Essays on health care reform, wealth inequality, and demography

This thesis contains three chapters. The first chapter uses a general equilibrium framework to simulate and compare the long run effects of the Patient Protection and Affordable Care Act (PPACA) and of health care costs reduction policies on macroeconomic variables, government budget, and welfare of individuals. We found that all policies were able to reduce uninsured population, with the PPACA being more effective than cost reductions. The PPACA increased public deficit mainly due to the Medicaid expansion, forcing tax hikes. On the other hand, cost reductions alleviated the fiscal burden of public insurance, reducing public deficit and taxes. Regarding welfare effects, the PPACA as a whole and cost reductions are welfare improving. High welfare gains would be achieved if the U.S. medical costs followed the same trend of OECD countries. Besides, feasible cost reductions are more welfare improving than most of the PPACA components, proving to be a good alternative. The second chapter documents that life cycle general equilibrium models with heterogeneous agents have a very hard time reproducing the American wealth distribution. A common assumption made in this literature is that all young adults enter the economy with no initial assets. In this chapter, we relax this assumption – not supported by the data – and evaluate the ability of an otherwise standard life cycle model to account for the U.S. wealth inequality. The new feature of the model is that agents enter the economy with assets drawn from an initial distribution of assets. We found that heterogeneity with respect to initial wealth is key for this class of models to replicate the data. According to our results, American inequality can be explained almost entirely by the fact that some individuals are lucky enough to be born into wealth, while others are born with few or no assets. The third chapter documents that a common assumption adopted in life cycle general equilibrium models is that the population is stable at steady state, that is, its relative age distribution becomes constant over time. An open question is whether the demographic assumptions commonly adopted in these models in fact imply that the population becomes stable. In this chapter we prove the existence of a stable population in a demographic environment where both the age-specific mortality rates and the population growth rate are constant over time, the setup commonly adopted in life cycle general equilibrium models. Hence, the stability of the population do not need to be taken as assumption in these models.

Investigação das alterações citogenéticas em pacientes pediátricos com leucemia linfóide aguda do Rio Grande do Norte

Leukemia is a heterogeneous group of hematologic malignancies that result from partial or total transformation of the blast cells. The Acute Lymphoblastic Leukemia (ALL) is the most common malignancy in childhood, especially in male, Caucasian children younger than 14 years. Several criteria are adopted to classify ALL, including the cell morphology, cytochemistry, immunophenotyping and cytogenetic analysis. Cytogenetic studies allow a more detailed analysis to detect chromosomal abnormalities of leukemic cells. These modifications will determine the diagnosis, classification, stage characterization, remission assessment and prognosis. In this study were evaluated 30 patients, aged from four months to seventeen years, of both sexes and various ethnicities. The age distribution showed that 67% of patients had between one and ten years (with mean age of XX years old), the most prevalent ethnic was Caucasian (50%) and 57% were males. According to immunophenotype, 93% of patients had B-cells progenitor ALL and 7% early lineage T. Considering the total studied population, the most frequent medical findings were lymphadenopathy (37%), hepatomegaly (77%) and splenomegaly (70%), where one patient could present more than one of these medical findings. Regarding the CBC, the majority of patients had hemoglobin below 10 g / dl (73%), leukocyte count less than 10.000/μL (60%) and platelet count below 150.000/μL (83%). Chromosomal abnormalities were observed in 64% of all patients, where hyperdiploidy was the most common numerical change (67%), followed by hypodiploid (33%). All these data are in agreement with the literature. Moreover, complexes structural and/or number changes not yet described in literature were observed, which indicated poor prognosis. Finally, we concluded that this study demonstrated the importance of cytogenetic study in the diagnosis and identification of prognostic factors in pediatric patients with ALL in Rio Grande do Norte. The results obtained in this study are extremely useful and emphasizes that surveys of this nature must be conducted more frequently in our state

Tabela de vida ecológica de Bemisia tabaci (Genn.) biótipo B (Hemiptera: Aleyrodidae)

Este trabalho teve por objetivo construir tabelas de vida ecológica para Bemisia tabaci (Genn.) biótipo B em soja. Para isso realizaram-se sucessivas infestações artificiais em plantas de soja, Glycine max (L.) Merrill, cultivar FT 2000. As amostragens foram realizadas retirando-se 10 folhas ao acaso com intervalos de três dias, durante oito gerações da mosca branca. O número de insetos vivos, mortos, parasitados e a distribuição etária foi registrado para cada folha amostrada. No presente trabalho os coeficientes de correlação para a mortalidade de ovos (0,1954), ninfas de 1º ínstar (0,5610) e pupas (0,6168), não foram significativos, porém as ninfas de 2º e 3º ínstar apresentaram coeficientes significativos de 0,7978 e 0,8641, respectivamente. No entanto o fator chave não foi identificado. O parasitóide Encarsia spp., apresentou-se como fator de mortalidade importante na fase de 'pupa' de B. tabaci biótipo B, porém o coeficiente de correlação não foi significativo.

Quantitative estimates of time-averaging in terebratulid brachiopod shell accumulations from a modern tropical shelf

Quantitative estimates of time-averaging in marine shell accumulations available to date are limited primarily to aragonitic mollusk shells. We assessed time-averaging in Holocene assemblages of calcitic brachiopod shells by direct dating of individual specimens of the terebratulid brachiopod Bouchardia rosea. The data were collected from exceptional (brachiopod-rich) shell assemblages, occurring surficially on a tropical mixed carbonate-siliciclastic shelf (the Southeast Brazilian Bight, SW Atlantic), a setting that provides a good climatic and environmental analog for many Paleozoic brachiopod shell beds of North America and Europe. A total of 82 individual brachiopod shells, collected from four shallow (5-25 m) nearshore (<2.5 km from the shore) localities, were dated by using amino acid racemization (D-alloisoleucine/L-isoleucine value) calibrated with five AMS-radiocarbon dates (r(2) = 0.933). This is the first study to demonstrate that amino acid racemization methods can provide accurate and precise ages for individual shells of calcitic brachiopods.The dated shells vary in age from modern to 3000 years, with a standard deviation of 690 years. The age distribution is strongly right-skewed: the young shells dominate the dated specimens and older shells are increasingly less common. However, the four localities display significant differences in the range of time-averaging and the form of the age distribution. The dated shells vary notably in the quality of preservation, but there is no significant correlation between taphonomic condition and age, either for individual shells or at assemblage level.These results demonstrate that fossil brachiopods may show considerable time-averaging, but the scale and nature of that mixing may vary greatly among sites. Moreover, taphonomic condition is not a reliable indicator of pre-burial history of individual brachiopod shells or the scale of temporal mixing within the entire assemblage. The results obtained for brachiopods are strikingly similar to results previously documented for mollusks and suggest that differences in mineralogy and shell microstructure are unlikely to be the primary factors controlling the nature and scale of time-averaging. Environmental factors and local fluctuations in populations of shell-producing organisms are more likely to be the principal determinants of time-averaging in marine benthic shelly assemblages. The long-term survival of brachiopod shells is incongruent with the rapid shell destruction observed in taphonomic experiments. The results support the taphonomic model that shells remain protected below (but perhaps near) the surface through their early taphonomic history. They may be brought back up to the surface intermittently by bioturbation and physical reworking, but only for short periods of time. This model explains the striking similarities in time-averaging among different types of organisms and the lack of correlation between time-since-death and shell taphonomy.

Prevalência de Demodex folliculorum e Demodex brevis em uma amostra da população de Botucatu, São Paulo, Brasil.

A survey was conducted to determine the prevalence of D. folliculorum and D. brevis for the first time in Brazil. In this study, association between the presence of mites and host factors (age, sex and race) were analysed. Samples were obtained from 100 individuals submitted to a facial cleaning in an aesthetic clinic in Botucatu city. All the samples were mounted in Berlese's medium and examined by dark-field phase microscopy. From 100 studied individuals, 72 were positive, among the positive cases, 51% showed D. folliculorum, 2% showed D. brevis and 19% both species. The parasite distribution in relation to sex was not taken in account because the sex ratio favoured females (90%). According to age, prevalence was high in all age groups. The factors influencing this distribution could be due. 1. the examination of extensive skin areas, 2. the group examined composed of individuals in treatment in an anaesthetic clinic could be more infested than a normal population, 3. the fact that in tropics, the prevalence is often high in all ages.

Distribución geográfica etaria y racial de la hemoglobina S en Brasil.

OBJECTIVES: This paper was meant to analyse distribution of HbS carriers in Brazil, comprising its regional prevalence and the relationship with racial settlement and age groups. MATERIAL AND METHODS: 67,667 blood samples from 48 Brazilian towns were analysed from 1976 to 1988. Such samples were classified as Caucasoid and Negroid. The diagnosis was defined by means of qualitative electrophoresis in alkaline and acid pH, quantification of haemoglobin fractions, cytological studies and some cases were confirmed after examination of the parents. RESULTS: The study of those 67,667 samples allowed us to detect 1,492 HbS carriers (2.2%). That frequency is higher among Negroids (5.16%) than among Caucasoids (1.22%): Z = 22.1397 (Zcritical; 0.05 = 1.9600). Taking the HbS carrier distribution into consideration, we noticed that it is relatively homogeneous among Negroids and higher than 5% in 9 out of the 16 areas involved in the study. By classifying the age group of the areas in the general sample and by comparing the proportions, we found out that there are significant differences (chi 2 = 50.88; chi 2 critical; 0.05; 5 gl = 11.070). CONCLUSIONS: Sickle-cell anaemia diseases play an important role among the pathologies found in several countries, including Brazil. This paper shows that the carriers prevalence varies in the several areas under study and is higher among Negroids in almost all of them. The decreasing frequency occurring from North to South in the general samples and among Caucasoids may be assigned to the contribution of the Negroes in the interracial crossing, particularly in the Northeast.

El tabaco y las periodontopatías.

The purpose of this research, which is part of a study on periodontal disease and its risk factors among workers in Araraquara, São Paulo, Brazil, was to determine the association between smoking and its frequency, on the one hand, and the presence of periodontal cavities on the other. A sample of 528 sugar and alcohol refinery employees from Araraquara between the ages of 18 and 64 was examined in March and April of 1992 by a trained examiner who applied the Index of Periodontal Treatment Needs in the Community. Questionnaires were used to record the individuals' age, smoking habits, and the number of cigarettes smoked daily. An oral examination was also performed to assess the presence of dental plaque and to determine the bacterial colony index. Data analysis revealed a positive association between the presence of periodontal cavities and smoking. After adjusting the data for age, presence of dental plaque, and bacterial colony index, the odds ratio for having periodontal cavities increased directly with the number of cigarettes smoked. These results suggest that smoking and its frequency should be taken into account when planning programs for the primary prevention and treatment of periodontal disease.

Acute renal failure in renal allograft recipients and patients with native kidneys

In order to evaluate the role of underlying disease in the high mortality observed in acute renal failure (ARF) and risk factors related to the development of oliguric ARF in renal allograft recipients, two groups were selected: 34 patients with native kidneys, aged 16 and 57 years, and presenting ischemic ARF caused by cardiovascular collapse, with no signs of infection at the time of diagnosis; and 34 renal allograft recipients who developed ARF immediately after transplantation, without rejection. ARF was defined either as 30% increase of basal plasmatic creatinine in patients with native kidneys or non-normalization of plasmatic creatinine at day 5 after transplantation in renal allograft recipients; oliguria as diuresis ≤ 400 mL/24 h. There were no differences in age, male frequency, oliguria presence and duration, need for dialysis, and infection episodes for renal allograft recipients and patients with native kidneys. The development of sepsis (3% and 41%) and death rate (3% and 44%) were higher in patients with native kidneys (p < 0.01). The renal allograft recipients with both oliguric (n = 18) and nonoliguric (n = 16) ARF were evaluated and no difference was observed in the recipient's age, donor's age, cold ischemia time, time elapsed until plasmatic creatinine normalization, donor's plasmatic creatinine or urea, and mean arterial pressure. No differences were observed between the groups regarding frequency of infection episodes during ARF and frequency of death. In conclusion, renal allograft recipients presented a lower death rate and were less susceptible to sepsis. Cold ischemia time, age, and hemodynamic characteristics of the donor did not affect the development of oliguria.

Hodgkin disease in adult and juvenile groups from two different geographic regions in Brazil: Characterization of clinicopathologic aspects and relationship with Epstein-Barr virus infection

We analyzed clinicopathologic data, immunophenotype, and Epstein-Barr virus (EBV) status in 96 cases of Hodgkin disease (HD) in juveniles (younger than 20 years) and adults (20 years or older) from 2 distinctive states in Brazil. We studied 34 juvenile (group 1) and 16 adult (group 2) cases from Ceara and 31 juvenile (group 3) and 15 adult (group 4) cases from São Paulo. Ceara has a socioeconomic profile similar to a developing country; São Paulo is in better economic condition. Mixed cellularity (MC) was the major histologic subtype among groups 1 (22 [65%]), 3 (21 [68%]), and 4 (7 [47%]); nodular sclerosis (NS) was more frequent in group 2 (8 [50%]). EBV infection was observed in 61 cases (64%), including the following (among others): group 1, MC, 22 (65%) and NS, 4 (12%); group 2, NS, 3 (19%) and MC, 2 (12%); group 3, MC, 16 (52%) and NS, 1 (3%); and group 4, MC, 7 (47%). There was predominance of EBV+ HD cases in group 1 compared with group 3. HD in Brazilian patients is highly associated with EBV infection, but geographic differences reflect histologic subtypes and age distribution.

Collateral cartilage ossification of the distal phalanx in the Brazilian Jumper horse

Collateral cartilage ossification of the distal phalanx in the Brazilian Jumper horse is a common finding. The objective of this study was to evaluate the prevalence and the degree of ossification of the collateral cartilages of the distal phalanx in Brazilian Jumper horses. In an analysis of 652 collateral cartilages from the front feet of 163 horses, 93% of these cartilages had collateral cartilage ossification (P < 0.005), and 7% of these cartilages did not have any type of ossification. In ossified cartilages, 86.4% had ossification beginning from the base, and 6.6% had a separate center of ossification.

Insulin secretion in monosodium glutamate (MSG) obese rats submitted to aerobic exercise training

The present study was designed to evaluate the effects of aerobic exercise training on glucose tolerance and insulin secretion of obese male Wistar rats (monosodium glutamate [MSG] administration, 4mg/g-body weight, each other day, from birth to the 14th day). Fourteen weeks after the drug administration, the rats were separated into two groups: MSG-S (sedentary) and MSG-T (T = swimming, 1 h/day, 5 days/week, with an overload of 5% body weight for 10 weeks). Rats of the same age and strain injected with saline were used as control (C) and subdivided into two groups: C-S and C-T. Insulin and glucose responses during an oral glucose tolerance test (GTT) were evaluated by the estimation of the total areas under serum insulin (AI) and glucose (AG) curves. Glucose-induced insulin secretion by isolated pancreatic islets was also evaluated. MSG-S rats showed higher AI than C-rats while MSG-T rats presented lower AI than MSG-S rats. No differences in AG were observed among the 4 groups. Pancreatic islets from MSG-rats showed higher insulin secretion in response to low (2.8) and moderate (8.3 mM) concentrations of glucose than those from their control counterparts and no differences were observed between MSG-S and MSG-T rats. These results provide evidences that the hyperinsulinemia at low or moderate glucose concentrations observed in MSG-obese rats is, at least in part, a consequence of direct hypersecretion of the B cells and that chronic aerobic exercise is able to partially counteract the hyperinsulinemic state of these animals without disrupting glucose homeostasis.

Tratamento do carcinoma metastático

The renal cell carcinoma (RCC) is the seventh most common malignancy, accounting for more than 3% of cancer incidence in the United States. RCC is more common in males, occurring primarily in the 5 th to 7 th decades of life. At the time of presentation one third of the patients have advanced disease and about 50% of the patients that underwent radical nephrectomy have recurrence. With the mainstream implementation of imaging modalities, such as ultrasound, the incidental detection of RCC has dramatically increased in recent years. Patients with metastatic RCC without treatment have na average survival of 6 to 10 months, and only 10 to 20% can be expected to survive 2 years. Treatment for patients with advanced disease remains unsatisfactory and the metastatic renal cancer continue to present a therapeutic challenge systemic therapies employed in patients with this tumor include chemotherapy, hormonal therapy, and immunotherapy. The authors review the treatment strategies of the metastatic renal cell carcinoma (RCC).

Laryngeal electromyography in movement disorders: Preliminary data

This study describes preliminary laryngeal electromyography (LEMG) data and botulinum toxin treatment in patients with dysphonia due to movement disorders. Twenty-five patients who had been clinically selected for botulinum toxin administration were examined, 19 with suspected laryngeal dystonia or spasmodic dysphonia (SD), 5 with vocal tremor, and 1 with Gilles de la Tourette syndrome (GTS). LEMG evaluations were performed before botulinum toxin administration using monopolar electrodes. Electromyography was consistent with dystonia in 14 patients and normal in 5, and differences in frequency suggesting essential tremor in 3 and Parkinson tremors in 2. The different LEMG patterns and significant improvement in our patients from botulinum toxin therapy has led us to perform laryngeal electromyography as a routine in UNICAMP movement disorders ambulatory.

Análise retrospectiva da toxicidade de gotas otológicas, medicamentos tópicos nasais e orofaríngeos registrada na Grande São Paulo.

BACKGROUND: Retrospective analysis of human toxicity files involving topical medicines for treatment of upper airways diseases (eardrops, topical nasal medicines, lozenges, drops and sprays for oropharyngeal affections). METHODS: Thirty-four brands of eardrops, 48 of topical nasal medicines and 22 of tablets, lozenges and sprays for oropharyngeal affections were selected, from a total of 104 products available in Brazil. We analyzed the registries in the electronic database from the Poison Control Centre of São Paulo (CCI-Jabaquara), Brazil, for the period from January 1996 through December 2000. The cases related to selected pharmaceuticals were collected. RESULTS: 10,823 cases of human toxicity caused by medicines were voluntarily reported to CCI-Jabaquara. Topical medicines for treatment of upper airways diseases accounted for 291 cases (2.68%), from which 240 (82.5%) represented poisoning; 12 (4.1%) involved ear drops, 268 (92%), topical nasal medicines and 11 (3.9%), topical medicines for oropharyngeal affections. Among topical nasal medicines, vasoconstrictors predominated (233 cases), and among medicines for oropharyngeal affections, it was tetracaine (four cases). Considering age distribution, toxicity predominated significantly in children aged from 1 to 4 years (p=0.0003). The main causes of toxicity were: accidental intake of medicines (43%) and error in drug administration (14.8%). Hypereflexia and vomiting were the most frequent symptoms related to toxicity. CONCLUSIONS: There was significant incidence of systemic toxicity due to eardrops, topical nasal and oropharyngeal medicines in children 1 to 4 years-old, whose main cause was accidental intake of these medicines.

Bone mineralization among male adolescents: Critical years for bone mass gain

Objective: To verify the behavior of the mineral bone content and density in male adolescents according to age and secondary sexual characters. Methods: 47 healthy adolescents between 10 and 19 years old were assessed according to weight, height, body mass index, puberty stage, calcium intake, bone mineral density and content in the lumbar spine and in the proximal femur. The bone mass was measured through bone densitometries. The intake of calcium was calculated through a 3-day diet. The BMI (body mass index) was calculated with the Quetelet Index and the puberty stage was defined according to Tanner's criteria. The analysis used descriptive statistics such as average and standard deviation, and variance estimates to compare the different age groups. Moreover, the Tukey test was used to determine the significant differences. Results: It was evident that the calcium intake in the different ages assessed has not reached the minimum value of 800 mg. The bone mineral density and content showed an increase after the age of 14, as well as when the teenagers reached the sexual maturation stage G4. The mineralization parameters showed a high level when the teenagers were in the G3 stage, however, without statistical significance. Conclusion: The results indicate an important level of bone mineralization during adolescence. Maturation levels superior to G3 have shown more mineralization. This study proves that the critical years for bone mass gain start after the 14-15 years old or older. Copyright © 2004 by Sociedade Brasileira de Pediatria.