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.

Surveillance for adverse events after DTwP/Hib vaccination in Brazil: sensitivity and factors associated with reporting

We estimated the sensitivity, i.e., the proportion of all cases of adverse events following immunization (AEFIs) reported to the Brazilian passive surveillance for adverse events following immunization (PSAEFI) with the diphtheria-tetanus-whole-cell pertussis-Haemophilus influenzae type b (DTwP-Hib) vaccine, as well as investigating factors associated with AEFIs reporting. During 2003–2004, 8303 AEFIs associated with DTwP-Hib were reported; hypotonic-hyporesponsive episodes (HHEs), fever and convulsions being the most common. Cure without sequel was achieved in 98.4 per cent of the cases. The mean sensitivity of the PSAEFI was 22.3 per cent and 31.6 per cent, respectively, for HHE and convulsions, varying widely among states. Reporting rates correlated positively with the Human Development Index and coverage of adequate prenatal care, correlating negatively with infant mortality rates. Quality of life indicators and the degree of organization of health services are associated with greater PSAEFI sensitivity. In addition to consistently describing the principal AEFIs, PSAEFI showed the DTwP/Hib vaccine to be safe and allayed public fears related to its use

Primary coronary angioplasty in 9,434 patients during acute myocardial infarction: predictors of major in- hospital adverse events from 1996 to 2000 in Brazil

OBJECTIVE: To verify the results after the performance of primary coronary angioplasty in Brazil in the last 4 years. METHODS: During the first 24 hours of acute myocardial infarction onset, 9,434 (12.2%) patients underwent primary PTCA. We analyzed the success and occurrence of major in-hospital events, comparing them over the 4-year period. RESULTS: Primary PTCA use increased compared with that of all percutaneous interventions (1996=10.6% vs. 2000=13.1%; p<0.001). Coronary stent implantation increased (1996=20% vs. 2000=71.9%; p<0.001). Success was greater (1998=89.5% vs. 1999=92.5%; p<0.001). Reinfarction decreased (1998=3.9% vs. 99=2.4% vs. 2000=1.5%; p<0.001) as did emergency bypass surgery (1996=0.5% vs. 2000=0.2%; p=0.01). In-hospital deaths remained unchanged (1996=5.7% vs. 2000=5.1%, p=0.53). Balloon PTCA was one of the independent predictors of a higher rate of unsuccessful procedures (odds ratio 12.01 [CI=95%] 1.58-22.94), and stent implantation of lower mortality rates (odds ratio 4.62 [CI=95%] 3.19-6.08). CONCLUSION: The success rate has become progressively higher with a significant reduction in reinfarction and urgent bypass surgery, but in-hospital death remains nearly unchanged. Coronary stenting was a predictor of a lower death rate, and balloon PTCA was associated with greater procedural failure.

Rare adverse events associated with oral poliovirus vaccine in Brazil

Oral poliovirus vaccine (OPV) developed by A. Sabin has been effectively used to control poliomyelitis in Brazil, and the last case with the isolation of a wild poliovirus strain occurred in March 1989. Although the vaccine controlled the circulation of wild strains and poliomyelitis cases associated with these strains were not detected during the last eight years, rare cases classified as vaccine-associated paralytic poliomyelitis (VAPP) have been detected. Molecular characterization studies of poliovirus strains isolated from VAPP cases and from healthy contacts have confirmed that the isolates are derived from the Sabin vaccine strains and also detected genomic modifications known or suspected to increase neurovirulence such as mutations and recombination. The molecular characterization of polioviruses isolated during the last eight years from paralysis cases classified as Guillain-Barré (GBS) syndrome and transverse myelitits (TM), and from facial paralysis (FP) cases also confirmed the vaccine origin of the strains and demonstrated mutations known to increase neurovirulence. Analysis of the epidemiologic data of these GBS, TM and FP cases demonstrated that in most of them the last OPV dose was given months or years before the onset of the disease and the isolation of the polioviruses. The temporal association between the isolation of these strains and the GBS, TM and FP suggested that the Sabin vaccine-derived poliovirus strains could also rarely trigger the diseases.

Surveillance for adverse events after DTwP/Hib vaccination in Brazil: Sensitivity and factors associated with reporting

We estimated the sensitivity, i.e., the proportion of all cases of adverse events following immunization (AEFIs) reported to the Brazilian passive surveillance for adverse events following immunization (PSAEFI) with the diphtheria-tetanus-whole-cell pertussis-Haemophilus influenzae type b (DTwP/Hib) vaccine, as well as investigating factors associated with AEFIs reporting. During 2003-2004, 8303 AEFIs associated with DTwP-Hib were reported; hypotonic-hyporesponsive episodes (HHEs), fever and convulsions being the most common. Cure without sequel was achieved in 98.4% of the cases. The mean sensitivity of the PSAEFI was 22.3% and 31.6%, respectively, for HHE and convulsions, varying widely among states. Reporting rates correlated positively with the Human Development Index and coverage of adequate prenatal care, correlating negatively with infant mortality rates. Quality of life indicators and the degree of organization of health services are associated with greater PSAEFI sensitivity. In addition to consistently describing the principal AEFIs, PSAEFI showed the DTwP/Hib vaccine to be safe and allayed public fears related to its use. (C) 2010 Elsevier Ltd. All rights reserved.

Mechanisms Associated with Large Daily Rainfall Events in Northeast Brazil

The mechanisms resulting in large daily rainfall events in Northeast Brazil are analyzed using data filtering to exclude periods longer than 30 days. Composites of circulation fields that include all independent events do not reveal any obvious forcing mechanisms as multiple patterns contribute to Northeast Brazil precipitation variability. To isolate coherent patterns, subsets of events are selected based on anomalies that precede the Northeast Brazil precipitation events at different locations. The results indicate that at 10 degrees S, 40 degrees W, the area of lowest annual rainfall in Brazil, precipitation occurs mainly in association with trailing midlatitude synoptic wave trains originating in either hemisphere. Closer to the equator at 5 degrees S, 37.5 degrees W, an additional convection precursor is found to the west, with a spatial structure consistent with that of a Kelvin wave. Although these two sites are located within only several hundred kilometers of each other and the midlatitude patterns that induce precipitation appear to be quite similar, the dates on which large precipitation anomalies occur at each location are almost entirely independent, pointing to separate forcing mechanisms.

Frequency of extreme rainfall events in Southern Brazil modulated by interannual and interdecadal variability

The frequency of extreme rainfall events in Southern Brazil is impacted by Ell Nino - Southern Oscillation (ENSO) episodes, especially in austral spring. There are two areas in which this impact is more significant: one is on the coast, where extreme events are more frequent during El Nino (EN) and the other one extends inland, where extreme events increase during EN and decrease during La Nina (LN). Atmospheric circulation patterns associated with severe rainfall in those areas are similar (opposite) to anomalous patterns characteristic of EN (LN) episodes, indicating why increase (decrease) of extreme events in EN (LN) episodes is favoured. The most recurrent precipitation patterns during extreme rainfall events in each of these areas are disclosed by Principal Component Analysis (PCA) and evidence the separation between extreme events in these areas: a severe precipitation event generally does not occur simultaneously in the coast and inland, although they may Occur inland and in the coastal region in sequence. Although EN predominantly enhances extreme rainfall, there are EN years in which fewer severe events occur than the average of neutral years, and also the enhancement of extreme rainfall is not uniform for different EN episodes, because the interdecadal non-ENSO variability also modulates significantly the frequency of extreme events in Southern Brazil. The inland region, which is more affected, shows increase (decrease) of extreme rainfall in association with the negative (positive) phase of the Atlantic Multidecadal Variability, with the negative (positive) phase of the Pacific Multidecadal Variability and with the positive (negative) phase of the Pacific Interdecadal Variability. Copyright (C) 2008 Royal Meteorological Society

On the diurnal cycle of urban aerosols, black carbon and the occurrence of new particle formation events in springtime Sao Paulo, Brazil

Large conurbations are a significant source of the anthropogenic pollution and demographic differences between cities that result in a different pollution burden. The metropolitan area of Sao Paulo (MASP, population 20 million) accounts for one fifth of the Brazilian vehicular fleet. A feature of MASP is the amount of ethanol used by the vehicular fleet, known to exacerbate air quality. The study describes the diurnal behaviour of the submicron aerosol and relies on total particle number concentration, particle number size distribution, light scattering and light absorption measurements. Modelled planetary boundary layer (PBL) depth and air mass movement data were used to aid the interpretation. During morning rush-hour, stagnant air and a shallow PBL height favour the accumulation of aerosol pollution. During clear-sky conditions, there was a wind shift towards the edge of the city indicating a heat island effect with implications on particulate pollution levels at the site. The median total particle number concentration for the submicron aerosol typically varied in the range 1.6 x 10(4)-3.2 x 10(4) cm(-3) frequently exceeding 4 x 10(4) cm-3 during the day. During weekdays, nucleation-mode particles are responsible for most of the particles by numbers. The highest concentrations of total particle number concentrations and black carbon (BC) were observed on Fridays. Median diurnal values for light absorption and light scattering (at 637 nm wavelength) varied in the range 12-33 Mm(-1) and 21-64 Mm(-1), respectively. The former one is equal to 1.8-5.0 mu g m(-3) of BC. The growth of the PBL, from the morning rush-hour until noon, is consistent with the diurnal cycle of BC mass concentrations. Weekday hourly median single-scattering albedo (omega(0)) varied in the range 0.59-0.76. Overall, this suggests a top of atmosphere (TOA) warming effect. However, considering the low surface reflectance of urban areas, for the given range of omega(0), the TOA radiative forcing can be either positive or negative for the sources within the MASP. On the average, weekend omega(0) values were 0.074 higher than during weekdays. During 11% of the days, new particle formation (NPF) events occurred. The analysed events growth rates ranged between 9 and 25 nm h(-1). Sulphuric acid proxy concentrations calculated for the site were less than 5% of the concentration needed to explain the observed growth. Thus, other vapours are likely contributors to the observed growth.

Adverse events related to vancomycin use in a University Hospital in Brazil

Introduction and Objectives: Vancomycin is indicated to patients who have not responded to treatment with other antibiotics in serious infections caused by organisms susceptible to it and resistant to other antimicrobials. However, over the last five years, many adverse reactions have been reported with this medicine in the University Hospital of the University of Silo Paulo (HU/USP), such as nephrotoxicity and toxicity related to infusion. Some critical patients, for example surgical patients with sepsis and severe trauma are generally susceptible to renal failure due to the severity of the underlying disease. The-aim of this study is to quantify and delineate the epidemiological profile of confirmed adverse reactions caused by vancomycin. Material and Methods: We conducted a retrospective observational quantitative study of medical records of patients who had confirmed.adverse reactions occurred with vancomycin in the period from January 2007 to May 2012, at the HU/USP - Brazil. All notifications related to vancomycin were evaluated in the following items: age and sex of patients, type and ward where the adverse event occurred involving this drug. Results and Conclusions: During the analysed period, were confinued 37 adverse events with vancomycn. The adults represented 75,7% of the cases, and the children 24,3%. The present study shows that adult patients admitted to the medical clinic had greater susceptibility to adverse reactions to vancomycin and for pediatric patients its higher frequency was at ICU. Despite the adverse skin reactions performed with greater frequency, it is known that the most severe reactions were related to the kidney resulting in more complex clinical interventions.

Extreme overirradiance events in Sao Paulo, Brazil

Phenomena of overirradiance have been pointed all over the World. This note presents the most extreme enhancement event reported in Brazil, which contains an irradiance reading of 1590 W/m2 measured in São Paulo (latitude 23°32′S) at relatively low altitude (760 m a.s.l.).

The Burden Of Eclampsia: Results From A Multicenter Study On Surveillance Of Severe Maternal Morbidity In Brazil.

Maternal mortality (MM) is a core indicator of disparities in women's rights. The study of Near Miss cases is strategic to identifying the breakdowns in obstetrical care. In absolute numbers, both MM and occurrence of eclampsia are rare events. We aim to assess the obstetric care indicators and main predictors for severe maternal outcome from eclampsia (SMO: maternal death plus maternal near miss). Secondary analysis of a multicenter, cross-sectional study, including 27 centers from all geographic regions of Brazil, from 2009 to 2010. 426 cases of eclampsia were identified and classified according to the outcomes: SMO and non-SMO. We classified facilities as coming from low- and high-income regions and calculated the WHO's obstetric health indicators. SPSS and Stata softwares were used to calculate the prevalence ratios (PR) and respective 95% confidence interval (CI) to assess maternal characteristics, clinical and obstetrical history, and access to health services as predictors for SMO, subsequently correlating them with the corresponding perinatal outcomes, also applying multiple regression analysis (adjusted for cluster effect). Prevalence of and mortality indexes for eclampsia in higher and lower income regions were 0.2%/0.8% and 8.1%/22%, respectively. Difficulties in access to health care showed that ICU admission (adjPR 3.61; 95% CI 1.77-7.35) and inadequate monitoring (adjPR 2.31; 95% CI 1.48-3.59) were associated with SMO. Morbidity and mortality associated with eclampsia were high in Brazil, especially in lower income regions. Promoting quality maternal health care and improving the availability of obstetric emergency care are essential actions to relieve the burden of eclampsia.

The Prevalence Of Tic Disorders In Children And Adolescents In Brazil.

Tourette syndrome (TS) and tic disorders represent events of familiar magnitude characterized by involuntary movements and/or vocalization. To determine the prevalence of TS/tic disorders we studied a sample of 762 subjects (388 M, 374 F), between 1992 and 1997, age 6 to 43 years old, taken out of a population of 10,155 subjects (4,918 M, 5,237 F; age: 3-56 years old). A structured 4-item questionnaire, direct interview (multistaged), >1 yr follow-up, were used. 9,565 subjects (4,614 M, 4,951 F) sent back the questionnaires, 3,354 of these (1,671 M, 1,683 F) with positive answers to tics. 42 subjects (31 M, 11 F, age: 7-21 years old, mean: 11 years old) met the DSM-III-R criteria. The total minimal prevalence of TS is 0.43%, with a 3:1 ratio male/female. The minimal prevalence of chronic tic disorder is 2.27%. The total minimal prevalence for tic disorders at all is 2.91%. No special education students participation.

Estimating cardiovascular risk in patients with type 2 diabetes: a national multicenter study in Brazil

According to Brazilian National Data Survey diabetes is the fifth cause for hospitalization and is one of the ten major causes of mortality in this country. Aims to stratify the estimated cardiovascular risk (eCVR) in a population of type 2 diabetics (T2DM) according to the Framingham prediction equations as well as to determine the association between eCVR with metabolic and clinical control of the disease. Methods From 2000 to 2001 a cross-sectional multicenter study was conducted in 13 public out-patients diabetes/endocrinology clinics from 8 Brazilian cities. The 10-year risk of developing coronary heart disease (CHD) was estimated by the prediction equations described by Wilson et al (Circulation 1998). LDL equations were preferably used; when patients missed LDL data we used total cholesterol equations instead. Results Data from 1382 patients (59.0% female) were analyzed. Median and inter-quartile range (IQ) of age and duration of diabetes were 57.4 (51-65) and 8.8 (3-13) years, respectively without differences according to the gender. Forty-two percent of these patients were overweight and 35.4% were obese (the prevalence of higher BMI and obesity in this T2DM group was significantly higher in women than in men; p < 0.001). The overall estimated eCVR in T2DM patients was 21.4 (13.5-31.3). The eCVR was high (> 20%) in 738 (53.4%), intermediate in 202 (14.6%) and low in 442 (32%) patients. Men [25.1(15.4-37.3)] showed a higher eCVR than women [18.8 (12.4-27.9) p < 0.001]. The most common risk factor was high LDL-cholesterol (80.8%), most frequently found in women than in men (p = 0.01). The median of risk factors present was three (2-4) without gender differences. Overall we observed that 60 (4.3%) of our patients had none, 154(11.1%) one, 310 (22.4%) two, 385 (27.9%) three, 300 (21.7%) four, 149 (10.5%) five and six, (2%) six risk factors. A higher eCVR was noted in overweight or obese patients (p = 0.01 for both groups). No association was found between eCVR with age or a specific type of diabetes treatment. A correlation was found between eCVR and duration of diabetes (p < 0.001), BMI (p < 0.001), creatinine (p < 0.001) and triglycerides levels (p < 0.001) but it was not found with HbA1c, fasting blood glucose and postprandial glucose. A higher eCVR was observed in patients with retinopathy (p < 0.001) and a tendency in patients with microalbuminuria (p = 0.06). Conclusion: our study showed that in this group of Brazilian T2DM the eCVR was correlated with the lipid profile and it was higher in patients with microvascular chronic complications. No correlation was found with glycemic control parameters. These data could explain the failure of intensive glycemic control programs aiming to reduce cardiovascular events observed in some studies.

The Development of Science Education Research in Brazil and Contributions from the History and Philosophy of Science

Over the last 50 years a new research area, science education research, has arisen and undergone singular development worldwide. In the specific case of Brazil, research in science education first appeared systematically 40 years ago, as a consequence of an overall renovation in the field of science education. This evolution was also related to the political events taking place in the country. We will use the theoretical work of Rene Kaes on the development of groups and institutions as a basis for our discussion of the most important aspects that have helped the area of science education research develop into an institution and kept it operating as such. The growth of this area of research can be divided into three phases: The first was related to its beginning and early configurations; the second consisted of a process of consolidation of this institution; and the third consists of more recent developments, characterised by a multiplicity of research lines and corresponding challenges to be faced. In particular, we will analyse the special contributions to this study gleaned from the field known as the history and philosophy of science.

Myocardial scintigraphy and clinical stratification as predictors of events in renal transplant candidates

Background: We tested the hypothesis that the universal application of myocardial scanning with single-photon emission computed tomography (SPECT) would result in better risk stratification in renal transplant candidates (RTC) compared with SPECT being restricted to patients who, in addition to renal disease, had other clinical risk factors. Methods: RTCs (n=363) underwent SPECT and clinical risk stratification according to the American Society of Transplantation (AST) algorithm and were followed up until a major adverse cardiovascular event (MACE) or death. Results: Of the 363 patients, 79 patients (22%) had an abnormal SPECT scan and 270 (74%) were classified as high risk. Both methods correctly identified patients with increased probability of MACE. However, clinical stratification performed better (sensitivity and negative predictive value 99% and 99% vs. 25% and 87%, respectively). High-risk patients with an abnormal SPECT scan had a modest increased risk of events (log-rank = 0.03; hazard ratio [HR] = 1.37; 95% confidence interval [95% CI], 1.02-1.82). Eighty-six patients underwent coronary angiography, and coronary artery disease (CAD) was found in 60%. High-risk patients with CAD had an increased incidence of events (log-rank = 0.008; HR=3.85; 95% CI, 1.46-13.22), but in those with an abnormal SPECT scan, the incidence of events was not influenced by CAD (log-rank = 0.23). Forty-six patients died. Clinical stratification, but not SPECT, correlated with the probability of death (log-rank = 0.02; HR=3.25; 95% CI, 1.31-10.82). Conclusion: SPECT should be restricted to high-risk patients. Moreover, in contrast to SPECT, the AST algorithm was also useful for predicting death by any cause in RTCs and for selecting patients for invasive coronary testing.