this review had small samples of subjects; some of them were feasibility and pilot studies ,46. ThisThe use of immersive VR in neurological rehabilitation in patients with upper limb dysfunction after a stroke is still being studied. This is a relatively new advance in technology that is not as extensively researched as non-immersive VR . This reIn recent years, many studies have been conducted using fully immersive environments for imbalances ,54,55, gA major barrier of virtual reality rehabilitation for the elderly can be modern technologies with touch equipment, large screens, goggles covering the entire eyes, or even motion controllers. Such equipment, if patients have not previously shown interest in virtual technology, can be a novelty or even a misunderstanding, which affects the emergence of digital exclusion. In the study by Kamińska, Miller, Rotter et al., patients of mature age found that training in virtual reality technology was a way to stop the process of digital exclusion. The benefit of getting used to the virtual world allowed them to adapt to modern technologies . The deployment of new digital services and platforms has been caused by the COVID-19 pandemic. Accelerated change can be a problem and a challenge for older and less prosperous people. The phenomenon of the digital divide is becoming increasingly noticeable. Divide is described as an incongruity between groups in which one group has the resources, the will, and the ability to use digital technologies, and in the other group, the capacity and resources for an advanced approach are lacking. In this group, lack of measures can lead to demographic and socioeconomic inequalities around the world ,64,65. TTechnology is constantly changing, which can pose a threat to the profession of physiotherapists, who indicate that they feel unprepared. There is a concern about whether all physiotherapists will cope with the progress of the digital and technological age . EmployeLike any other therapy, rehabilitation with the use of virtual reality also has its drawbacks, in particular, fully immersive therapy. Studies relating to the side effects of immersive VR therapy are mixed. Some of them have shown that using full immersion had a negative effect on static balance and was associated with side effects: headaches, dizziness, eye strain, and motion sickness ,69. In aInterest in virtual technology in rehabilitation is constantly growing. The first scientific articles on rehabilitation and virtual reality date back to 1962, according to the PUBMED research viewer. In 2022, 2040 works had been published under the keyword “VR rehabilitation”. The keyword “Immersion Head Mounted Display rehabilitation” has been used in 65 articles since 1998, which shows that more and more people from the medical world are no longer interested only in using non-immersive reality for the rehabilitation of patients. Rehabilitation with the use of HMDs in virtual reality does not seem to have the danger of losing interest in therapy among patients. In order to preserve the progress of technology and motivation among users, the level and variety of games used in rehabilitation programs should be constantly improved. Program updates with the ability to get new games would contribute to maintaining clinical progress. Fully immersive virtual reality therapy with head-mounted displays (HMD) appears to be beneficial for patients with upper limb complications after a stroke. Despite the small amount of research, the therapy seems to be promising, affecting the regeneration of the upper limb. In order to clearly prove the positive effects of VR immersion therapy, a larger number of studies should be performed with a larger research sample and a longer study time.


The Synthetic Sentence Identification (SSI) test assesses central auditory pathways by measuring auditory and visual sensitivity and testing selective attention. Cerebellum activation in auditory attention and sensorial activity modulation have already been described. Assessing patients with cerebellar lesions alone using the SSI test can confirm the role of the cerebellum in auditory processing.To evaluate the role of the cerebellum in auditory processing in individuals with normal hearing and in those with chronic cerebellum lesions, using the SSI test.Cross-sectional cohort study. A study group comprising 18 patients with chronic cerebellar lesion and a control group of 20 healthy individuals were assessed. The SSI test was applied in an Ipsilateral Competitive Message (ICM) and Contralateral Competitive Message (CCM) modes. To compare the results between groups, we used the chi-square test for qualitative variables.p=0.035), but not in the CCM mode (p=0.083).A statistically significant difference was found between the study and control groups using the ICM mode of the SSI test (The results on the SSI confirmed cerebellar participation in auditory processing in individuals with chronic cerebellar lesions and in those with normal hearing assessed in this study. The classic idea that the cerebellum was part of the central nervous system has been changing, and numerous studies in the past 30 years have demonstrated the cerebellum participation in the cognitive process, especially that associated with hearingThe studies involving auditory processing are part of an emerging set which show potential cerebellum participation in cognitive functions4With the new functional neuroimaging exams, studies started to be carried out in human beings, trying to demonstrate which the cerebellum participation in cognition is. These studies provided surprising evidence that the cerebellum is intensively and selectively active during sensorial and cognitive tasks, even in the absence of implicit or explicit motor behaviorKnowledge about auditory pathway processing is not totally clear. Auditory processing involves not only the perception of sounds and their integration with other types of sensitivity, but also how they are identified, located, submitted to attention, analyzed, memorized and recovered. Auditory processing may be associated with difficulties in hearing, speech understanding, language development and learningThe investigation of the relationship between the cerebellum and the auditory pathways has produced a substantial body of evidence which requires the review of concepts about its functional role, including informing patients and family members about the need to understand the behavioral consequences of cerebellum diseases and rehabilitation treatments.The Synthetic Sentences Identification test (SSI) is an important means of diagnosis and easy to perform in the assessment of central auditory pathways, using auditory and visual skills. The physiological mechanism assessed in the test is associated with the inhibition of sounds which, although present in the communication environment, are relatively ignored, and this may be considered selective attention. Numerous studies have shown the cerebellum activation during auditory attention tasks, as well as its role in sensorial activity. Therefore, assessing patients with cerebellar lesion by means of the SSI test may confirm or refuse the hypothesis of cerebellum participation in auditory processing.The SSI test may also provide information as to the supra or infratentorial location of the lesions; and in the ICM mode, test faults happen in infratentorial disorders or lesions. As to the affected side, the lesions cause changes to contralateral stimuli responsesThe goal of the present study is to use the SSI test to assess cerebellum participation in the auditory processing of individuals with chronic cerebellar disorders and normal tonal audiometry.Our sample had 20 healthy individuals making up the control group and 18 individuals with chronic cerebellar lesions, making up the study group. Because of the very nature of the affliction, the study group was sequentially allocated. Both groups were made up by individuals from both genders, with ages varying between 9 and 56 years, without distinction of race and without a past of ear disease. All individuals signed an informed consent form after proper explanations from the researcher. This research project (376/05) was submitted to and approved by the Ethics in Research Committee of the institution and registered at SISNEP/MS under number CAAE 0009.0.270.000-05.Inclusion criteria: no ear diseases, no exposure to noise, no use of ototoxic drugs and no family history of hearing disorder. Individuals with hearing thresholds in the frequencies of 250 to 8000 Hz within normal values (up to 25 dB HL); type A tympanometry (pressure peak between +100 and -100 daPa), alphabetized and able to read easily. For the study group, the individuals had clinically diagnosed chronic cerebellar lesion, confirmed by an image study, without evidence of central nervous system lesions outside the cerebellum.Exclusion criteria: individuals with visual disorders which prevented them from reading the phrases and individuals with important motor incoordination.®). Tympanometric curve with the Madsen® ZS77-MB device.In both groups we assessed auditory threshold values in the frequencies between 250 and 8000 Hz, vocal discrimination, including the speech recognition threshold and the speech discrimination index, with an Itera audiometer (Madsen®). A list with 10 third-order synthetic phrases with seven words each (phrases presenting three words with meaning and dependence among each other), without semantic meaning, was transmitted to the patient, who pressed the button corresponding to the phrase heard after reading a printed set of these phrases located in front of him/her. Two series of third-order phrases were employed in both groups at a fixed intensity of 40dB SL, having as basis the mean values of the air conduction tonal auditory thresholds in the frequencies of 500; 1,000 and 2,000 Hz. The first series was introduced as an ipsilateral competitive message (ICM), in the phrases/competition ratio 0 and -10 dB, in other words, the competitive message was introduced in the same intensity as the phrases and at 10 dB above the intensity of the phrases and the other with the phrases being introduced in one ear and the competitive message in the contralateral ear (CCM), in the phrases/competition ratio 0 and -40 dB. Ten sentences were presented for each phrases/competition ratio to both ears. The test was first presented to the right ear and then to the left. The correct answers were analyzed in terms of their percentage, thus the performance of the individual was established by the percentage of correct answers in the different test situations.The SSI test was carried out in a sound treated booth, with the phonetic message being introduced through earphones. The message was reproduced by recording the phrases and a competitive message was provided, by a two-channel Itera audiometer  was fixed at 5% (< 0.05).In order to compare the results between the groups, we used the chi-square test for qualitative variables. The software used was the Epi InfoIn the study group, age varied between 9 and 56 years, seven women and 11 men, and statistically significant differences were not found insofar as gender and age were concerned between the study and control groups. The time of cerebellar lesion evolution varied between two months and seven years. As to its location, six were on the left side and six were bilateral. In relation to its etiology, nine individuals had tumors; three had stroke sequela, three had congenital changes and three individuals had cerebellar ataxia.As to the SSI results in the ICM and CCM modes in the control group, we observed two individuals with an altered response in the ICM mode and no alterations in the CCM mode.In the ICM mode of the SSI test, eight individuals had altered responses in the study group, seven with changes to both ears and one with a unilateral change. In the ICM mode of the SSI test, eight individuals had changed responses in the study group, seven with changes in both ears and one with a unilateral change. As far as the CCM mode is concerned, we observed three cases of altered response, three bilateral and one unilateral .Graph 1Rp= 0.035 Another interesting application for the SSI test in individuals with cerebellar disease would be to follow them up during rehabilitation programs, when one could observe the individual's performance in the test as the cerebellar function is correctedSince the SSI test is able to assess each side separately, we detected that in those individuals from the study group in the ICM mode who had altered results, most happened bilaterally . NonetheIn the literature we found a predominance of rightside cerebellar activation in response to the auditory stimuli in normal individuals, followed by the bilateral cerebellar activationIn the SSI test we used the integration between the auditory and visual stimuli, since the individual had to identify the phrase heard among ten written in front of him/her. This integration of sensorial stimuli has been reported in numerous papers about the cerebellum. Studies have suggested a common neural network for the visual and auditory memories, and for the auditory and visual processing of words, respectively, involving the left-lower, anterior-pre-frontal, supplementary-anterior motor, upper parietal cortex and posterior cerebellar areasThe activation of different cerebellar areas leads us to infer about a functional specificity of cerebellar areas, suggesting an analogy with computer functions, in which the cerebellum behaves as a computer which processes specialized data, integrating information from numerous origins and modesThe great difficulty in finding patients with cerebellar lesions only made our study group very restrictive, including individuals with different cerebellar lesion etiologies. Further studies are needed, with a greater number of individuals, in order to have a better understanding of the functional role performed by the cerebellum.The results obtained by the SSI test pointed to the cerebellum participation in auditory processing in individuals with chronic cerebellar lesions and normal tonal hearing assessed in this study.


Chagas is a complex and multidimensional socio-environmental health phenomenon, in which different components converge and interact. Historically, this disease was associated with insect vectors found in the rural environment. However, in the Americas, we are currently facing a new paradigm, in which different scenarios allow maintaining the vectorial transmission of the parasite through triatomine populations that either occasionally enter the dwellings or colonize urban environments.Triatoma and Panstrongylus, with most species  infected with the parasite, and that infestation of triatomine species occurs in all types of cities , from Argentina to the USA.Records of scientific reports available in the PubMed and LILACS search engines were retrieved, using three criteria according to the main triatomine genera of epidemiological importance and to the general scientific production on Chagas disease in urban contexts. Results showed that records on the occurrence of vectors in urban dwellings began to increase in the last three decades. Results also showed that the main species of triatomines collected inside dwellings  belong mainly to the genera Urban Chagas represents a new challenge that adds a different dimension to the problem of Chagas disease due to the particular characteristics of the lifestyle in urban agglomerates. The new scenario will require adaptations of the programs of control of vector to this shift from rural to urban settlements. Trypanosoma cruzi and transmitted to humans through insects called triatomines, which feed on warm-blooded animals. Although this disease has been historically associated with the rural environment, in the last years, triatomines have been found either entering urban dwellings intrusively or colonizing urban environments of Latin American cities. In this study, we reviewed publications referring to urban Chagas that include the presence of the main vectors of this disease to find out how important the occurrence of triatomines in large cities is, which triatomine species involved are, whether or not these insects are infected with the parasite, and what the geographical distribution of the vectors and the parasite is. The results confirmed the existence of vectors in urban areas of Latin America and showed that records began to increase in the last three decades. Species of the genera Triatoma and Panstrongylus were the ones mainly recorded in the dwellings and the ones most infected with the parasite. Records of infected triatomine species have been reported from Argentina to the USA. This new scenario of Chagas disease raises the need to adapt the control of urban populations of the vectors found in these areas.Chagas disease is caused by the parasite  Trypanosoma cruzi and affects mammals, including humans T. cruzi.Opinion articles, articles that did not present entomological searches in urban environments, articles that did not present research results with laboratory vector populations, and articles that were not experimental works performed with insects collected in urban areas  were excluded and/or considered irrelevant, and used only for the introduction and/or discussion of this study. The inclusion/exclusion of documents was independently evaluated by ALCF, JN and PSC and discrepancies were resolved by consensus.T. cruzi were mapped using the QGIS Girona 3.0 free access program (QGIS Development Team 2018). The database for compiling the bibliographic documents was gathered in a spreadsheet for further analysis.Data were extracted independently, using predefined data fields. Subsequently, the results of the data extraction were reviewed and the inconsistencies were resolved by re-revising the original documents. The distribution and number of species reported, the biomes where they were observed, and their infection with Searches on the two engines used allowed retrieving a total of 719 documents. The largest number of documents was obtained using the combination of words "Chagas + urban" . However, this combination mostly reported documents that were excluded either because they were considered repetitions of works retrieved by one of the other criteria or because they did not meet the inclusion requirements. Most were studies related to the diagnosis and/or treatment of vertically transmitted Chagas disease. The PubMed search engine yielded the higher number of papers (n = 666), compared to LILACS (n = 53). However, only 36 articles satisfied the selected criteria .Although the search was focused on the period 1909–2021, the records that related the occurrence of vectors in dwellings in urban areas began to increase positively in the last three decades . During T. cruzi at least in one of the urban areas where each species was recorded (16/18) (Triatoma (n = 11), followed by Rhodnius (n = 5) and Panstrongylus (n = 2), distributed in the geographical-ecological gradient represented in The spatial and ecological coverage of the revised documents is represented in  (16/18) . The larT. cruzi infection with population density showed that this phenomenon occurs in cities with very heterogeneous population densities  and Rhodnius prolixus (Brazil) were reported indoors in urban dwellings. The former was found forming significantly abundant colonies, while the latter was found without signs of colonization. Both species showed high prevalence of T. cruzi infection . Only Triatoma sanguisuga (found in the USA) and Triatoma sordida  were collected in association with the vegetation of green spaces. The species Rhodnius neglectus (Brazil) and R. pallescens (Colombia) were found colonizing palm trees in green spaces and were associated with the invasion of nearby dwellings. In Colombia, the occurrence of R. pallescens infected with T. cruzi was associated with an acute Chagas outbreak caused by oral transmission in 2010.T. cruzi ,31–64. TT. cruzi infection in triatomines was observation of feces under the light microscope (21/36). Determination of infection by polymerase chain reaction (PCR) or direct immunoassay (ELISA) was rarely used (3/36). A notable proportion of documents did not report whether they had made a diagnosis of infection (11/36).The most frequently reported diagnostic technique used to determine T. cruzi in urban areas, and the size of the urban agglomerates where these events occur. Our results show that the urban infestation in the Americas is associated with 18 species of triatomines with varying degrees of adaptation to urban areas. The diagnosis of T. cruzi infection revealed that the parasite is transmitted by 17 different species of triatomines. The results also showed that the spatial and ecological coverage of triatomine infestation and parasite infection extends across the continent from Argentina to southern USA and that urban infestation has been increasing from the 1990s to the present. This phenomenon has become more prominent and reported more frequently over the past three decades. An important point to highlight is that at least 18 species of triatomines belonging to the genera Panstrongylus, Rhodnius and Triatoma occur in urban areas. The results of a study that modeled the geo-spatial distributions  of the thirty most commonly reported triatomine species and putative vectors of T. cruzi partially coincide with our results, showing 14 of our 18 species reported in urban areas )ectively , developT. cruzi ,69. PerfT. cruzi .T. infestans), which is opposed to the rural one in architectural, socio-demographic, cultural and environmental terms, when finding an infested urban dwelling, control programs are frequently faced with questions such as: i) Should the insecticide be sprayed only in the infested dwelling, in the adjoining dwellings or in all the dwellings that make up the block?, ii) How to act if the infested home is located in a vertical building where there are several floors and apartments per floor?, iii) How to act in surrounding homes/buildings that are across the street: must they be included within the protocol to be evaluated and sprayed with the insecticide as well?, iv) How far should a vector control program be extended within the scope of a city that has more than 600,000 homes and scarce human and financial resources? and v) If we increase the scale of work, is it necessary to cover all the houses in the city? How much time and resources would this take? Questions such as these have led research groups and vector control programs at the national and provincial levels in both Argentina and Peru to unify efforts [Given the high density of people living in close proximity to domestic and peridomestic animals, urbanization can create conditions for the spread of vector transmission of diseases . As a co efforts ,74, withT. cruzi infection in each country would be an interesting tool to allow accurate and up-to-date data for both rural and urban areas. Starting in the 1990s, Chagas disease-endemic countries and the Pan American Health Organization-World Health Organization (PAHO-WHO) launched a series of multinational initiatives for Chagas disease control-surveillance. An overview of the initiatives’ aims, achievements, and challenges can be found in Rojas de Arias et al. 2021 [The study was limited to a bibliographic search for a period greater than a century (1909–2021), but it did not consider data that could be obtained from direct sources like National or Provincial Vector Control Programs from countries with urban Chagas cases. This was due to the lack of shared information about the topic and the difficulties to request vector information among countries. The implementation of a public database collecting details on the vectors and circulation of al. 2021 . With anT. cruzi in peri or suburban areas [Numerous studies approach the problem of triatomine infestation and its infection by an areas –77. Howean areas  recommenT. infestans and infection by T. cruzi in the urban context. It is already known that it is hindered by roads between city blocks, making it unlikely that the vector facilitates T. cruzi block-to-block migration [T. cruzi dispersal within a block occurs regularly and that occasional long-range dispersal events allow the establishment of new T. cruzi populations in distant blocks. Movement of domestic animals may be the primary mechanism of inter-block and inter-district T. cruzi dispersal [In Peru, an important collaborative work has been carried out for approximately two decades between local and foreign academic institutions, government authorities at different jurisdictional levels, and the Ministry of Health. Their interest focuses on the ecoepidemiology and control of Chagas disease in the city of Arequipa . Numerouigration . Additioispersal .T. cruzi transmission in some areas of the continent. However, urban Chagas represents a new challenge that adds a different edge to the problem of Chagas disease due to the particular characteristics of urban agglomerates. Insecticide resistance is another difficult problem that may develop in an urban setting because it renders the most popular control methods ineffective. Triatomines may be subjected to insecticides used to control other urban insects in residential areas . In light of this novel situation, the insecticide resistance of urban triatomines is highly relevant and should be the focus of systematized monitoring by the responsible authorities. Over the years the WHO has recommended the use of an integrated approach to vector control, involving both chemical and nonchemical methods, and environmental management [Since the discovery of Chagas disease in 1909, abundant scientific evidence has been gathered, and research initially linked to vectors has played an important role in the history of Chagas disease control. This has allowed a decrease in vector and transfusion transmission as well as in the interruption of nagement . Integranagement ,82. Currnagement . Howevernagement .T. cruzi, diagnosing pregnant person and children, stimulating community participation through Information, Education and Communication activities, and considering spontaneous complaints by the population [For all the above we believe that the most feasible proposal for the control of urban Chagas would be an integrative approach that considers the multidimensionality of the problem, determining the thresholds of infestation and infection by pulation ,12 adaptS1 Table(XLSX)Click here for additional data file.


Leptomeningeal carcinomatosis (LC) is a rare but serious complication of cancer in which cancer cells spread to the leptomeninges, the membranes that surround the brain and spinal cord. The diagnosis and treatment of LC can be challenging due to the non-specific symptoms and the difficulty of accessing the leptomeninges for a biopsy. In this case report, we describe a patient with advanced breast cancer who was diagnosed with LC and underwent treatment with chemotherapy. Despite aggressive treatment, the patient's condition worsened over time, and she was referred to palliative care, where adequate symptom control was achieved, and she was discharged to her home country as per her wish. Our case highlights the difficulties associated with the diagnosis and treatment of LC and the need for continued research to improve outcomes for patients with this condition. It specifically highlights the approach a palliative care team can take for this condition. Leptomeningeal carcinomatosis (LC) is a rare but serious complication of cancer that occurs when cancer cells spread to the leptomeninges, which are the membranes that surround the brain and spinal cord . LC is aThe leptomeninges is composed of two layers: the pia mater, which is closest to the surface of the brain and spinal cord, and the arachnoid mater, which is a more fibrous layer that covers the surface of the brain and spinal cord. The cerebrospinal fluid (CSF) that surrounds the brain and spinal cord is contained within the leptomeninges .The most common type of cancer that spreads to the leptomeninges is breast cancer, although it can also occur in other types of cancer such as lung cancer, melanoma, and other types of solid tumors . LC is oThe diagnosis of LC can be difficult because the symptoms are often non-specific and can be similar to other neurological conditions. Some of the common symptoms of LC include headache, nausea, vomiting, confusion, memory loss, seizures, and changes in mood or behavior . In someTreatment for LC is challenging and often involves a combination of chemotherapy, radiation therapy, and other supportive measures to manage symptoms. Chemotherapy is the primary treatment for LC, and the type of chemotherapy used will depend on the type of cancer and its responsiveness to different drugs. Radiation therapy can also be used to shrink tumors and relieve symptoms. In some cases, surgery may be necessary to remove tumors or relieve pressure on the spinal cord .In addition to chemotherapy and radiation therapy, other supportive measures such as pain management, physical therapy, and rehabilitation can be used to manage symptoms and improve the quality of life for patients with LC.Despite advances in the treatment of LC, the prognosis for patients with this condition is often poor. The average survival time for patients with LC is between three and six months, although some patients may survive for longer periods of time with aggressive treatment . PalliatA 52-year-old post-menopausal woman presented to the emergency department in February 2023 with symptoms of severe headache and confusion. The patient had no other positive signs or symptoms. Since she was up and about more than 50% of her waking time and able to carry out any activity of self-care, her performance status was deemed as 2 according to the Eastern Cooperative Oncology Group (ECOG) performance scale .This patient initially presented with a lump in the upper outer quadrant of the right breast a year ago. The patient had no other co-morbidities or symptoms at the time. An ultrasound-guided biopsy of the breast lesion confirmed malignancy, and subsequent immunohistochemistry testing demonstrated negative expression of estrogen (Er), progesterone (Pr), and human epidermal growth factor 2 (HER2/neu) receptors. She underwent a complete work-up, including a bone scan and CT of the whole body, which reported that the tumour was limited to the right breast and axilla. She was staged as a stage 3 tumour according to the American Joint Committee on Cancer (AJCC 8th ed.) . She wasSix weeks after the surgery, the patient developed a severe headache, nausea, and vomiting. Multiple MRI of the brain and spine revealed no specific abnormality, and a CSF analysis and microscopy reported the presence of malignant cells, confirming leptomeningeal carcinomatosis. The patient underwent intrathecal methotrexate therapy and completed 12 weekly cycles before returning to the hospital emergency department with severe headache and confusion in February 2023. A repeat CT scan of her brain demonstrated no definitive mass lesions  were initiated to control nausea and vomiting. The patient and her family were provided with detailed information about the disease, the prognosis, and the importance of an advanced care plan. The palliative care team ensured that the patient's preferences were the top priority and committed to achieving complete symptom control and optimal quality of life for the patient and her family.Within 24 hours of meeting with the palliative care team, the patient's symptoms were controlled, and the patient reported minimal pain (2/10) according to the numerical pain scale . The patThe World Health Organisation defines palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual" .Every year, approximately 56.8 million individuals require palliative care, and only 14% of those who need this type of care around the world actually receive it . The WorEarly recognition of the need for palliative care and appropriate referral can help build a rapport between clinicians, patients, and their families, leading to better symptom management and ultimately better end-of-life decision-making ,17. EarlInternational recommendations advise early palliative care as it enhances the quality of life through better symptom management, including reducing depression and improving survival. Patients receiving early palliative care have reported greater satisfaction with care . TherefoSeveral barriers have been identified that hinder appropriate palliative and end-of-life care for patients, with delayed referral to a palliative care specialist team being one of the most critical barriers. Late referral often results in difficulties in achieving the goal of improving the patient's quality of life. While evidence supports the benefits of early palliative care in patients with advanced cancers, the question of barriers to early referral and proper utilization remains .One of the significant obstacles is the lack of understanding of the term "palliative care" and confusion with terminal care, which hinders early referral . The lacTo overcome these barriers, it is crucial to define early palliative care more precisely and present it to patients and healthcare professionals . StandarIn conclusion, LC is a rare but serious complication of cancer that can cause a variety of symptoms. The diagnosis of LC can be difficult due to the non-specific symptoms, but a combination of imaging studies and a lumbar puncture can provide a definitive diagnosis. Treatment for LC is challenging and often involves a combination of chemotherapy, radiation therapy, and other supportive measures. Despite advances in treatment, the prognosis for patients with LC is often poor, with an average survival time of 3 to 6 months.This case report demonstrates effectively the importance of early referral to a specialized palliative care unit, which resulted in a better quality of life for the patient and the family.