An evaluation of the personal response system program for the elderly in Harris County, Texas

The Personal Response System Program at Huffington Center on Aging, Baylor College of Medicine, provides emergency call systems for elderly people living independently in Houston, Texas. The goal of the project was to complete a formative evaluation of the Personal Response System Program. The specific aims of the evaluation were three-fold. One aim was to evaluate participant health status and level of disability. The second aim was to develop a health care cost estimation strategy. Finally, a preliminary cost-effectiveness analysis was completed to evaluate the program's impact on health care costs and health status among the elderly target population. ^ The evaluation was a longitudinal, randomized experimental design. After the screening of 120 volunteers for eligibility, clients were asked to complete a written questionnaire and a monthly health service contact diary. Volunteers were contacted by telephone interviewers to collect health status information from 100 eligible clients (83%) on three occasions during the six months of follow-up. ^ Initially, volunteers were randomized to two experimental groups. The two groups were found to be comparable at the beginning of the study. No significant differences were detected related to health status, level of disability, or history of physician visits at baseline. However, the group with the Personal Response System (PRS) device had more adverse health events, higher IADL scores, more frequent use of walkers, lower average health status scores, and fewer community volunteers hours than the usual care comparison group. ^ The health care costs were estimated based on an algorithm adapted from the American Medical Association guidelines. Average total health care costs for the group with the PRS device ($912) were greater than the usual care group ($464). However, median health care values for the PRS group ($263) were similar to the usual care comparison group ($234). The preliminary findings indicated that the use of the PRS device was not associated with health care cost savings. ^ In the preliminary cost-effectiveness analysis, use of the personal response system was found to be associated with increased mental health status among elderly clients. The cost-effectiveness evaluation indicated that the associated cost for six months was $710 per unit increase in mental component score when the $150 PRS subscription was included. However, clients with the PRS device were found to have a greater decline in physical health status during the six-month follow-up. The beneficial effect on mental health status was found to be in contrast to negative findings associated with changes in physical health status. The implications for future research relate to the need to identify risk factors among geriatric populations to better target groups that would most likely benefit from PRS Program enrollment. ^

Sharing evidence of sustainable land management impacts

Ensuring sustainable use of natural resources is crucial for maintaining the basis for our livelihoods. With threats from climate change, disputes over water, biodiversity loss, competing claims on land, and migration increasing worldwide, the demands for sustainable land management (SLM) practices will only increase in the future. For years already, various national and international organizations (GOs, NGOs, donors, research institutes, etc.) have been working on alternative forms of land management. And numerous land users worldwide – especially small farmers – have been testing, adapting, and refining new and better ways of managing land. All too often, however, the resulting SLM knowledge has not been sufficiently evaluated, documented and shared. Among other things, this has often prevented valuable SLM knowledge from being channelled into evidence-based decision-making processes. Indeed, proper knowledge management is crucial for SLM to reach its full potential. Since more than 20 years, the international WOCAT network documents and promotes SLM through its global platform. As a whole, the WOCAT methodology comprises tools for documenting, evaluating, and assessing the impact of SLM practices, as well as for knowledge sharing, analysis and use for decision support in the field, at the planning level, and in scaling up identified good practices. In early 2014, WOCAT’s growth and ongoing improvement culminated in its being officially recognized by the UNCCD as the primary recommended database for SLM best practices. Over the years, the WOCAT network confirmed that SLM helps to prevent desertification, to increase biodiversity, enhance food security and to make people less vulnerable to the effects of climate variability and change. In addi- tion, it plays an important role in mitigating climate change through improving soil organic matter and increasing vegetation cover. In-depth assessments of SLM practices from desertification sites enabled an evaluation of how SLM addresses prevalent dryland threats. The impacts mentioned most were diversified and enhanced production and better management of water and soil degradation, whether through water harvesting, improving soil moisture, or reducing runoff. Among others, favourable local-scale cost-benefit relationships of SLM practices play a crucial role in their adoption. An economic analysis from the WOCAT database showed that land users perceive a large majority of the technologies as having benefits that outweigh costs in the long term. The high investment costs associated with some practices may constitute a barrier to adoption, however, where appropriate, short-term support for land users can help to promote these practices. The increased global concerns on climate change, disaster risks and food security redirect attention to, and trigger more funds for SLM. To provide the necessary evidence-based rationale for investing in SLM and to reinforce expert and land users assessments of SLM impacts, more field research using inter- and transdisciplinary approaches is needed. This includes developing methods to quantify and value ecosystem services, both on-site and off-site, and assess the resilience of SLM practices, as currently aimed at within the EU FP7 projects CASCADE and RECARE.

Cost-effectiveness of peer role play and standardized patients in undergraduate communication training.

BACKGROUND The few studies directly comparing the methodological approach of peer role play (RP) and standardized patients (SP) for the delivery of communication skills all suggest that both methods are effective. In this study we calculated the costs of both methods (given comparable outcomes) and are the first to generate a differential cost-effectiveness analysis of both methods. METHODS Medical students in their prefinal year were randomly assigned to one of two groups receiving communication training in Pediatrics either with RP (N = 34) or 19 individually trained SP (N = 35). In an OSCE with standardized patients using the Calgary-Cambridge Referenced Observation Guide both groups achieved comparable high scores (results published). In this study, corresponding costs were assessed as man-hours resulting from hours of work of SP and tutors. A cost-effectiveness analysis was performed. RESULTS Cost-effectiveness analysis revealed a major advantage for RP as compared to SP (112 vs. 172 man hours; cost effectiveness ratio .74 vs. .45) at comparable performance levels after training with both methods. CONCLUSIONS While both peer role play and training with standardized patients have their value in medical curricula, RP has a major advantage in terms of cost-effectiveness. This could be taken into account in future decisions.

The Colic Clinic---a comprehensive program evaluation

Child abuse correlated with excessive infant crying affects millions of families each year, with consequences of the abuse lasting a lifetime. The University Of Texas School Of Medicine's Colic Clinic is currently in the early stages of testing Dr. Harvey Karp's combinatorial soothing technique for infants called "The Happiest Baby on the Block". In order to gauge the program's potential effectiveness, the Colic Clinic Protocol was examined in order to assess the applicability of the intervention to known causal factors of child abuse associated with excessive infant crying. ^ This evaluation also carried out an anticipated cost-benefit breakout analysis for the implementation of the intervention for 100 children and compared the cost of the program implementation to the cost associated with a single instance of child abuse. The analysis revealed that while accounting for materials, advertising, salaried personnel and other overhead expenses, the cost to implement the intervention was less than half the cost of the medical treatment associated with a single victim of whiplash-shaken infant syndrome. ^ Although the program is still in its early evaluative phase, the future implications of this work are extensive. If this intervention is revealed to be relevant and cost effective, it will precipitate sweeping changes in medical education and training, public health detection and prevention programs, and law enforcement.^

Cost -effectiveness of services and treatments for ambulatory dually diagnosed CMHC clients: Implications for managed care

This paper reports a cost-effectiveness analysis of standard therapeutic interventions received by ambulatory dually diagnosed clients of a Community Mental Health Center (CMHC). For the purposes of this study dually diagnosed was defined as a DSM-III-R or IV diagnosis of a major mental disorder and a concomitant substance abuse disorder. The prevalence of dually diagnosed people among the mentally ill and their unique and problematic nature continues to challenge and encumber CMHCs and poses grave public health risks. An absence of research on these clients in community-based settings and the cost-effectiveness of their standard CMHC care has hindered the development of effective community-based intervention strategies. This exploratory and descriptive effort is a first step toward providing information on which to base programmatic management decisions.^ Data for this study were derived from electronic client records of a CMHC located in a large Southwestern, Sun-belt metropolitan area. A total of 220 records were collected on clients consecutively admitted during a two-and-one-half year period. Information was gathered profiling the clients' background characteristics, receipt of standard services and treatments, costs of the care they received, and length of CMHC enrollment and subsequent psychiatric hospitalizations. The services and treatments were compared with regard to their costs and predicted contributions toward maintaining clients in the community and out of public psychiatric hospitals.^ This study investigated: (1) the study groups' background, mental illness, and substance abuse characteristics; (2) types, extent, and patterns of their receipt of standard services and treatments; (3) associations between the receipt of services and treatments, community tenure, and risk of psychiatric hospitalization; and, (4) comparisons of average costs for services and treatments in terms of their contributions toward maintaining the clients in the community.^ The results suggest that substance abuse and other lifestyle factors were related to the dually diagnosed clients' admissions to the CMHC. The dually diagnosed clients' receipt of care was associated strongly with their insurability and global functioning. Medication Services were the most expensive yet effective service or treatment. Supported Education was the third most expensive and second most effective. Psychosocial Services, the second most expensive, were only effective in terms of maintaining clients in the community. Group Counseling, the fourth most expensive, had no effect on community maintenance and increased the risk of hospitalization when accompanied by Medication Services. Individual Counseling, the least expensive, had no effect on community maintenance. But it reduced the risk of hospitalization when accompanied by Medication Services. Networking/Referral, the fifth most expensive service or treatment, was ineffective.^ The study compared the results with findings in the literature. Implications are discussed regarding further research, study limitations, practical applications and benefits, and improvements to theoretical understandings, in particular, concepts underscoring Managed Care. ^

Zum Einfluss vorschulischer Kinderbetreuung auf den Bildungsweg und den erwarteten Erfolg am Arbeitsmarkt

In dem Beitrag wird der Frage nachgegangen, welchen Einfluss die Inanspruchnahme frühkindlicher Bildungs- und Betreuungsangebote auf den späteren Schulbesuch von Kindern hat und wie sich dies längerfristig auf die zu erwartenden Lebenseinkommen und damit einhergehend den langfristigen volkswirtschaftlichen Nutzen auswirkt. Untersucht werden Kinder in Deutschland der Jahrgänge 1990 bis 1995. Die Datengrundlage liefert das Sozio-oekonomische Panel (SOEP). Der Schwerpunkt der Analysen liegt auf der Bestimmung des Effekts des Krippenbesuchs auf die spätere Einstufung in die verschiedenen Schultypen in Abhängigkeit der sozialen Herkunft und des Migrationshintergrunds der Kinder. Ausgehend von diesen Schätzungen werden dann die zu erwartenden, über den Bildungsabschluss vermittelten Auswirkungen des Krippenbesuchs auf das spätere Lebenseinkommen bestimmt, um einen Eindruck der langfristigen volkswirtschaftlichen Folgen vorschulischer Kinderbetreuung zu erhalten. Der Beitrag zeigt, dass der Krippenbesuch die Wahrscheinlichkeit einer Einstufung ins Gymnasium nach Kontrolle relevanter Drittvariablen im Schnitt um rund 14 Prozentpunkte erhöht. Dieser Einfluss entspricht einem erwarteten Lebenseinkommenszuwachs von rund 27000 Euro. Wird dieser Ertrag auf den Zeitpunkt des Krippenbesuchs abdiskontiert und den Kosten eines durchschnittlichen Krippenbesuchs in der Höhe von rund 8000 Euro gegenübergestellt, so ergibt sich ein Kosten-Nutzen-Verhältnis von 1 zu 2.7. (DIPF/Orig.).

Combining static analysis and profiling for estimating execution times in logic programs

Effective static analyses have been proposed which allow inferring functions which bound the number of resolutions or reductions. These have the advantage of being independent from the platform on which the programs are executed and such bounds have been shown useful in a number of applications, such as granularity control in parallel execution. On the other hand, in certain distributed computation scenarios where different platforms come into play, with each platform having different capabilities, it is more interesting to express costs in metrics that include the characteristics of the platform. In particular, it is specially interesting to be able to infer upper and lower bounds on actual execution time. With this objective in mind, we propose a method which allows inferring upper and lower bounds on the execution times of procedures of a program in a given execution platform. The approach combines compile-time cost bounds analysis with a one-time profiling of the platform in order to determine the values of certain constants for that platform. These constants calibrate a cost model which from then on is able to compute statically time bound functions for procedures and to predict with a significant degree of accuracy the execution times of such procedures in the given platform. The approach has been implemented and integrated in the CiaoPP system.

Efecto de la fertilización orgánica y mineral en las propiedades del suelo, la emisión de los principales gases de efecto invernadero y en las diferentes fases fenológicas del cultivo de café (Coffea arabica L.)

El cultivo de café es de gran importancia a nivel mundial (ICO, 2011), y en el Ecuador ha sido uno de los cultivos más importantes en la generación de divisas (COFENAC, 2011). Sin embargo en los sistemas productivos de este país se puede apreciar el uso inapropiado de fertilizantes, lo que conlleva a una pérdida de nutrientes, por lo que es importante estudiar las dosis adecuadas para la fertilización tanto mineral como orgánica. El objetivo del trabajo fue evaluar el efecto de la fertilización mineral y orgánica en diferentes dosis en un monocultivo de café en la provincia de Loja, sobre las propiedades del suelo, la emisión de los principales gases que provocan el efecto invernadero y la fenología y productividad del cultivo. En la provincia de Loja (Ecuador) se seleccionó un área de 2.520 m2 en la que se establecieron 21 parcelas de café arábigo (Coffea arabica L.) var. caturra y se aplicó tres tratamientos con tres repeticiones de fertilización mineral y tres orgánicos con dosis: bajas minerales (MIN 1= 157 Kg NPK ha-1 año-1 para el primer año y 425 Kg NPK ha-1 año-1 para el segundo año), medias minerales (MIN 2= 325 Kg NPK ha-1 año-1 para el primer año y 650 Kg NPK ha-1 año-1 en el segundo año) y altas minerales (MIN 3= 487 y 875 Kg NPK ha-1 año-1 para el primer y segundo año respectivamente), bajas orgánicas (ORG 1= 147 Kg NPK ha-1 año-1 en el primer año y 388 Kg NPK ha-1 año-1 en el año dos), medias orgánicas (ORG 2= 265 Kg NPK ha-1 año-1 para el primer año y 541 Kg NPK ha-1 año-1 en el segundo año), altas orgánicas (ORG 3= 368 Kg NPK ha-1 año-1 para el primer año y 727 Kg NPK ha-1 año-1 en el segundo año) y fertilización cero (TES = sin fertilización). Se usó urea, roca fosfórica y muriato de potasio en la fertilización mineral y humus (Bioabor) en la orgánica, más un tratamiento testigo, cada tratamiento tuvo tres repeticiones. El tiempo de evaluación de los fertilizantes aplicados fue de dos años consecutivos, la fertilización se la realizó dos veces por año y en base a análisis del suelo y demandas nutricionales del cultivo. para determinar las características del suelo se realizó muestreos de suelos en cada parcela a una profundidad de 20 cm de estas muestras los parámetro iniciales determinados fueron: color (Munsell), textura (método del hidrómetro), pH (relación 1:2,5 suelo-agua), Materia orgánica (Walkey y Black), Nitrógeno (Micro Kjendahl), Fósforo (Bray y Kurtz), Potasio (Olsen), estos procesos se repitieron cada seis meses para poder evaluar los cambios de que se producen debido a la fertilización mineral y orgánica en el cultivo. Las emisiones de gases efecto invernadero desde el suelo al ambiente se determinaron por el método de cámara cerrada (Rondón, 2000) y la concentración por cromatografía de gases. Las mediciones fisiológicas (altura de planta, ancho de copa, grosor de tallo y producción) se las evaluó cada dos meses, a excepción de la producción que fue anual al término de cada cosecha. Además se realizó el análisis económico de la productividad del cultivo. El análisis estadístico de datos se lo realizó con el programa SPSS v. 17.0. Las medias fueron comprobadas mediante ANOVAS de un factor con test de Tukey (P < 0,05). El beneficio económico se estimó en términos de ingresos y gastos totales que se presentaron en el ensayo. Los resultados obtenidos al término del ensayo indican que los tratamientos MIN 2 y MIN 3 produjeron cambios más significativos en comparación con los otros tratamientos establecidos en la mejora de fertilidad del suelo, el pH ha sido menos afectado en la acidificación en comparación con los tratamientos orgánicos que se han acidificado mayormente; la materia orgánica (MO) tuvo incrementos considerablemente bueno en estos dos tratamientos, sin embargo fueron superados por los tratamientos de fertilización orgánica; el nitrógeno total (Nt )y el potasio (K) también presentaron mejores valores al termino del ensayo y el fósforo (P) mostro incrementos buenos aunque un poco menores que los de los tratamientos ORG 2 y ORG 3. En lo que respecta a las emisiones de gases efecto invernadero, los flujos acumulados de óxido nitroso (N2O) en los dos años han aumentado en todos los tratamientos en comparación con el tratamiento Testigo, pero de manera considerable y con mayores flujos en el tratamiento MIN 3 y MIN 2 que se podrían considerarse los de mayor contaminación por N2O al ambiente lo que se le atribuye a las dosis de fertilización mineral aplicadas en el periodo de investigación, los tratamiento MIN 1 y todos los tratamientos orgánicos muestran menores emisiones al ambiente. Las emisiones de metano (CH4) no muestran mayores diferencias de emisiones entre tratamientos, siendo los mayores emisores los tratamientos ORG 3 y ORG 2 posiblemente debido al abono orgánico y añadido al suelo; para las emisiones de dióxido de carbono (CO2) de manera similar al CH4 el tratamiento ORG 3 fue el que presento mayores emisiones, los flujos de CO2 al ambiente de los otros tratamientos fueron menores y no presentaron diferencias significativas entre ellos. La variables fisiológicas en todos los casos apoyaron al desarrollo de las plantas de café, esto al ser comparadas con el tratamiento Testigo, sin embargo las que alcanzaron las mayores altitudes, anchos de copas y diámetro de tallo fueron las plantas del tratamiento MIN 3, seguido del MIN 3, no mostrando significancia entre ellos, y para los tratamientos orgánicos el que presento muy buenos resultados en estas variables ha sido el ORG 3, el cual no presento diferencias significativas con el MIN 2, lo cual comprueba que la fertilización mineral es más efectiva en este caso frente a la orgánica. Para el primer año de producción el tratamiento mineral con fertilización MIN 3 es el que obtuvo mayor producción no presentando diferencia estadística con el tratamiento con el MIN 2, no obstante fueron significativamente mayores que los otros tratamientos. Vale indicar que también el tratamiento MIN 1 y el tratamiento ORG 3 han presentado una producción considerable de café no mostrando diferencias estadísticas entre ellos. Para el segundo año la producción el cultivo mostró mayores rendimientos que el primer año de evaluación en todos los tratamientos, esto debido a la fisiología propia del cultivo y por otra parte se atribuye a la adición de fertilizantes que se ha realizado durante todo el ensayo; de manera similar al anterior los tratamientos MIN 3 y MIN 2 obtuvieron mejores rendimientos, no enseñando diferencias estadísticas significativas entre ellos, no obstante el tratamiento mineral dosis MEDIA no presentó significancia estadística con el ORG 3. El benéfico económico ha resultado mayor en el tratamiento MIN 3 y MIN 2, aunque el tratamiento MIN 2, es el que obtiene la mejor relación costo-beneficio; los tratamientos ORG 2 y ORG 3 y Testigo has producido beneficios negativos para el productor. En cuanto a la parte ambiental se considera que los mejores tratamientos en cuanto ha cuidado ambiental serían los tratamientos MIN 1 y ORG 1, sin embargo a nivel de producción y rentabilidad para el productor baja. ABSTRACT Coffee growing has great importance worldwide (ICO, 2011), and in Ecuador, it has been one of the most important crops to generate income (COFENAC, 2011). However, in the productive systems of this country, the inappropriate use of fertilizers has been observed which produces loss of nutrients, thus it is important to study suitable doses for mineral and organic fertilizing. The purpose of the study was to evaluate the effect of mineral and organic fertilizing at different doses in a coffee monoculture in the province of Loja on soil characteristics, emission of the main gasses that produce the greenhouse effect and the phenology and productivity of crops. In the province of Loja (Ecuador) an area of 2.520 m2 was chosen, where 21 plots of Arabica coffee (Coffea arabica L.), the caturra variety were cultivated and three treatments with three repetitions each one for mineral and organic fertilization were used with doses that ranged from: mineral low (MIN 1= 157 Kg NPK ha-1 año-1 for the first year y 425 Kg NPK ha-1 año-1 for the second year), mineral medium (MIN 2= 325 Kg NPK ha-1 año-1 for the first year y 650 Kg NPK ha-1 año-1 I the second year) y mineral high (MIN 3= 487 y 875 Kg NPK ha-1 año-1 for the first and second year respectively), organic low (ORG 1= 147 Kg NPK ha-1 año-1 in the first year y 388 Kg NPK ha-1 año-1 in the second year), organics medium (ORG 2= 265 Kg NPK ha-1 año-1 for the first year y 541 Kg NPK ha-1 año-1 in the second year), organics high (ORG 3= 368 Kg NPK ha-1 año-1 for the first year and 727 Kg NPK ha-1 año-1 in the second year) y fertilization zero (TES = no fertilization).; urea, phosphoric rock and muriate of potash were used in the mineral fertilization and humus (Bioabor) in the organic, plus a blank treatment. Time to evaluate the applied fertilizers was for two consecutive years, fertilization was done twice per year based on soil analysis and nutritional requirements of the crops. In order to determine the characteristics of the soil, samples of soil in each plot with a depth of 20 cm were done; from these samples, the determined initial parameters were: color (Munsell), texture (hydrometer method), pH (soil-water 1:2,5 relation), organic matter (Walkey y Black), nitrogen (Micro Kjendahl), phosphorus (Bray y Kurtz), potassium (Olsen); these processes were repeated each six months in order to evaluate the changes that are produced due to mineral and organic fertilization in the crops. The emissions of greenhouse gasses from the soil to the atmosphere were determined by using enclosure method (Rondón, 2000) and the concentration, by using gas chromatography during the whole testing. The physiological measures (plant height, width of the top of the tree, thickness of the stem and production) were evaluated each two months, except for production which was annual at the end of each harvest. Moreover, the economic analysis of the productivity of the crops was done. The statistical analysis of the data was done using SPSS v. 17.0. The means were proved by ANOVAS with a factor of a Tukey test (P < 0,05). The economic benefit was estimated in terms of incomes and total expenses which were presented in the essay. The results obtained at the end of the essay show that the MIN 2 and MIN 3 treatments produced more meaningful changes in comparison with the other treatments used to improve soil fertility; pH was less affected in the acidification compared with the organic treatments which were greatly acidified; organic matter (MO) had increased considerably in these two treatments; however, they were surpassed by the organic treatments of fertilization; total nitrogen (Nt) and potassium (K) also presented better results at the end of the essay and phosphorus (P) showed good increasing figures although a little lower compared with ORG 2 and ORG 3 treatments. Regarding the emission of the greenhouse gasses, the fluxes accumulated from nitrous oxide (N2O) in two years increased in all the treatments in comparison with the blank treatment, but in a greater form and with higher fluxes in the MIN 3 and MIN 2 treatments which can be considered as the ones with greater contamination of N2O in the atmosphere, this can be due to the applied mineral doses to fertilize during the process; MIN 1 treatments and all the organic ones showed lower emission to the atmosphere. Methane emissions (CH4) did not show major differences in emissions in the treatments, being the greater emissions the ORG 3 and ORG 2 treatments; this is possibly due to the organic compost added to the soil; regarding carbon dioxide (CO2) emissions, in a similar way to CH4, the ORG 3 treatment was the one that presented greater emissions, the CO2 emissions to the atmosphere in the other treatments were lower and did not present meaningful differences among them. The physiological variables in all the cases helped coffee crops grow, this was observed when compared with the blank treatment; however, plants that reached the greatest height, width of top and diameter of stem were the plants of the MIN 3 treatment, followed by MIN 3, which did not show much significance among them, and for the organic treatments, the one that presented great results in these variables was ORG 3, which did not show meaningful differences compared with MIN 2, which proves that mineral fertilization is more effective in this case compared with the organic. In the first year of production, the mineral treatment with MIN 3 fertilization obtained greater production and thus did not show statistical difference with MIN 2 treatment, although the other treatments were greater. It is worth mentioning that MIN 1 treatment and ORG 3 treatment presented a meaningful production of coffee, not showing statistical differences among them. For the second year, the production of the crops showed greater profits than in the first year of evaluation in all the treatments, this was due to the physiological properties of the crops and on the other hand, it might be due to the addition of fertilizers during the whole essay; in a similar way, MIN 3 and MIN 2 performed better, not showing greater statistical differences among them, although the mineral treatment MEDIUM doses did not show statistical difference compared with ORG 3. The economic benefit was greater in the MIN 3 and MIN 2 treatments, although MIN 2 treatment is the one that shows the best cost-benefit ratios; ORG 2 and ORG 3 treatments and the blank produced negative benefits for the producer. Regarding the environment, the best treatments to care for the atmosphere are considered to be MIN 1 and ORG 1 treatments; however, regarding production volume and profitability they were low for the producer.

Base de dados de informação nutricional, relacionados com doenças crônicas não transmissíveis, de alimentos comercializados no Brasil

A recente evolução das doenças crônicas não transmissíveis (DCNT), possivelmente associadas às mudanças de hábitos alimentares, tem sido um desafio para a promoção da alimentação saudável em vários países, inclusive no Brasil, onde o sódio tem sido o foco de atenção, pela possibilidade da redução da sua elevada ingestão ser uma das medidas com melhor custo benefício para saúde pública. É necessário conhecer o conteúdo de sódio e de componentes específicos, relacionados às DCNT nos alimentos comercializados no país, para orientar o consumidor na seleção adequada dos alimentos e mesmo para modificar sua composição; no entanto, nas bases de dados, o conteúdo desse mineral está presente em um número reduzido de alimentos. O objetivo da presente pesquisa foi a elaboração de uma base de dados de alimentos processados com componentes específicos associados às DCNT, dando ênfase ao sódio, e avaliar o uso dessa base de dados para estimar a sua ingestão. Informações nutricionais de rótulos e de websites de indústrias de alimentos foram coletadas para inclusão na base de dados, elaborada de acordo com as diretrizes do International collaborative project to compare and monitor the nutritional composition of processed foods, coordenado pelo The George Institute for Global Health (Austrália). A avaliação da variação do conteúdo de sódio foi realizada para alguns alimentos processados presentes na base de dados, considerando os de maior consumo nacional. O conteúdo de sódio em refeições de restaurantes populares de São Paulo foi analisado por espectrofotometria de absorção atômica de chama e estimado pela base de dados elaborada para comparação. Na base de dados estão incluídas informações de 2.319 alimentos distribuídos em 14 grupos. Foi observada grande variação no conteúdo de sódio entre diferentes tipos de pães de forma industrializados, de salsichas, de linguiças, de queijos e iogurtes. O conteúdo de sódio analisado nas refeições (base integral) variou de 215,9 mg a 427,9 mg por 100 kcal, enquanto que o conteúdo de sódio estimado variou de 204,2 mg a 486,8 mg por 100 kcal (418 kJ). A análise do coeficiente de correlação entre valores analíticos e estimados do conteúdo de sódio em refeições mostrou forte correlação entre esses dados para dois restaurantes (r=0,703 e 0,897) e moderada correlação para outros dois (r=0,513 e 0,622) dos cinco restaurantes estudados, indicando que através da base de dados elaborada é possível obter uma estimativa da ingestão de sódio. A importância de se conhecer o conteúdo de sódio de refeições e/ou alimentos está na possibilidade de uso dessas informações para orientar a redução do sal empregado no preparo da refeição, e ampliar para o consumidor informações que permitam identificar alternativas para redução do consumo de sal.

Reaching for a Calculator or a Mirror? Why the EU Joins International Human Rights Treaties. EU Diplomacy Paper 01/2013

Why does the European Union (EU) join international human rights treaties? This paper develops motivational profiles pertaining either to a ‘logic of appropriateness’ or a ‘logic of consequentialism’ in order to answer this question. It compares the EU’s motivations for its recent accession to the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) with those dominating the EU’s nonaccession to the Council of Europe Convention on preventing and combating violence against women and domestic violence (Istanbul Convention). Based on this cross-case analysis, I argue that the EU’s accession decisions are best viewed as cost-benefit calculations and explained by the strength of opposition and the desire to spread its norms. The EU is only marginally concerned with efforts to construct an ‘appropriate role’, although its accession considerations are positively influenced by (varying degrees) of an internalized commitment to human rights. The paper aims at deepening the understanding of the EU’s motivations in the paradigmatic hard case of accession to international human rights treaties not least to evaluate the EU’s ‘exceptional nature’, facilitate its predictability for stake-holders and contribute to political and ethical debates surrounding future rites of passage as a global actor.

The place of DPP-4 inhibitors in the treatment algorithm of diabetes type 2 : a systematic review of cost-effectiveness studies

Tese de mestrado, Epidemiologia, Universidade de Lisboa, Faculdade de Medicina, 2015

Testing for Subsidiarity. Bruges European Economic Policy (BEEP) Briefing 13/2006

In the EU circuit (especially the European Parliament, the Council and Coreper) as well as in national parliaments of the EU Member States, one observes a powerful tendency to regard 'subsidiarity' as a 'political' issue. Moreover, subsidiarity is frequently seen as a one-way street : powers going 'back to' Member States. Both interpretations are at least partly flawed and less than helpful when looking for practical ways to deal with subsidiarity at both EU and Member states' levels. The present paper shows that subsidiarity as a principle is profoundly 'functional' in nature and, hence, is and must be a two-way principle. A functional subsidiarity test is developed and its application is illustrated for a range of policy issues in the internal market in its widest sense, for equity and for macro-economic stabilisation questions in European integration. Misapplications of 'subsidiarity' are also demonstrated. For a good understanding, subsidiarity being a functional, two-way principle neither means that elected politicians should not have the final (political!) say (for which they are accountable), nor that subsidiarity tests, even if properly conducted, cannot and will not be politicised once the results enter the policy debate. Such politicisation forms a natural run-up to the decision-making by those elected for it. But the quality and reasoning of the test as well as structuring the information in a logical sequence ( in accordance with the current protocol and with the one in the constitutional treaty) is likely to be directly helpful for decisionmakers, confronted with complicated and often specialised proposals. EU debates and decision-making is therefore best served by separating the functional subsidiarity test (prepared by independent professionals) from the final political decision itself. If the test were accepted Union-wide, it would also assist national parliaments in conducting comparable tests in a relatively short period, as the basis for possible joint action (as suggested by the constitutional treaty). The core of the paper explains how the test is formulated and applied. A functional approach to subsidiarity in the framework of European representative democracy seeks to find the optimal assignment of regulatory or policy competences to the various tiers of government. In the final analysis, this is about structures facilitating the highest possible welfare in the Union, in the fundamental sense that preferences and needs are best satisfied. What is required for such an analysis is no less than a systematic cost/benefit framework to assess the (de)merits of (de)centralisation in the EU.

Precautionary principles: a jurisdiction-free framework for decision-making under risk

Fundamental principles of precaution are legal maxims that ask for preventive actions, perhaps as contingent interim measures while relevant information about causality and harm remains unavailable, to minimize the societal impact of potentially severe or irreversible outcomes. Such principles do not explain how to make choices or how to identify what is protective when incomplete and inconsistent scientific evidence of causation characterizes the potential hazards. Rather, they entrust lower jurisdictions, such as agencies or authorities, to make current decisions while recognizing that future information can contradict the scientific basis that supported the initial decision. After reviewing and synthesizing national and international legal aspects of precautionary principles, this paper addresses the key question: How can society manage potentially severe, irreversible or serious environmental outcomes when variability, uncertainty, and limited causal knowledge characterize their decision-making? A decision-analytic solution is outlined that focuses on risky decisions and accounts for prior states of information and scientific beliefs that can be updated as subsequent information becomes available. As a practical and established approach to causal reasoning and decision-making under risk, inherent to precautionary decision-making, these (Bayesian) methods help decision-makers and stakeholders because they formally account for probabilistic outcomes, new information, and are consistent and replicable. Rational choice of an action from among various alternatives-defined as a choice that makes preferred consequences more likely-requires accounting for costs, benefits and the change in risks associated with each candidate action. Decisions under any form of the precautionary principle reviewed must account for the contingent nature of scientific information, creating a link to the decision-analytic principle of expected value of information (VOI), to show the relevance of new information, relative to the initial ( and smaller) set of data on which the decision was based. We exemplify this seemingly simple situation using risk management of BSE. As an integral aspect of causal analysis under risk, the methods developed in this paper permit the addition of non-linear, hormetic dose-response models to the current set of regulatory defaults such as the linear, non-threshold models. This increase in the number of defaults is an important improvement because most of the variants of the precautionary principle require cost-benefit balancing. Specifically, increasing the set of causal defaults accounts for beneficial effects at very low doses. We also show and conclude that quantitative risk assessment dominates qualitative risk assessment, supporting the extension of the set of default causal models.

Cost-effectiveness of screening with contrast enhanced magnetic resonance imaging vs X-ray mammography of women at a high familial risk of breast cancer

Contrast enhanced magnetic resonance imaging (CE MRI) is the most sensitive tool for screening women who are at high familial risk of breast cancer. Our aim in this study was to assess the cost-effectiveness of X-ray mammography (XRM), CE MRI or both strategies combined. In total, 649 women were enrolled in the MARIBS study and screened with both CE MRI and mammography resulting in 1881 screens and 1-7 individual annual screening events. Women aged 35-49 years at high risk of breast cancer, either because they have a strong family history of breast cancer or are tested carriers of a BRCA1, BRCA2 or TP53 mutation or are at a 50% risk of having inherited such a mutation, were recruited from 22 centres and offered annual MRI and XRM for between 2 and 7 years. Information on the number and type of further investigations was collected and specifically calculated unit costs were used to calculate the incremental cost per cancer detected. The numbers of cancer detected was 13 for mammography, 27 for CE MRI and 33 for mammography and CE MRI combined. In the subgroup of BRCA1 (BRCA2) mutation carriers or of women having a first degree relative with a mutation in BRCA1 (BRCA2) corresponding numbers were 3 (6), 12 (7) and 12 (11), respectively. For all women, the incremental cost per cancer detected with CE MRI and mammography combined was 28 pound 284 compared to mammography. When only BRCA1 or the BRCA2 groups were considered, this cost would be reduced to 11 pound 731 (CE MRI vs mammography) and 15 pound 302 (CE MRI and mammography vs mammography). Results were most sensitive to the unit cost estimate for a CE MRI screening test. Contrast-enhanced MRI might be a cost-effective screening modality for women at high risk, particularly for the BRCA1 and BRCA2 subgroups. Further work is needed to assess the impact of screening on mortality and health-related quality of life.

Comparative cost-effectiveness of policy instruments for reducing the global burden of alcohol, tobacco and illicit drug use

Alcohol, tobacco and illicit drug use together pose a formidable challenge to international public health. Building on earlier estimates of the demonstrated burden of alcohol, tobacco and illicit drug use at the global level, this review aims to consider the comparative cost-effectiveness of evidence-based interventions for reducing the global burden of disease from these three risk factors. Although the number of published cost-effectiveness studies in the addictions field is now extensive ( reviewed briefly here) there are a series of practical problems in using them for sector-wide decision making, including methodological heterogeneity, differences in analytical reference point and the specificity of findings to a particular context. In response to these limitations, a more generalised form of cost-effectiveness analysis (CEA) is proposed, which enables like-with-like comparisons of the relative efficiency of preventive or individual-based strategies to be made, not only within but also across diseases or their risk factors. The application of generalised CEA to a range of personal and non-personal interventions for reducing the burden of addictive substances is described. While such a development avoids many of the obstacles that have plagued earlier attempts and in so doing opens up new opportunities to address important policy questions, there remain a number of caveats to population-level analysis of this kind, particularly when conducted at the global level. These issues are the subject of the final section of this review.