WTO safeguards and trade liberalization: lessons from the Argentine footwear case

The footwear case provides an example of the complexities of World Trade Organization (WTO) rules on the use of safeguards, and of the interaction of multilateral and regional processes of liberalization. As a result both of Argentina's unilateral liberalization and the removal of barriers within Mercosur, imports of footwear increased rapidly. As Mercosur provides no intra-regional safeguard mechanism, the government of Argentina responded by applying import relief and WTO safeguards against third countries. The WTO Dispute Settlement Body addressed these measures and as a consequence, Argentina dismantled most of them, leading to four main conclusions: The jurisprudence of the WTO's Appellate Body has created serious uncertainty as to when a country can use safeguards. This does not contribute to the political balance that has to be maintained when developing countries implement trade liberalization programs. In fact, it detracts from this crucial goal. It is an error to negotiate ambiguous multilateral agreements on the expectation that the WTO Dispute Settlement mechanism will clarify them. An overvalued currency heightened the industry's problems. In the case of footwear, the decline in imports following the recent devaluation was more important than that following the implementation of earlier relief measures. The political economy of liberalization also indicates the need for regional agreements to include adequate transition mechanisms that will facilitate adjustment to free trade and to maintain support for it.Trade Policy,Rules of Origin,TF054105-DONOR FUNDED OPERATION ADMINISTRATION FEE INCOME AND EXPENSE ACCOUNT,Environmental Economics&Policies,Economic Theory&Research

Political economy of antidumping and safeguards in Argentina

Beginning in the late 1980s, Argentina implemented a series of reforms that were revolutionary in speed and scope, including trade liberalization. After the implementation of these policies, a record number of antidumping petitions came forward. Under a situation of high inflation, the government reinforced its fiscal and monetary policies by announcing that it would minimize the use of such measures. The flexible disciplines of the existing domestic antidumping regulations facilitated this objective. Later, when the GATT/WTO-sanctioned trade remedies were implemented, the government made a serious attempt to establish discipline by including liberal regulations and creating special institutional arrangements. A presumption built into the construction of the new mechanisms was that adhering to WTO requirements would strengthen the resistance against protection. This presumption turned out to be false. Changing circumstances, including severe peso overvaluation, had significant effects on the number and outcome of antidumping investigations. Regarding safeguards, the government followed the letter and the spirit of the WTO agreement. In relation to the number of petitions, few measures have been implemented. Rejections were based on a concern for consumer costs and on failure of the industry seeking protection to provide a convincing modernization plan. This, plus the fact that some cases were brought to the WTO Dispute Settlement Body, have made safeguards a less attractive instrument for protection-seekers than antidumping. An important positive side of the story is that unlike previous balance of payments adjustments, in spite of the major crisis that followed the recent devaluation, the hard-won liberalization has been maintained.Environmental Economics&Policies,TF054105-DONOR FUNDED OPERATION ADMINISTRATION FEE INCOME AND EXPENSE ACCOUNT,Economic Theory&Research,Insurance&Risk Mitigation,Trade Policy

Triage And Risk Classification Protocols In Pediatric Emergency

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Diagnostic accuracy of stereotactic core-needle biopsy of non-palpable breast lesions categorized as BI-RADS® 4

PURPOSE: to assess the accuracy (rate of correct predictions) of stereotactic core needle biopsy (CNB) of risk category BI-RADS® 4 breast lesions. METHODS: a retrospective analysis of category BI-RADS® 4 breast lesions that had been submitted to a stereotactic core-needle biopsy from June 1998 to June 2003. Patients with histological benign results consistent with the radiographic image were referred to mammographic follow-up. Patients with malign diagnosis and papillary lesions were submitted to standard specific treatment. Excisional biopsies were performed when results were benign, but in disagreement with the mammographic image. It was considered as a gold-standard attendance: (1) the mammographic follow-up of low suspicion lesions with benign results at CNB, which stayed unchanged for, at least, three years, and (2) surgical resection when specimen results were malign or benign, but with a high suspicion on mammography. Sensitivity (S) specificity (E) and overall accuracy of stereotactic CNB were statistically analyzed. RESULTS: among the 118 non-palpable lesions of category BI-RADS® 4 submitted to CNB, the results obtained were: 27 malign cases, 81 benign, and ten lesions with atypical or papillary lesions. The statistical analysis comprised 108 patients (atypical and papillary lesions were excluded). CNB sensitivity was 87.1% and specificity 100%. The positive predictive value was 100% and the negative, 95.1%. False negatives occurred in 3.7% (4/108) of cases. The prevalence of malign diagnostics in the BI-RADS® 4 lesions of this sample was 29.7 (31/118).The accuracy of this method in this casuistic was 96.3%. CONCLUSIONS: these results support stereotactic CNB as an extremely reliable alternative to open biopsy, in the diagnosis and definition of breast lesions. In positive results, it is possible to indicate the appropriate therapy, and, in negative (when mammography shows low suspicion), it allows a follow up.OBJETIVO: avaliar a acurácia da biópsia com agulha grossa (BAG) orientada por estereotaxia nas lesões mamárias categoria BI-RADS® 4. MÉTODOS: realizou-se uma análise retrospectiva das lesões categoria BI-RADS® 4 que foram submetidas à BAG orientada por estereotaxia no período de junho de 1998 a junho de 2003. As pacientes com resultados benignos, mas com baixa suspeição à imagem radiográfica, foram orientadas a acompanhamento mamográfico. As pacientes com resultados malignos ou com lesões especiais (atipias e lesões papilíferas) foram submetidas ao tratamento padronizado. Aquelas com resultado benigno, mas que apresentavam imagem mamográfica de maior risco, foram encaminhadas para biópsia cirúrgica (BC). Foram considerados padrão-ouro (1) o acompanhamento radiográfico inalterado por, no mínimo, três anos daquelas lesões de baixa suspeição que resultaram benigno na BAG e (2) os resultados das biópsias cirúrgicas, quando essas foram realizadas (nas BAG cujos resultados foram malignos ou benignos com imagem de maior risco). Foram realizados os cálculos estatísticos de sensibilidade, especificidade e valor preditivo positivo e negativo do método. RESULTADOS: das 118 lesões não palpáveis categoria BI-RADS® 4 submetidas à BAG orientada por estereotaxia, 27 casos correspondiam à doença maligna, 81 eram benignas e 10 eram lesões com atipia ou papilíferas. Para a análise estatística, foram selecionados 108 pacientes (excluídas as lesões com atipia e papilíferas). A sensibilidade da BAG foi de 87,1% e a especificidade foi de 100%. O valor preditivo positivo foi de 100% e o negativo, de 95,1%. A acurácia da BAG nessa casuística foi de 96,3%. A taxa de falso-negativo foi de 3,7% (4/108). A prevalência de diagnóstico de malignidade nas lesões BI-RADS® 4 nessa amostra foi de 29,7% (31/118). CONCLUSÕES: a biópsia estereotáxica com agulha grossa mostrou-se uma alternativa segura à BC. Quando seu resultado é positivo, orienta o planejamento terapêutico, e, quando negativo (em imagens radiográficas de baixa suspeição), permite o acompanhamento.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de GinecologiaUniversidade de São Paulo Departamento de GinecologiaUNIFESP, EPM, Depto. de GinecologiaSciEL

Acidentes por serpentes Crotalus durisssus ssp em crianças em Campinas, São Paulo, Brasil

From January, 1984 to March, 1999, 31 children under 15 y old (ages 1-14 y, median 8 y) were admitted after being bitten by rattlesnakes (Crotalus durissus ssp). One patient was classified as "dry-bite", 3 as mild envenoming, 9 as moderate envenoming and 18 as severe envenoming. Most patients had neuromuscular manifestations, such as palpebral ptosis (27/31), myalgia (23/31) and weakness (20/31). Laboratory tests suggesting rhabdomyolysis included an increase in total blood creatine kinase (CK, 28/29) and lactate dehydrogenase (LDH, 25/25) levels and myoglobinuria (14/15). The main local signs and symptoms were slight edema (20/31) and erythema (19/31). Before antivenom (AV) administration, blood coagulation disorders were observed in 20/25 children that received AV only at our hospital (incoagulable blood in 17/25). AV early reactions were observed in 20 of these 25 cases (9/9 patients not pretreated and 11/16 patients pretreated with hydrocortisone and histamine H1 and H2 antagonists). There were no significant differences in the frequency of patients with AV early reactions between the groups that were and were not pretreated (Fisher's exact test, p = 0.12). Patients admitted less than and more than 6 h after the bite showed the same risk of developing severe envenoming (Fisher's exact test, p = 1). No children of the first group (< 6 h) showed severe complications whereas 3/6 children admitted more than 6 h post-bite developed acute renal failure. Patients bitten in the legs had a higher risk of developing severe envenoming (Fisher's exact test, p = 0.04). There was a significant association between both total CK and LDH blood enzyme levels and severity (p < 0.001 for CK and p < 0.001 for LDH; Mann-Whitney U test). No deaths were recorded.De janeiro de 1984 a março de 1999, 31 crianças com menos de 15 anos de idade (1 a 14 anos, mediana = 8 anos) foram admitidas após terem sido picadas por Crotalus durissus ssp. Uma criança não apresentou manifestações clínicas de envenenamento, enquanto 3 foram classificadas como acidente leve, 9 como moderado e 18 como grave. A maioria das crianças apresentou envolvimento neuromuscular, tais como ptose palpebral (27/31), mialgia (23/31) e fraqueza (20/31). Alterações laboratoriais sugerindo rabdomiólise também foram observadas, como aumento das enzimas séricas CK (28/29) e LDH (25/25) e mioglobinúria (14/15). As principais manifestações locais observadas foram edema discreto (20/31) e eritema (19/31). Alterações da coagulação, antes da administração da soroterapia antiveneno (SAV), foram observadas em 20 das 25 crianças que receberam a SAV exclusivamente em nosso hospital (sangue incoagulável em 17/25). Reações precoces à SAV foram observadas em 20 destes 25 casos, em todos os pacientes não pré-tratados (N = 9) e em 11 dentre os 16 pré-tratados com antagonistas H1 e H2 da histamina e hidrocortisona. Não foram constatadas diferenças estatísticas significativas comparando-se a freqüência de reações precoces à SAV entre os grupos que receberam ou não o pré-tratamento (teste exato de Fisher, p = 0,12). Pacientes atendidos com menos ou mais de 6 horas após o acidente apresentaram o mesmo risco quanto a evolução para casos graves (teste exato de Fisher, p = 1), não se observando complicações graves no 1º grupo (< 6 h), enquanto 3/6 admitidos mais de 6 horas após a picada evoluíram com insuficiência renal aguda. Pacientes picados na perna apresentaram um maior risco de desenvolver acidentes graves (teste exato de Fisher, p = 0,04). Houve uma associação significativa entre os níveis séricos das enzimas CK e LDH total e gravidade (teste U de Mann-Whitney, CK, p < 0,001; LDH, p < 0,001). Nenhum óbito foi registrado

Acidentes por serpentes do gênero Bothrops em crianças em Campinas, São Paulo, Brasil

From January, 1984 to March, 1999, 73 children under 15 y old (ages 1-14 y, median 9 y) were admitted after being bitten by snakes of the genus Bothrops. Twenty-six percent of the children were classified as mild envenoming, 50.7% as moderate envenoming and 20.6% as severe envenoming. Two patients (2.7%) showed no signs of envenoming. Most of the patients presented local manifestations, mainly edema (94.5%), pain (94.5%) ecchymosis (73.9%) and blisters (11%). Local and/or systemic bleeding was observed in 28.8% of the patients. Before antivenom (AV) administration, blood coagulation disorders were observed in 60.7% (incoagulable blood in 39.3%) of the 56 children that received AV only in our hospital. AV early reactions, most of which were considered mild, were observed in 44.6% of these cases (in 15/30 patients not pretreated and in 10/26 patients pretreated with hydrocortisone and histamine H1 and H2 antagonists). The main clinical complications observed were local infection (15.1%), compartment syndrome (4.1%), gangrene (1.4%) and acute renal failure (1.4%). No deaths were recorded. There were no significant differences with regard to severity of envenoming versus the frequency of blood coagulation disorders among the three categories of envenoming (p = 0.75) or in the frequency of patients with AV early reactions between the groups that were and were not pretreated (p = 0.55). The frequency of local infection was significantly greater in severe cases (p < 0.001). Patients admitted more than 6 h after the bite had a higher risk of developing severe envenoming (p = 0.04).De janeiro de 1984 a março de 1999, 73 crianças com menos de 15 anos de idade (1 a 14 anos, mediana = 9 anos) foram admitidas após terem sido picadas por serpentes do gênero Bothrops. 26,0% das crianças foram classificadas como acidente leve, 50,7% como moderado e 20,6% como grave. Dois pacientes (2,7%) não apresentaram sinais de envenenamento. A maioria dos pacientes apresentou manifestações locais, principalmente edema (94,5%), dor (94,5%), equimoses (73,9%) e bolhas (11,0%). Sangramento local e/ou sistêmico foi constatado em 28,8% das crianças. Alterações da coagulação, antes da administração da soroterapia antiveneno (SAV), foram observadas em 60,7% (sangue incoagulável em 39,3%) das 56 crianças que receberam a SAV exclusivamente em nosso hospital. Reações precoces à SAV foram observadas em 44,6% destes 56 casos, sendo 15 em 30 pacientes não pré-tratados e 10 dentre 26 pré-tratados com antagonistas H1 e H2 da histamina e hidrocortisona, a maioria das quais foi considerada leve. As principais complicações observadas foram a infecção local (15,1%), a síndrome de compartimento (4,1%), gangrena (1,4%) e insuficiência renal aguda (1,4%). Nenhum óbito foi registrado. Não foram constatadas diferenças estatísticas significativas comparando-se a freqüência de distúrbios da coagulação de acordo com a gravidade (p = 0,75), bem como na freqüência de reações precoces à SAV entre os grupos que receberam ou não o pré-tratamento (p = 0,55). A freqüência de infecção local foi significativamente maior nos casos graves (p < 0,001). Pacientes atendidos mais de 6 horas após o acidente apresentaram um maior risco quanto à evolução para casos graves (p = 0,04)

Hemorrhagic Shock Secondary To Button Battery Ingestion.

Button battery ingestion is a frequent pediatric complaint. The serious complications resulting from accidental ingestion have increased significantly over the last two decades due to easy access to gadgets and electronic toys. Over recent years, the increasing use of lithium batteries of diameter 20 mm has brought new challenges, because these are more detrimental to the mucosa, compared with other types, with high morbidity and mortality. The clinical complaints, which are often nonspecific, may lead to delayed diagnosis, thereby increasing the risk of severe complications. A five-year-old boy who had been complaining of abdominal pain for ten days, was brought to the emergency service with a clinical condition of hematemesis that started two hours earlier. On admission, he presented pallor, tachycardia and hypotension. A plain abdominal x-ray produced an image suggestive of a button battery. Digestive endoscopy showed a deep ulcerated lesion in the esophagus without active bleeding. After this procedure, the patient presented profuse hematemesis and severe hypotension, followed by cardiorespiratory arrest, which was reversed. He then underwent emergency exploratory laparotomy and presented a new episode of cardiorespiratory arrest, which he did not survive. The battery was removed through rectal exploration. This case describes a fatal evolution of button battery ingestion with late diagnosis and severe associated injury of the digestive mucosa. A high level of clinical suspicion is essential for preventing this evolution. Preventive strategies are required, as well as health education, with warnings to parents, caregivers and healthcare professionals.132184-

Choque hemorrágico secundário à ingestão de bateria em disco

CONTEXT: Button battery ingestion is a frequent pediatric complaint. The serious complications resulting from accidental ingestion have increased significantly over the last two decades due to easy access to gadgets and electronic toys. Over recent years, the increasing use of lithium batteries of diameter 20 mm has brought new challenges, because these are more detrimental to the mucosa, compared with other types, with high morbidity and mortality. The clinical complaints, which are often nonspecific, may lead to delayed diagnosis, thereby increasing the risk of severe complications. CASE REPORT: A five-year-old boy who had been complaining of abdominal pain for ten days, was brought to the emergency service with a clinical condition of hematemesis that started two hours earlier. On admission, he presented pallor, tachycardia and hypotension. A plain abdominal x-ray produced an image suggestive of a button battery. Digestive endoscopy showed a deep ulcerated lesion in the esophagus without active bleeding. After this procedure, the patient presented profuse hematemesis and severe hypotension, followed by cardiorespiratory arrest, which was reversed. He then underwent emergency exploratory laparotomy and presented a new episode of cardiorespiratory arrest, which he did not survive. The battery was removed through rectal exploration. CONCLUSION: This case describes a fatal evolution of button battery ingestion with late diagnosis and severe associated injury of the digestive mucosa. A high level of clinical suspicion is essential for preventing this evolution. Preventive strategies are required, as well as health education, with warnings to parents, caregivers and healthcare professionals1323184188CONTEXTO: A ingestão de bateria em disco é queixa frequente em pediatria. As complicações graves decorrentes de ingestão acidental têm aumentado significativamente nas últimas duas décadas, devido ao fácil acesso aos aparelhos e brinquedos eletrônicos. Nos últimos anos, o aumento do uso de baterias de lítio com diâmetro de 20 mm trouxe novos desafios, por serem mais prejudiciais para a mucosa em comparação com outros tipos, com elevada morbidade e mortalidade. As queixas clínicas, muitas vezes inespecíficas, podem levar ao atraso no diagnóstico, aumentando o risco de complicação grave. RELATO DE CASO: Menino de cinco anos, com queixa de dor abdominal há 10 dias, é trazido ao serviço de emergência com quadro clínico de hematêmese há duas horas. Na admissão, apresentava palidez, taquicardia e hipotensão. Imagem sugestiva de bateria em disco foi visualizada na radiografia simples de abdome. A endoscopia digestiva demonstrou lesão ulcerada profunda no esôfago sem sangramento ativo. Após o procedimento, o paciente apresentou hematêmese profusa e hipotensão grave, seguidos de parada cardiorrespiratória (PCR), revertida. Submetido a laparotomia exploradora de urgência, apresentou novo episódio de PCR, sem reversão. A bateria foi removida por exploração retal. CONCLUSÃO: Este caso descreve a evolução fatal de ingestão da bateria em disco com diagnóstico tardio e associação com lesão grave de mucosa digestiva. Alto nível de suspeita clínica é obrigatório para evitar tal evolução. As estratégias de prevenção são necessárias, bem como a educação em saúde, com alerta aos pais, cuidadores e profissionais de saúdesem informaçã

Cost estimate of mammographic screening in climacteric women

PURPOSE: to evaluate the cost of preventive mammographic screening in climacteric women, as compared to the cost of breast cancer treatment in more advanced stages. METHODS: one thousand and fourteen patients attended at the Climacteric outpatient service of the Gynecology Department, Federal University of São Paulo Paulista School of Medicine, were included in the study and submitted to mammographic test. All mammographic test's were analyzed by the same two physicians and classified according to the BI-RADS (Breast Imaging Reporting and Data System American College of Radiology) categories. The detected lesions were submitted to cytological and histological examination. RESULTS: the final diagnostic impression of the 1014 examinations, according to the classification of BI-RADS categories was: 1=261, 2=671, 3=59, 4=22 and 5=1. The invasive procedures were performed through a needle guided by ultrasound or stereotactic examinations: 33 fine-needle aspiration biopsies, 6 core biopsies guided by ultrasound and 20 core biopsies guided by stereotactic examination. Five cancer diagnoses were established. The total cost of this screening based on Brazilian procedure values was R$76,593.79 (25,534 dollars). Therefore, the cost of the diagnosis of the five cases of cancer in this screening was R$ 15,318.75 (5,106 dollars) each. However, the average cost per patient screened was R$75.53 (25 dollars). CONCLUSIONS: considering that the total treatment cost of only one case of breast cancer in advanced stage including hospital costs, surgery, chemotherapy, radiotherapy and hormonal treatment is similar to the cost of 1,000 mammographic screenings in climacteric women, it may be concluded that the cost of the early cancer diagnosis program is worth it and should be included in the public health program, as a way of lowering the public health expense.OBJETIVOS: analisar os custos de um ciclo de rastreamento mamográfico do câncer de mama em população de 1014 mulheres no climatério e comparar com os custos do tratamento do câncer da mama em estádios mais avançados. MÉTODOS: realizou-se rastreamento em 1014 mulheres atendidas em ambulatório de Climatério. Todas as mamografias foram classificadas de acordo com as categorias do BI-RADSä (Breast Imaging Reporting and Data System American College of Radiology) e as lesões detectadas foram submetidas a estudo citológico ou histológico. A estimativa dos custos dos exames e procedimentos realizados foram obtidos da Tabela AMB 92. RESULTADOS: a impressão diagnóstica final dos 1014 exames, de acordo com a classificação em categorias do BI-RADSä, foi: 1=261; 2=671; 3=59; 4=22; 5=1. Os procedimentos invasivos realizados totalizaram 33 punções com agulha fina dirigida por USG, 6 biópsias com agulha grossa orientada por USG e 20 biópsias orientadas por mamografia (estereotaxia). Com base nos valores da tabela AMB 92, foram necessários para rastrear e diagnosticar essa população cerca de R$ 76.000,00. Detectaram-se 5 cânceres de mama, ao custo aproximado de R$15.318,75 por diagnóstico e média de custo por paciente de R$ 75,53. CONCLUSÕES: considerando que o custo total do tratamento de um único caso de câncer de mama em estádio II ou mais pode atingir R$ 75.000,00, concluímos que os programas de rastreamento mamográfico podem ser incluídos entre as políticas de saúde.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de GinecologiaUNIFESP, EPM, Depto. de GinecologiaSciEL