Cost-Effectiveness of High, Moderate and Low-Dose Statins in the Prevention of Vascular Events in the Brazilian Public Health System

Background:Statins have proven efficacy in the reduction of cardiovascular events, but the financial impact of its widespread use can be substantial.Objective:To conduct a cost-effectiveness analysis of three statin dosing schemes in the Brazilian Unified National Health System (SUS) perspective.Methods:We developed a Markov model to evaluate the incremental cost-effectiveness ratios (ICERs) of low, intermediate and high intensity dose regimens in secondary and four primary scenarios (5%, 10%, 15% and 20% ten-year risk) of prevention of cardiovascular events. Regimens with expected low-density lipoprotein cholesterol reduction below 30% (e.g. simvastatin 10mg) were considered as low dose; between 30-40%, (atorvastatin 10mg, simvastatin 40mg), intermediate dose; and above 40% (atorvastatin 20-80mg, rosuvastatin 20mg), high-dose statins. Effectiveness data were obtained from a systematic review with 136,000 patients. National data were used to estimate utilities and costs (expressed as International Dollars - Int$). A willingness-to-pay (WTP) threshold equal to the Brazilian gross domestic product per capita (circa Int$11,770) was applied.Results:Low dose was dominated by extension in the primary prevention scenarios. In the five scenarios, the ICER of intermediate dose was below Int$10,000 per QALY. The ICER of the high versus intermediate dose comparison was above Int$27,000 per QALY in all scenarios. In the cost-effectiveness acceptability curves, intermediate dose had a probability above 50% of being cost-effective with ICERs between Int$ 9,000-20,000 per QALY in all scenarios.Conclusions:Considering a reasonable WTP threshold, intermediate dose statin therapy is economically attractive, and should be a priority intervention in prevention of cardiovascular events in Brazil.

Acute Coronary Syndrome Treatment Costs from the Perspective of the Supplementary Health System

AbstractBackground:Acute coronary syndrome (ACS) is defined as a “group of clinical symptoms compatible with acute myocardial ischemia”, representing the leading cause of death worldwide, with a high clinical and financial impact. In this sense, the development of economic studies assessing the costs related to the treatment of ACS should be considered.Objective:To evaluate costs and length of hospital stay between groups of patients treated for ACS undergoing angioplasty with or without stent implantation (stent+ / stent-), coronary artery bypass surgery (CABG) and treated only clinically (Clinical) from the perspective of the Brazilian Supplementary Health System (SHS).Methods:A retrospective analysis of medical claims of beneficiaries of health plans was performed considering hospitalization costs and length of hospital stay for management of patients undergoing different types of treatment for ACS, between Jan/2010 and Jun/2012.Results:The average costs per patient were R$ 18,261.77, R$ 30,611.07, R$ 37,454.94 and R$ 40,883.37 in the following groups: Clinical, stent-, stent+ and CABG, respectively. The average costs per day of hospitalization were R$ 1,987.03, R$ 4,024.72, R$ 6,033.40 and R$ 2,663.82, respectively. The average results for length of stay were 9.19 days, 7.61 days, 6.19 days and 15.20 days in these same groups. The differences were significant between all groups except Clinical and stent- and between stent + and CABG groups for cost analysis.Conclusion:Hospitalization costs of SCA are high in the Brazilian SHS, being significantly higher when interventional procedures are required.

Assessing the performance of macroinvertebrate metrics in the Challhuaco-Ñireco System (Northern Patagonia, Argentina)

ABSTRACT Seven sites were examined in the Challhuaco-Ñireco system, located in the reserve of the Nahuel Huapi National Park, however part of the catchment is urbanized, being San Carlos de Bariloche (150,000 inhabitants) placed in the lower part of the basin. Physico-chemical variables were measured and benthic macroinvertebrates were collected during three consecutive years at seven sites from the headwater to the river outlet. Sites near the source of the river were characterised by Plecoptera, Ephemeroptera, Trichoptera and Diptera, whereas sites close to the river mouth were dominated by Diptera, Oligochaeta and Mollusca. Regarding functional feeding groups, collector-gatherers were dominant at all sites and this pattern was consistent among years. Ordination Analysis (RDA) revealed that species assemblages distribution responded to the climatic and topographic gradient (temperature and elevation), but also were associated with variables related to human impact (conductivity, nitrate and phosphate contents). Species assemblages at headwaters were mostly represented by sensitive insects, whereas tolerant taxa such as Tubificidae, Lumbriculidae, Chironomidae and crustacean Aegla sp. were dominant at urbanised sites. Regarding macroinvertebrate metrics employed, total richness, EPT taxa, Shannon diversity index and Biotic Monitoring Patagonian Stream index resulted fairly consistent and evidenced different levels of disturbances at the stream, meaning that this measures are suitable for evaluation of the status of Patagonian mountain streams.

Impact of direct seeding mulch-based cropping systems on soil nematodes in a long-term experiment in Madagascar

The objective of this work was to assess the effects of conventional tillage and of different direct seeding mulch-based cropping systems (DMC) on soil nematofauna characteristics. The long-term field experiment was carried out in the highlands of Madagascar on an andic Dystrustept soil. Soil samples were taken once a year during three successive years (14 to 16 years after installation of the treatments) from a 0-5-cm soil layer of a conventional tillage system and of three kinds of DMC: direct seeding on mulch from rotation soybean-maize residues; direct seeding of maize-maize rotation on living mulch of silverleaf (Desmodium uncinatum); direct seeding of bean (Phaseolus vulgaris)-soybean rotation on living mulch of kikuyu grass (Pennisetum clandestinum). The samples were compared with samples from natural fallows. The soil nematofauna, characterized by the abundance of different trophic groups and indices (MI, maturity index; EI and SI, enrichment and structure indices), allowed the discrimination of the different cropping systems. The different DMC treatments had a more complex soil food web than the tillage treatment: SI and MI were significantly greater in DMC systems. Moreover, DMC with dead mulch had a lower density of free-living nematodes than DMC with living mulch, which suggested a lower microbial activity.

Breeding objectives for a Nellore cattle rearing system

Abstract:The objective of this work was to define the traits that should be included as breeding objectives for Nellore cattle, according to simulations with a bio-economic model for rearing systems. The economic values (EVs) of the traits were calculated as the differences between the profits due to an increased performance of 1% in each trait, with the others traits remaining constant. To determine the impact of each selection on the revenue system, two scenarios were simulated based on the traits being selected. In the first scenario, the adopted selection criteria were: weaning weight (WW), weaning rate (WR), yearling weight (YW), and mature cow weight (MCW). In the second scenario, the cumulative productivity (CP) of dams was used as an indirect evaluation of the performance of calves, with all the other traits included, except WW. In the first scenario, an EV of R$ 1.44 kg-1 was obtained for WW. In the second scenario, an EV of R$ 2.91 kg-1 was obtained for CP. The trait with the highest EV in both scenarios was WR, which enhanced the profits by R$ 3.21 for each 1% increased performance. The meat price paid to the producer is the factor with the greatest impact on the EVs of all examined traits.

Potential impact of the global climate changes on the spatial distribution of areas of risk for the occurrence of eucalyptus rust in Brazil

Rust, caused by Puccinia psidii, is one of the most important diseases affecting eucalyptus in Brazil. This pathogen causes disease in mini-clonal garden and in young plants in the field, especially in leaves and juvenile shoots. Favorable climate conditions for infection by this pathogen in eucalyptus include temperature between 18 and 25 ºC, together with at least 6-hour leaf wetness periods, for 5 to 7 consecutive days. Considering the interaction between the environment and the pathogen, this study aimed to evaluate the potential impact of global climate changes on the spatial distribution of areas of risk for the occurrence of eucalyptus rust in Brazil. Thus, monthly maps of the areas of risk for the occurrence of this disease were elaborated, considering the current climate conditions, based on a historic series between 1961 and 1990, and the future scenarios A2 and B2, predicted by IPCC. The climate conditions were classified into three categories, according to the potential risk for the disease occurrence, considering temperature (T) and air relative humidity (RH): i) high risk (18 < T < 25 ºC and RH > 90%); ii) medium risk (18 < T < 25 ºC and RH < 90%; T< 18 or T > 25 ºC and RH > 90%); and iii) low risk (T < 18 or T > 25 ºC and RH < 90%). Data about the future climate scenarios were supplied by GCM Change Fields. In this study, the simulation model Hadley Centers for Climate Prediction and Research (HadCm3) was adopted, using the software Idrisi 32. The obtained results led to the conclusion that there will be a reduction in the area favorable to eucalyptus rust occurrence, and such a reduction will be gradual for the decades of 2020, 2050 and 2080 but more marked in scenario A2 than in B2. However, it is important to point out that extensive areas will still be favorable to the disease development, especially in the coldest months of the year, i.e., June and July. Therefore, the zoning of areas and periods of higher occurrence risk, considering the global climate changes, becomes important knowledge for the elaboration of predicting models and an alert for the integrated management of this disease.

The impact of the law 10,267/2001 in the brazilian rural registration

The publication of the Law 10,267 of 08/28/2001 changed the paradigm of rural registration in Brazil, because this law known as the "Law of Georeferencing" has created the National Registration of Rural Property, that unifies in a common basis different registrations present in several government agencies, such as the National Institute for Colonization and Agrarian Reform (INCRA), the Secretariat of Federal Revenue, the Brazilian Institute of Environment and Natural Resources, and the National Indian Foundation. Also, this new registration system has a graphical component which has not existed until such date, where the boundaries of rural property are georeferenced to the Brazilian Geodetic System. This new paradigm has resulted in a standardization of the survey and its representation of rural properties according to the Technical Standard for Georeferencing of Rural Properties, published by INCRA in compliance with the new legislation. Due to the georeferencing, the creation of a public GIS of free access on the Internet was possible. Among the difficulties found it may be observed the great Brazilian territory, the need for specialized professionals, and especially the certification process that INCRA has to perform for each georeferenced property. It is hoped that this last difficulty is solved with the implementation of the Land Management System that will allow automated and online certification, making the process more transparent, agile and fast.

The impact of evaporative cooling on the thermoregulation and sensible heat loss of sows during farrowing

Pigs are more sensitive to high environmental temperatures explained by the inability of sweating and panting properly when compared to other species of farmed livestock. The evaporative cooling system might favor the thermal comfort of animals during exposure to extreme environmental heat and reduce the harmful effects of heat stress. The purpose of this study was to assess the sensible heat loss and thermoregulation parameters from lactating sows during summer submitted to two different acclimatization systems: natural and evaporative cooling. The experiment was carried out in a commercial farm with 72 lactating sows. The ambient variables (temperature, relative humidity and air velocity) and sows physiological parameters (rectal temperature, surface temperature and respiratory rate) were monitored and then the sensible heat loss at 21days lactation was calculated. The results of rectal temperature did not differ between treatments. However, the evaporative cooling led to a significant reduction in surface temperature and respiratory rate and a significant increase in the sow's sensible heat loss. It was concluded that the use of evaporative cooling system was essential to increase sensible heat loss; thus, it should reduce the negative effects of heat on the sows' thermoregulation during summer.

Impact of Sacrospinous Colpopexy Associated with Anterior Colporrhaphy for the Treatment of Dome Prolapse on all Three Vaginal Compartments

Objective To evaluate the results of sacrospinous colpopexy surgery associated with anterior colporrhaphy for the treatment of women with post-hysterectomy vaginal vault prolapse. Methods This prospective study included 20women with vault prolapse, PelvicOrgan Prolapse Quantification System (POP-Q) stage≥2, treated between January 2003 and February 2006, and evaluated in a follow-up review (more than one year later). Genital prolapse was evaluated qualitatively in stages and quantitatively in centimeters. Prolapse stage < 2 was considered to be the cure criterion. Statistical analysis was performed using the Wilcoxon test (paired samples) to compare the points and stages of prolapse before and after surgery. Results Evaluation of the vaginal vault after one year revealed that 95% of subjects were in stage zero and that 5% were in stage 1. For cystocele, 50% were in stage 1, 10% were in stage 0 (cured) and 40% were in stage 2. For rectocele, three women were in stage 1 (15%), one was in stage 2 (5%) and 16 had no further prolapse. The most frequent complication was pain in the right buttock, with remission of symptoms in all three cases three months after surgery. Conclusions In this retrospective study, the surgical correction of vault prolapse using a sacrospinous ligament fixation technique associatedwith anterior colporrhaphy proved effective in resolving genital prolapse. Despite the low complication rates, there was a high rate of cystocele, which may be caused by posterior vaginal shifting due to either the technique or an overvaluation by the POP-Q system.

Resveratrol inhibits the intracellular calcium increase and angiotensin/endothelin system activation induced by soluble uric acid in mesangial cells

Resveratrol (Resv) is natural polyphenol found in grapes. This study evaluated the protective effect of Resv against the effects of uric acid (UA) in immortalized human mesangial cells (ihMCs). ihMCs were preincubated with Resv (12.5 µM) for 1 h and treated with UA (10 mg/dL) for 6 or 12 h. The intracellular calcium concentration [Ca2+]i was quantified by fluorescence using flow cytometry. Angiotensinogen (AGT) and pre-pro endothelin-1 (ppET-1) mRNA were assayed by quantitative real-time RT-PCR. Angiotensin II (AII) and endothelin-1 (ET-1) were assayed by ELISA. UA significantly increased [Ca2+]i. Pre-incubation with Resv significantly reduced the change in [Ca2+]i induced by UA. Incubation with UA for 6 or 12 h also increased AGT mRNA expression and AII protein synthesis. Resv blunted these increases in AGT mRNA expression and AII protein. Incubation with UA in the ihMCs increased ppET-1 expression and ET-1 protein synthesis at 6 and 12 h. When ihMCs were pre-incubated with Resv, UA had a significantly diminished effect on ppET-1 mRNA expression and ET-1 protein synthesis at 6 and 12 h, respectively. Our results suggested that UA triggers reactions including AII and ET-1 production in mesangial cells. The renin-angiotensin system may contribute to the pathogenesis of renal function and chronic kidney disease. Resv can minimize the impact of UA on AII, ET-1 and the increase of [Ca2+]i in mesangial cells, suggesting that, at least in part, Resv can prevent the effects of soluble UA in mesangial cells.

Effect of trellising system on grape and wine composition of Syrah vines grown in the cerrado region of Minas Gerais

Based on the concept that the trellising system affects not only sunlight interception and carbon assimilation, but also the fruitzone microclimate, which has a great impact on fruit composition and consequently on wine quality, the effect of two trellising systems - Vertical Shoot Position (VSP) and modified Geneva Double Curtain (GDC) - on wine and berry composition of Syrah grapes grown in João Pinheiro, Northeast region of Minas Gerais State, Brazil was investigated. The parameters such as pH, berry size and weight, and seeds total phenolic contents were not affected by the training system. The GDC system produced fruits with the highest Brix and lowest titratable acidity. Berries from the VSP system presented lower anthocyanin concentration than those from the GDC system. Similar results were found for the total phenolic content of the skin of grape berries from the VSP system. GDC wines were characterized by high anthocyanin content and red color, resulting in wines with high color intensity. These data suggest that in the tropical region of Minas Gerais state, with high temperature and high sunlight intensity, the trellising system, which protects bunches against excessive radiation, should be chosen.

Citizens against the State: the riddle of high impact, low functionality courts in Brazil

The Brazilian federal judiciary offers an interesting riddle to scholars of judicial politics and policy change. While the courts have played a major policy role over the past two decades, constraining and altering federal policy across a range of subjects, the court system has simultaneously been labeled "dysfunctional." This paper investigates this riddle: a system plagued by major systemic flaws in its day-to-day operations, which nonetheless still manages to exert a powerful influence on public policy in Brazil. I adopt a new institutional perspective, focusing on how the institutional and normative structure within which judges and other legal actors operate affects policy outcomes.