Ecological Condition of Coastal Ocean Waters within Stellwagen Bank National Marine Sanctuary: 2008

In June 2008, the NOAA National Ocean Service (NOS), in conjunction with the EPA National Health and Environmental Effects Laboratory (NHEERL), conducted an assessment of the status of ecological condition of soft-bottom habitat and overlying waters within the boundaries of Stellwagen Bank National Marine Sanctuary (SBNMS). The sanctuary lies approximately 20 nautical miles east of Boston, MA in the southwest Gulf of Maine between Cape Ann and Cape Cod and encompassing 638 square nautical miles (2,181 km2). A total of 30 stations were targeted for sampling using standard methods and indicators applied in prior NOAA coastal studies and EPA’s Environmental Monitoring and Assessment Program (EMAP) and National Coastal Assessment (NCA). A key feature adopted from these studies was the incorporation of a random probabilistic sampling design. Such a design provides a basis for making unbiased statistical estimates of the spatial extent of ecological condition relative to various measured indicators and corresponding thresholds of concern. Indicators included multiple measures of water quality, sediment quality, and biological condition (benthic fauna, fish tissue contaminant levels). Depths ranged from 31 – 137 m throughout the study area. About 76 % of the area had sediments composed of sands (< 20 % silt-clay), 17 % of the area was composed of intermediate muddy sands (20 – 80 % silt-clay), and 7 % of the sampled area consisted of mud (> 80 % siltclay). About 70 % of the area (represented by 21 sites) had sediment total organic carbon (TOC) concentrations < 5 mg/g and all but one site (located in Stellwagen Basin) had levels of TOC < 20 mg/g, which is well below the range potentially harmful to benthic fauna (> 50 mg/g). Surface salinities ranged from 30.6 – 31.5 psu, with the majority of the study region (approximately 80 % of the area) having surface salinities between 30.8 and 31.4 psu. Bottom salinities varied between 32.1 and 32.5 psu, with bottom salinities at all sites having values above the range of surface salinities. Surface-water temperatures varied between 12.1 and 16.8 ºC, while near-bottom waters ranged in temperature from 4.4 – 6.2 ºC. An index of density stratification (Δσt) indicated that the waters of SBNMS were stratified at the time of sampling. Values of Δσt at 29 of the 30 sites sampled in this study (96.7 % of the study area) varied from 2.1 – 3.2, which is within the range considered to be indicative of strong vertical stratification (Δσt > 2) and typical of the western Gulf of Maine in summer. Levels of dissolved oxygen (DO) were confined to a fairly narrow range in surface (8.8 – 10.4 mg/L) and bottom (8.5 – 9.6 mg/L) waters throughout the survey area. These levels are within the range considered indicative of good water quality (> 5 mg/L) with respect to DO. None of these waters had DO at low levels (< 2 mg/L) potentially harmful to benthic fauna and fish.

Microbial community analysis of Acropora palamata mucus swabs, water and sediment samples from Hawksnest Bay, St. John, U.S. Virgin Islands

Colonies of the scleractinian coral Acropora palmata, listed as threatened under the US Endangered Species Act in 2006, have been monitored in Hawksnest Bay, within Virgin Islands National Park, St. John, from 2004 through 2010 by scientists with the US Geological Survey, National Park Service, and the University of the Virgin Islands. The focus has been on documenting the prevalence of disease, including white band, white pox (also called patchy necrosis and white patches), and unidentified diseases (Rogers et al., 2008; Muller et al., 2008). In an effort to learn more about the pathologies that might be involved with the diseases that were observed, samples were collected from apparently healthy and diseased colonies in July 2009 for analysis. Two different microbial assays were performed on Epicentre Biotechnologies DNA swabs containing A. palmata coral mucus, and on water and sediment samples collected in Hawksnest Bay. Both assays are based on polymerase chain reaction (PCR) amplification of portions of the small rRNA gene (16S). The objectives were to determine 1) if known coral bacterial pathogens Serratia marcescens (Acroporid Serratiosis), Vibrio coralliilyticus (temperature-dependent bleaching, White Syndrome), Vibrio shiloi (bleaching, necrosis), and Aurantimonas coralicida (White Plague Type II) were present in any samples, and 2) if there were any differences in microbial community profiles of each healthy, unaffected or diseased coral mucus swab. In addition to coral mucus, water and sediment samples were included to show ambient microbial populations. In the first test, PCR was used to separately amplify the unique and diagnostic region of the 16S rRNA gene for each of the coral pathogens being screened. Each pathogen test was designed so that an amplified DNA fragment could be seen only if the specific pathogen was present in a sample. A positive result was indicated by bands of DNA of the appropriate size on an agarose gel, which separates DNA fragments based on the size of the molecule. DNA from pure cultures of each of the pathogens was used as a positive control for each assay.

Palmyra Atoll coral reef habitat mapping completion report

The United States Coral Reef Task Force (USCRTF) was established in 1998 by Presidential Executive Order 13089 to lead U.S. efforts to preserve and protect coral reef ecosystems. Current, accurate, and consistent maps greatly enhance efforts to preserve and manage coral reef ecosystems. With comprehensive maps and habitat assessments, coral reef managers can be more effective in designing and implementing a variety of conservation measures, including: • Long-term monitoring programs with accurate baselines from which to track changes; • Place-based conservation measures such as marine protected areas (MPAs); and • Targeted research to better understand the oceanographic and ecological processes affecting coral reef ecosystem health. The National Oceanic and Atmospheric Administration’s (NOAA) National Ocean Service (NOS) is tasked with leading the coral ecosystem mapping element of the U.S. Coral Reef Task Force (CRTF) under the authority of the Presidential Executive Order 13089 to map and manage the coral reefs of the United States.

Shallow-water benthic habitats of St. John, U.S. Virgin Islands

Coral reef ecosystems of the Virgin Islands Coral Reef National Monument, Virgin Islands National Park and the surrounding waters of St. John, U.S. Virgin Islands are a precious natural resource worthy of special protection and conservation. The mosaic of habitats including coral reefs, seagrasses and mangroves, are home to a diversity of marine organisms. These benthic habitats and their associated inhabitants provide many important ecosystem services to the community of St. John, such as fishing, tourism and shoreline protection. However, coral reef ecosystems throughout the U.S. Caribbean are under increasing pressure from environmental and anthropogenic stressors that threaten to destroy the natural heritage of these marine habitats. Mapping of benthic habitats is an integral component of any effective ecosystem-based management approach. Through the implementation of a multi-year interagency agreement, NOAA’s Center for Coastal Monitoring and Assessment - Biogeography Branch and the U.S. National Park Service (NPS) have completed benthic habitat mapping, field validation and accuracy assessment of maps for the nearshore marine environment of St. John. This work is an expansion of ongoing mapping and monitoring efforts conducted by NOAA and NPS in the U.S. Caribbean and replaces previous NOAA maps generated by Kendall et al. (2001) for the waters around St. John. The use of standardized protocols enables the condition of the coral reef ecosystems around St. John to be evaluated in context to the rest of the Virgin Island Territories and other U.S. coral ecosystems. The products from this effort provide an accurate assessment of the abundance and distribution of marine habitats surrounding St. John to support more effective management and conservation of ocean resources within the National Park system. This report documents the entire process of benthic habitat mapping in St. John. Chapter 1 provides a description of the benthic habitat classification scheme used to categorize the different habitats existing in the nearshore environment. Chapter 2 describes the steps required to create a benthic habitat map from visual interpretation of remotely sensed imagery. Chapter 3 details the process of accuracy assessment and reports on the thematic accuracy of the final maps. Finally, Chapter 4 is a summary of the basic map content and compares the new maps to a previous NOAA effort. Benthic habitat maps of the nearshore marine environment of St. John, U.S. Virgin Islands were created by visual interpretation of remotely sensed imagery. Overhead imagery, including color orthophotography and IKONOS satellite imagery, proved to be an excellent source from which to visually interpret the location, extent and attributes of marine habitats. NOAA scientists were able to accurately and reliably delineate the boundaries of features on digital imagery using a Geographic Information System (GIS) and fi eld investigations. The St. John habitat classification scheme defined benthic communities on the basis of four primary coral reef ecosystem attributes: 1) broad geographic zone, 2) geomorphological structure type, 3) dominant biological cover, and 4) degree of live coral cover. Every feature in the benthic habitat map was assigned a designation at each level of the scheme. The ability to apply any component of this scheme was dependent on being able to identify and delineate a given feature in remotely sensed imagery.

Moderate-depth benthic habitats of St. John, U.S. Virgin Islands

The National Oceanic and Atmospheric Administration’s (NOAA) Center for Coastal Monitoring and Assessment’s (CCMA) Biogeography Branch and the U.S. National Park Service (NPS) have completed mapping the moderate-depth marine environment south of St. John. This work is an expansion of ongoing mapping and monitoring efforts conducted by NOAA and NPS in the U.S. Caribbean. The standardized protocols used in this effort will enable scientists and managers to quantitatively compare moderate-depth coral reef ecosystems around St. John to those throughout the U.S. Territories. These protocols and products will also help support the effective management and conservation of the marine resources within the National Park system.

Atlas of the shallow-water benthic habitats of American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands

The National Oceanic and Atmospheric Administration (NOAA) National Ocean Service (NOS) initiated a coral reef research program in 1999 to map, assess, inventory, and monitor U.S. coral reef ecosystems (Monaco et al. 2001). These activities were implemented in response to requirements outlined in the Mapping Implementation Plan developed by the Mapping and Information Synthesis Working Group (MISWG) of the Coral Reef Task Force (CRTF) (MISWG 1999). As part of the MISWG of the CRTF, NOS' Biogeography Branch has been charged with the development and implementation of a plan to produce comprehensive digital coral-reef ecosystem maps for all U.S. States, Territories, and Commonwealths within five to seven years. Joint activities between Federal agencies are particularly important to map, research, monitor, manage, and restore coral reef ecosystems. In response to the Executive Order 13089 and the Coral Reef Conservation Act of 2000, NOS is conducting research to digitally map biotic resources and coordinate a long-term monitoring program that can detect and predict change in U.S. coral reefs, and their associated habitats and biological communities. Most U.S. coral reef resources have not been digitally mapped at a scale or resolution sufficient for assessment, monitoring, and/or research to support resource management. Thus, a large portion of NOS' coral reef research activities has focused on mapping of U.S. coral reef ecosystems. The map products will provide the fundamental spatial organizing framework to implement and integrate research programs and provide the capability to effectively communicate information and results to coral reef ecosystem managers. Although the NOS coral program is relatively young, it has had tremendous success in advancing towards the goal to protect, conserve, and enhance the health of U.S. coral reef ecosystems. One objective of the program was to create benthic habitat maps to support coral reef research to enable development of products that support management needs and questions. Therefore this product was developed in collaboration with many U.S. Pacific Territory partners. An initial step in producing benthic habitat maps was the development of a habitat classification scheme. The purpose of this document is to outline the benthic habitat classification scheme and protocols used to map American Samoa, Guam and the Commonwealth of the Northern Mariana Islands. Thirty-two distinct benthic habitat types (i.e., four major and 14 detailed geomorphological structure classes; eight major and 18 detailed biological cover types) within eleven zones were mapped directly into a geographic information system (GIS) using visual interpretation of orthorectified IKONOS satellite imagery. Benthic features were mapped that covered an area of 263 square kilometers. In all, 281 square kilometers of unconsolidated sediment, 122 square kilometers of submerged vegetation, and 82.3 square kilometers of coral reef and colonized hardbottom were mapped.

Synopsis of researcher meeting -- Bottlenose Dolphin Health & Risk Assessment Project, February 22-24, 2005

A meeting was convened on February 22-24, 2005 in Charleston, South Carolina to bring together researchers collaborating on the Bottlenose Dolphin Health and Risk Assessment (HERA) Project to review and discuss preliminary health-related findings from captured dolphins during 2003 and 2004 in the Indian River Lagoon (IRL), FL and Charleston (CHS), SC. Over 30 researchers with diverse research expertise representing government, academic and marine institutions participated in the 2-1/2 day meeting. The Bottlenose Dolphin HERA Project is a comprehensive, integrated, multi-disciplinary research program designed to assess environmental and anthropogenic stressors, as well as the health and long-term viability of Atlantic bottlenose dolphins (Tursiops truncatus). Standardized and comprehensive protocols are being used to evaluate dolphin health in the coastal ecosystems in the IRL and CHS. The Bottlenose Dolphin Health and Risk Assessment (HERA) Project was initiated in 2003 by Dr. Patricia Fair at the National Oceanic and Atmospheric Administration/National Ocean Service/Center for Coastal Environmental Health and Biomolecular Research and Dr. Gregory Bossart at the Harbor Branch Oceanographic Institution under NMFS Scientific Research Permit No. 998-1678-00 issued to Dr. Bossart. Towards this end, this study focuses on developing tools and techniques to better identify health threats to these dolphins, and to develop links to possible environmental stressors. Thus, the primary objective of the Dolphin HERA Project is to measure the overall health and as well as the potential health hazards for dolphin populations in the two sites by performing screening-level risk assessments using standardized methods. The screening-level assessment involves capture, sampling and release activities during which physical examinations are performed on dolphins and a suite of nonlethal morphologic and clinicopathologic parameters, to be used to develop indices of dolphin health, are collected. Thus far, standardized health assessments have been performed on 155 dolphins during capture-release studies conducted in Years 2003 and 2004 at the two sites. A major collaboration has been established involving numerous individuals and institutions, which provide the project with a broad assessment capability toward accomplishing the goals and objectives of this project.

Issues of HIV/AIDS/ health among the fisher communities of Lake Albert and Kyoga

The fisheries resources of Lakes Albert and Kyoga present a high potential for economic growth, food, employment and foreign earnings. However, livelihoods appear to be compromised with the emergence and rapid spread of HIV/AIDS in the fisher communities of L. Albert and Kyoga. HIV/AIDS is considered a silent epidemic that is unique, posing a great challenge to the fisheries managers, health service providers, development planners and the resource users themselves. Fishers have high HIV prevalence, as well as AIDS-related illnesses and mortality rates. The high HIV prevalence rates among the fishing communities in Uganda is between 10-40% compared to the national rates which lie between 6% and 7%. This indicates that the national programmes have not adequately addressed the plight of the fishing communities of Lakes Albert, and Kyoga and the consequences have been devastating. Men and women living in fishing villages across the world have been found to be between five and ten times more vulnerable to the disease than other communities (Tarzan et al 2005, FAO, 2007). The present prevalence rates among the fishing communities stands at 10 to 40 % (LVFO, 2008). Meanwhile the same fishing communities are the essential labour for the Lakes’ fishery industry which is thriving nationally and internationally. That resource potentially can alleviate poverty and the HIV/AIDS threat. Fishing communities are the hidden victims of the disease, mixing patterns with the general population could act as a reservoir of infection that could spill over into the general population to drive the epidemic. On L. Albert, a quarter of the fisher folk were HIV-positive by 1992 compared to 4% in a nearby Agricultural village. Since then, there have been no targeted studies to address or monitor the prevalence rates eight years later, yet the multiplicity factor is high. HIV/AIDS can be linked to unsustainable fisheries, as the labour force available would not go to deep waters to fish, instead would fish in the shallow waters as a coping mechanism. A further effect is the loss to National and local economies and reduced nutritional security for the wider population. HIV/AIDS remains a significant challenge that has created a mosaic of complexity in the fishery sector. This needs to be addressed. It is, therefore, paramount that a comprehensive study was under taken to address this pandemic and the phenomenon of HIV/AIDS based on the study objectives. 1. To determine the trend in HIV/AIDS infection among fishing communities and the factors affecting it 2. To assess the impacts of HIV/AIDS on fish production and the implications for fisheries management.

Articulating current service development practices: a qualitative analysis of eleven mental health projects.

BACKGROUND: The utilisation of good design practices in the development of complex health services is essential to improving quality. Healthcare organisations, however, are often seriously out of step with modern design thinking and practice. As a starting point to encourage the uptake of good design practices, it is important to understand the context of their intended use. This study aims to do that by articulating current health service development practices. METHODS: Eleven service development projects carried out in a large mental health service were investigated through in-depth interviews with six operation managers. The critical decision method in conjunction with diagrammatic elicitation was used to capture descriptions of these projects. Stage-gate design models were then formed to visually articulate, classify and characterise different service development practices. RESULTS: Projects were grouped into three categories according to design process patterns: new service introduction and service integration; service improvement; service closure. Three common design stages: problem exploration, idea generation and solution evaluation - were then compared across the design process patterns. Consistent across projects were a top-down, policy-driven approach to exploration, underexploited idea generation and implementation-based evaluation. CONCLUSIONS: This study provides insight into where and how good design practices can contribute to the improvement of current service development practices. Specifically, the following suggestions for future service development practices are made: genuine user needs analysis for exploration; divergent thinking and innovative culture for idea generation; and fail-safe evaluation prior to implementation. Better training for managers through partnership working with design experts and researchers could be beneficial.

The effects of copayment policies on adherence to prescription medicines in publicly insured populations

Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.

An Unkind Cut: Circumcision, Death and the Impact of Irish Health Policy on Asylum Seekers

Healthcare and the wider social determinants of health are the keystone of a number of complex progressive social justice issues that evoke complex emotions. As the demography of Ireland rapidly changes, the practices and expectations of some asylum seekers presents new opportunities for the providers of health service provision and reform. This paper looks at some of the emotions evoked in health care issues and draws on observations and interviews from empirical fieldwork carried out for the Health Research Board. The research was conducted both in the Adelaide and Meath Hospital, incorporating the National Children’s Hospital, Tallaght and in a number of refugee reception centres in Ireland. At one level honouring faith choices within a healthcare setting is a societal acknowledgement made to people at their most vulnerable, that the potent and cathartic transformative rituals they value are significant in mediating and managing their emotions - at another level, it is a practical and a symbolic communication of a statutory commitment to inter-culturalism and community cohesion..

Estimating the incidence, prevalence and true cost of asthma in the UK: Secondary analysis of national stand-alone and linked databases in England, Northern Ireland, Scotland and Wales-a study protocol

Introduction Asthma is now one of the most common long-term conditions in the UK. It is therefore important to develop a comprehensive appreciation of the healthcare and societal costs in order to inform decisions on care provision and planning. We plan to build on our earlier estimates of national prevalence and costs from asthma by filling the data gaps previously identified in relation to healthcare and broadening the field of enquiry to include societal costs. This work will provide the first UK-wide estimates of the costs of asthma. In the context of asthma for the UK and its member countries (ie, England, Northern Ireland, Scotland and Wales), we seek to: (1) produce a detailed overview of estimates of incidence, prevalence and healthcare utilisation; (2) estimate health and societal costs; (3) identify any remaining information gaps and explore the feasibility of filling these and (4) provide insights into future research that has the potential to inform changes in policy leading to the provision of more cost-effective care.

Methods and analysis Secondary analyses of data from national health surveys, primary care, prescribing, emergency care, hospital, mortality and administrative data sources will be undertaken to estimate prevalence, healthcare utilisation and outcomes from asthma. Data linkages and economic modelling will be undertaken in an attempt to populate data gaps and estimate costs. Separate prevalence and cost estimates will be calculated for each of the UK-member countries and these will then be aggregated to generate UK-wide estimates.

Ethics and dissemination Approvals have been obtained from the NHS Scotland Information Services Division's Privacy Advisory Committee, the Secure Anonymised Information Linkage Collaboration Review System, the NHS South-East Scotland Research Ethics Service and The University of Edinburgh's Centre for Population Health Sciences Research Ethics Committee. We will produce a report for Asthma-UK, submit papers to peer-reviewed journals and construct an interactive map.

Cancer survivors with self-reported late effects: their health status, care needs and service utilisation

OBJECTIVE: Cancer survivors (CSs) are at risk of developing late effects (LEs) associated with the disease and its treatment. This paper compares the health status, care needs and use of health services by CSs with LEs and CSs without LEs.

METHODS: Cancer survivors (n = 613) were identified via the Northern Ireland Cancer Registry and invited to participate in a postal survey that was administered by their general practitioner. The survey assessed self-reported LEs, health status, health service use and unmet care needs. A total of 289 (47%) CSs responded to the survey, and 93% of respondents completed a LEs scale.

RESULTS: Forty-one per cent (111/269) of CSs reported LEs. Survivors without LEs and survivors with LEs were comparable in terms of age and gender. The LEs group reported a significantly greater number of co-morbidities, lower physical health and mental health scores, greater overall health service use and more unmet needs. Unadjusted logistic regression analysis found that cancer site, time since diagnosis and treatment were significantly associated with reporting of LEs. CSs who received combination therapies compared with CSs who received single treatments were over two and a half times more likely to report LEs (OR = 2.63, 95% CI = 1.32-5.25) after controlling for all other variables.

CONCLUSIONS: The CS population with LEs comprises a particularly vulnerable group of survivors who have multiple health care problems and needs and who require tailored care plans that take account of LEs and their impact on health-related quality of life.

Impact of the elderly on household health expenditure in Bihar and Kerala, India

Dans le contexte d’une population vieillissante, nous avons étudié l’impact de la présence de personnes âgées sur les dépenses catastrophiques de santé (DCS), ainsi que leur impact sur trois effets reliés (le fait d’éviter des traitements, la perte de revenu, et l’utilisation de sources de financement alternatives). Nous avons utilisé les données d’une enquête du National Sample Survey Organization (Inde) en 2004, portant sur les dépenses reliées à la santé. Nous avons choisi un état développé (Kerala) et un état en voie de développement (Bihar) pour faire une comparaison des effets de la présence de personnes âgées sur les ménages. Nous avons trouvé qu’il y avait plus de DCS au Kerala et que ceci était probablement lié à la présence accrue de personnes âgées au Kerala ce qui mène à plus de maladies chroniques. Nous avons supposé que l’utilisation de services de santé privés serait lié à une augmentation de DCS, mais l’effet a varié en fonction de l’état, du présence d’une personne âgée, et du type de service utilisé (ambulatoire ou hospitalisation). Nous avons aussi trouvé que les femmes âgées au Bihar utilisait les services de santé moins qu’elle ne devrait, que les ménages ayant plus de 4 personnes ont possiblement un effet protecteur pour les personnes âgées, et que certains castes et group religieux ont dû emprunter plus souvent que d’autres groupes pour payer les frais de santé. La présence de personnes âgées, les maladies chroniques, et l’utilisation de services de santé privées sont tous liés aux DCS, mais, d’après nos résultats, d’autres groupes retardent les conséquences économiques en empruntant ou évitant les traitements. Nous espérons que ces résultats seront utilisés pour approfondir les connaissances sur l’effet de personnes âgées sur les dépenses de santé ou qu’ils seront utilisés dans des discussions de politiques de santé.

Apendicitis aguda perforada en adultos; aproximación a las inequidades sociales en salud, Bogotá 2012

La perforación del apéndice es una complicación temprana de la apendicitis aguda, demoras en el diagnóstico o tratamiento incrementan la tasa de perforación. Se desconoce si la perforación dl apéndice es un reflejo de inequidades sociales. Se pretendió determinar la asociación de la apendicitis aguda perforada en adultos y la equidad en acceso a salud. Estudio tipo cohorte retrospectivo documental, de historias clínicas de pacientes con apendicitis aguda; el análisis se realizó con Stata 11.1 y Epi-info. Los resultados se presentaron en tablas y figuras. Se incluyeron 540 casos (292 hombre y 248 mujeres), el grupo de edad que aporto más datos fue el de 18 a 49 años (391 pacientes); el tiempo medio de síntomas a consulta fue de 37,45 horas, y de 5,3 horas para el paso a cirugía desde el ingreso, fueron solicitadas 76 ecografías y 53 tomografías, 50 interconsultas a urología y 10 a ginecología hasta el diagnostico. El grupo de mayores de 49 años, el estrato socioeconómico tres y la tomografía fueron factores de riesgo independientes para perforación del apéndice. El análisis multivariado mostró asociación lineal entre el estrato socioeconómico y tiempo de síntomas al ingreso, tiempo para paso a cirugía, solicitud de ayudas diagnósticas e interconsultas, con buena significación estadística. La apendicitis aguda perforada en adultos, podría ser un indicador de inequidad en salud. Se requiere de estudios multi-céntricos, con mayor tiempo de evaluación y muestra para demostrar si el apéndice perforado es un trazador de inequidades en salud en Colombia.