Generalized cost-effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina

<p>Abstract</p> <p>Background</p> <p>Chronic diseases, represented mainly by cardiovascular disease (CVD) and cancer, are increasing in developing countries and account for 53% of chronic diseases in Argentina. There is strong evidence that a reduction of 50% of the deaths due to CVD can be attributed to a reduction in smoking, hypertension and hypercholesterolemia. Generalized cost-effectiveness analysis (GCE) is a methodology designed by WHO to inform decision makers about the extent to which current or new interventions represent an efficient use of resources. We aimed to use GCE analysis to identify the most efficient interventions to decrease CVD.</p> <p>Methods</p> <p>Six individual interventions (treatment of hypertension, hypercholesterolemia, smoking cessation and combined clinical strategies to reduce the 10 year CVD Risk) and two population-based interventions (cooperation between government, consumer associations and bakery chambers to reduce salt in bread, and mass education strategies to reduce hypertension, hypercholesterolemia and obesity) were selected for analysis. Estimates of effectiveness were entered into age and sex specific models to predict their impact in terms of age-weighted and discounted DALYs saved (disability-adjusted life years). To translate the age- and sex-adjusted incidence of CVD events into health changes, we used risk model software developed by WHO (PopMod). Costs of services were measured in Argentine pesos, and discounted at an annual rate of 3%. Different budgetary impact scenarios were explored.</p> <p>Results</p> <p>The average cost-effectiveness ratio in argentine pesos (ARS$) per DALY for the different interventions were: (i) less salt in bread$151; (ii) mass media campaign $547; (iii) combination drug therapy provided to subjects with a 20$3,599, $4,113 and$4,533, respectively; (iv) high blood pressure (HBP) lowering therapy $7,716; (v) tobacco cessation with bupropion$ 33,563; and (iv) high-cholesterol lowering therapy with statins $ 70,994.</p> <p>Conclusion</p> <p>Against a threshold of average per capita income in Argentina, the two selected population-based interventions (lowering salt intake and health education through mass-media campaigns) plus the modified polypill strategy targeting people with a 20% or greater risk were cost-effective. Use of this methodology in developing countries can make resource-allocation decisions less intuitive and more driven by evidence.</p

Simulación numérica aplicada a la interacción agua subterránea-humedales en la Llanura Pampeana, Provincia de Buenos Aires

En la llanura pampeana los cuerpos de agua superficial son parte activa del sistema de flujo del agua subterránea. La laguna La Salada y su área de influencia se ubican en las cercanías de la localidad La Dulce (Provincia de Bs. As.), sobre la divisoria sur de la cuenca del Río Quequén. El objetivo del trabajo es cuantificar la interacción entre los cuerpos de agua de la laguna, acuífero y río y establecer el balance global de masas a través de la modelación numérica. Los resultados de la simulación del flujo muestran en régimen estacionario el comportamiento efluente – influente de la laguna y el flujo de agua subterránea hacia el río. La simulación del régimen transitorio muestra un buen ajuste entre los niveles observados y calculados durante el periodo 2007-2010 en un freatímetro ubicado entre la laguna y el río. Los términos del balance global de masas incluyen precipitación 116 hm3/año, evapotranspiración 82.1 hm3/año, escurrimiento superficial 1.8 hm3/año, evaporación en la laguna 5 hm3/año, recarga del acuífero 16 hm3/año, descarga de agua subterránea a la laguna 6 hm3/año, descarga de agua subterránea al río 9.5 hm3/año y extracción para consumo urbano 0.5 hm3/año. La integración de herramientas numéricas de simulación del flujo con estudios previos de modelación hidrogeoquímica permitió alcanzar resultados consistentes de la evaporación en la laguna con respecto al valor obtenido por el balance hídrico. La metodología utilizada constituye un aporte al abordaje de estudios cuantitativos sobre la interacción aguas subterráneas – aguas superficiales en la llanura pampeana.In the Pampa plain the surface water bodies are integral parts of groundwater flow systems. La Salada wetland is located on the watershed of the Quequén River basin, next to La Dulce town (Buenos Aires Province).The aim of the present study is both to quantify the wetland - aquifer – river interactions and to establish the mass global balance through the numerical modeling. Results of flow simulation in the steady regime show the effluent-influent behavior of the wetland and the discharge of groundwater to the Quequén River. The transient regime shows a noticeable fitness observed between the simulated and the measured values compared to the daily record piezometer (2007-2010). Mass global balance comprise precipitation 116 hm3/year, evapotranspiration 82.1 hm3/year, runoff 1.8 hm3/año, evaporation in the wetland 5 hm3/year, recharge to the aquifer 16 hm3/ year, groundwater discharge to the wetland 6 hm3/ year, groundwater discharge to the river 9.5 hm3/ year y extraction for human consumption 0.5 hm3/ year. The joint tools of numerical simulation of flow and previous studies of hydrogeochemical modeling allow reach similar results for the evaporation in the wetland compared to those from the water balance. The study constitutes a contribution to the assessment of the groundwater – surface water interactions in the Pampa plain

Desigualdades en la distribución de factores de riesgo en enfermedades cardiovasculares en la Argentina: un estudio a partir de la Encuesta Nacional de Factores de Riesgo (ENFR) de 2005, 2009 y 2013

Background: Cardiovascular health inequalities have been documented in the literature in both developed and undeveloped countries and there is an inverse association between the incidence and mortality for specific cause of cardiovascular disease and levels of income, education and employment. Objective: The aim of this study was to identify the existence of inequalities in the prevalence of risk factors by socioeconomic status in Argentina. Methods: Data from the 2005, 2009 and 2013 National Risk Factor Surveys (NRFS) were analyzed. The prevalence of obesity, smoking, hypertension and cholesterol were studied. Differences for each risk factor were estimated in relation to socioeconomic status (measured by education, income and health coverage). The independent association between socioeconomic status and risk factors was assessed using logistic regression models. Results: Educational level was inversely associated with the prevalence of obesity (p<0.01), hypercholesterolemia (p<0.01), hypertension (p<0.01) and smoking (p<0.05) and the effect varied by gender and age group. Income level was significantly and inversely associated with the prevalence of hypertension (p<0.01). The temporal evolution of inequalities indicates there was no attenuation between surveys and, on the contrary, it showed an increase in smoking gaps. Conclusions: Deep inequalities were recorded in the distribution of cardiovascular risk factors by educational level. Groups with high burden of risk factors are vulnerable populations upon which preventive policies should be targeted.Introducción: Las desigualdades en salud cardiovascular se han documentado en la literatura tanto en países desarrollados como no desarrollados y existe una asociación inversa entre la incidencia y mortalidad por causa específica de enfermedades cardiovasculares y los niveles de ingreso, educación y empleo. Objetivo: Identificar la existencia de desigualdades en la prevalencia de factores de riesgo por nivel socioeconómico en la Argentina. Material y métodos: Análisis de los datos de la Encuesta Nacional de Factores de Riesgo (ENFR) de 2005, 2009 y 2013. Se estudió la prevalencia de obesidad, tabaquismo, hipertensión arterial y colesterol. Se estimaron las brechas para cada factor de riesgo en relación con el nivel socioeconómico (medido con educación, ingreso y cobertura de salud). La asociación independiente entre nivel socioeconómico y factores de riesgo se evaluó con modelos de regresión logística. Resultados: El nivel educativo se asoció inversamente con la prevalencia de obesidad (p < 0,01), hipercolesterolemia (p < 0,01), hipertensión arterial (p < 0,01) y tabaquismo (p < 0,05) y el efecto varió por grupos de edad y sexo. El nivel de ingreso se asoció significativamente y de manera inversa con la prevalencia de hipertensión (p < 0,01). La evolución temporal de las desigualdades indica que no hubo atenuación de estas entre las encuestas y, por el contrario, muestra un incremento en las brechas de tabaquismo. Conclusiones: Se registraron profundas desigualdades en la distribución de factores de riesgo cardiovascular por niveles educativos. Los grupos con elevada carga de factores de riesgo constituyen poblaciones vulnerables sobre las cuales deberían orientarse políticas preventivasFacultad de Ciencias Económica

Multiclass semantic segmentation and quantification of traumatic brain injury lesions on head CT using deep learning: an algorithm development and multicentre validation study

Background: Computed tomography (CT) is the most common imaging modality in traumatic brain injury (TBI). However, its conventional use requires expert clinical interpretation and does not provide detailed quantitative outputs, which may have prognostic importance. Deep learning could reliably and efficiently detect, distinguish, and quantify different lesion types, providing opportunities for personalised treatment strategies and clinical research. Methods: An initial convolutional neural network (CNN) was trained and validated on expert manual segmentations (97 scans). This CNN was then used to automatically segment a new set of 839 scans, which were then manually corrected by experts. From these, a subset of 184 scans was used to train a final CNN for multi-class, voxel-wise segmentation of lesion types. The performance of this CNN was evaluated on a held-out test set with 655 scans. External validation was performed on a large, independent set of 500 patients from a different continent. Findings: When compared to manual reference, CNN-derived lesion volumes showed a mean error of 0·86mL (95% CI -5·23 to 6·94) for intraparenchymal haemorrhage (IPH), 1·83mL (-12·01 to 15·66) for extra-axial haemorrhage (EAH), 2·09mL (-9·38 to 13·56) for perilesional oedema and 0·07mL (-1·00 to 1·13) for intraventricular haemorrhage (IVH). Further, the CNN detected lesions with AUCs of 0·90 (0·86-0·94) for IPH, 0·80 (0·75-0·85) for EAH, 0·95 (0·89-1·00) for IVH on the external, independent patient dataset. Interpretation: We demonstrate the ability of a CNN to separately segment, detect and quantify multi-class haemorrhagic lesions and importantly, perilesional oedema. These volumetric lesion estimates allow clinically relevant quantification of lesion burden and progression, with potential applications in clinical care and research in TBI. Funding: European Union 7th Framework Programme, Hannelore Kohl Stiftung; OneMind; Integra Neurosciences; European Research Council Horizon 2020; Engineering and Physical Sciences Research Council (UK); Academy of Medical Sciences/Health Foundation (UK); National Institute for Health Research (UK).CENTER-TBI study was supported by the European Union 7th Framework program (EC grant 602150). Additional funding sources: Hannelore Kohl Stiftung; NeuroTrauma Sciences; Integra Neurosciences; European Research Council (ERC) Horizon 2020 (EC grant 757173); Engineering and Physical Sciences Research Council (EPSRC) (EP/R511547/1); Academy of Medical Sciences/The Health Foundation (UK); National Institute for Health Research (UK)

Dimensão Ambiental em Assentamentos Rurais: Presença Controversa

This study emphasizes the introduction of environmental concerns in agrarian legislation and public policies related to agrarian reform in the country. As this process is adjusting the assumptions outlined legal needs greater attention and valuation of the environmental dimension. This process reflects the advancement of conceptualization about the design of sustainable development and also expresses the social pressures, represented by the social movements and non-governmental organizations at the national and international exerted on the government in the execution of the legal and institutional apparatus for the theme. It also addresses the difficult adequacy standards imposed on tangible progress regarding the respect for the environment and building a land reform policy that effectively enhances the environmental dimension.Keywords: Agrarian reform; Sustainability; Environmental legislation.O presente trabalho enfatiza a introdução da questão ambiental na legislação agrária e nas políticas públicas relacionadas à reforma agrária no país. Discute como esse processo, se delineou adequando os pressupostos legais às necessidades de maior atenção e valoração da dimensão ambiental. Este processo reflete o avanço da conceituação a respeito da concepção de desenvolvimento sustentável e também exprime as pressões sociais, representadas pelos movimentos sociais e pelas organizações não governamentais de âmbito nacional e internacional, exercidas sobre o poder público na efetivação do aparato jurídicoinstitucionalreferente ao tema. Aborda igualmente a difícil adequação das normas instituídas no que tange ao respeito ao meio ambiente e à construção de uma política de reforma agrária que valorize efetivamente a dimensão ambiental