Estimates of avoided costs attributed to a short cervix screening program to prevent preterm birth from the perspective of the Unified Health System (SUS) / Estimativa de custos evitados atribuídos a um programa de rastreio de colo curto para prevenção da prematuridade na perspectiva do SUS

ABSTRACT OBJECTIVE To perform an economic cost analysis of the implementation of a short cervix screening program to reduce preterm birth in singleton pregnancies in a short-term time horizon. METHODS We performed a cost-benefit economic analysis using the P5 trial database, a randomized multicenter clinical trial for prevention of preterm birth. Data collection was conducted from July 2015 to March 2019 in 17 different Brazilian hospitals. We conducted a cost analysis for universal cervical screening in singleton pregnancies between 18 weeks and 22 weeks plus 6 days. In subjects with a cervical length ≤ 25 mm, the analysis incorporated the costs of administering 200 mg/day of vaginal progesterone prophylactically until 36 weeks gestation. These findings were subsequently compared with the economic implications of forgoing cervical screening. The time horizon comprised from birth to 10 weeks postpartum. The outcome was measured monetarily in Brazilian real (R$) from the perspective of the Unified Health System. RESULTS Among 7,844 women, 6.67% (523) had a cervix ≤ 25 mm. The cost of screening with transvaginal ultrasound and vaginal progesterone for prevention of births with < 34 weeks was estimated at R$ 383,711.36, while non-screening generated an estimated additional cost of R$ 446,501.69 (related to the 29 non-screened preterm deliveries). Thus, screening and prophylaxis would generate a final cost reduction of R$ 62,790.33, constituting a possible cost-benefit strategy. CONCLUSION Universal short cervix screening for preterm birth has lower costs compared to non-screening within a short-term time horizon, which suggests an interesting benefit-cost ratio. Future studies should consider the cost-effectiveness of prophylactic treatment using sensitivity analyses in different scenarios within the Brazilian health system, as well as analyses that consider the long-term costs associated with preterm births, to robustly justify the implementation of a short cervix screening program.

RESUMO OBJETIVO Realizar uma análise econômica de custo da implementação de um programa de rastreio de colo curto para redução da prematuridade em gestações únicas num horizonte temporal de curto prazo. MÉTODOS Realizamos uma análise econômica do tipo custo-benefício utilizando o banco de dados do P5 trial, um ensaio clínico multicêntrico randomizado para prevenção da prematuridade. A coleta de dados ocorreu de julho de 2015 a março de 2019 em 17 diferentes hospitais do Brasil. Comparamos os custos do rastreamento universal em mulheres com gestação única de 18 a 22 semanas e 6 dias associado à progesterona vaginal profilática 200 mg/dia até 36 semanas naquelas com colo ≤ 25 mm com os do não rastreamento. O horizonte temporal foi do nascimento até 10 semanas após o parto. O desfecho foi medido monetariamente em real brasileiro (R$) na perspectiva do Sistema Único de Saúde. RESULTADOS Entre 7.844 mulheres, 6,67% (523) apresentaram colo ≤ 25mm. O custo do rastreio com a ultrassonografia transvaginal mais a progesterona vaginal para prevenção de nascimentos < 34 semanas foi estimado em R$ 383.711,36, enquanto o não rastreamento gerou custo adicional estimado de R$ 446.501,69 (relacionado aos 29 partos prematuros não rastreados). Assim, o rastreamento mais a profilaxia geraria uma redução de custo final de R$ 62.790,33, apresentando-se como uma possível estratégia de custo-benefício. CONCLUSÃO O rastreamento universal de colo curto para prematuridade apresenta menores custos em relação ao não rastreamento dentro de um horizonte temporal de curto prazo, o que sugere uma interessante relação de custo versus benefício. Novos estudos que considerem a custo-efetividade do tratamento profilático utilizando-se de análises de sensibilidade em diferentes cenários dentro do sistema de saúde brasileiro, assim como análises que considerem os custos de longo prazo atrelados ao nascimento prematuro, são necessários para justificar com robustez a implementação de um programa de rastreamento.

Kidney health for everyone everywhere - from prevention to detection and equitable access to care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. However, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions - be it primary, secondary, or tertiary. This article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management, and treatment are often lacking. Hence, there is an urgent need to increase the awareness of preventive measures throughout populations, professionals, and policy makers.

Estimation of the costs of invasive cervical cancer treatment in Brazil: A micro-costing study / Estimativa dos custos do tratamento do câncer do colo do útero invasivo no Brasil: um estudo de microcustos

Abstract Objective Themain objective of the present study was to estimate the annual treatment costs of invasive cervical cancer (ICC) per patient at an oncology center in Brazil from a societal perspective by considering direct medical, direct nonmedical, and indirect costs. Methods A cost analysis descriptive study, in which direct medical, direct nonmedical, and indirect costs were collected using a microcosting approach, was conducted between May 2014 and July 2016 from a societal perspective. The study population consisted of women diagnosed with ICC admitted to a tertiary hospital in Recife, state of Pernambuco, Brazil. The annual cost per patient was estimated in terms of the value of American Dollars (US$) in 2016. Results From a societal perspective, the annual ICC treatment cost per patient was US $ 2,219.73. Direct medical costs were responsible for 81.2% of the total value, of which radiotherapy and outpatient chemotherapy had the largest share. Under the base-case assumption, the estimated cost to the national budget of a year of ICC treatment in the Brazilian population was US$ 25,954,195.04. Conclusion We found a high economic impact of health care systems treating ICC in a poor region of Brazil. These estimates could be applicable to further evaluations of the cost-effectiveness of preventing and treating ICC.

Resumo Objetivo O objetivo principal do presente estudo foi estimar os custos anuais por paciente do tratamento do câncer do colo do útero (CCU) invasivo em um centro de oncologia no Brasil, sob a perspectiva da sociedade, considerando os custos diretos médicos, diretos não médicos e indiretos. Métodos Foi realizado um estudo descritivo de análise de custos, no qual os custos médicos diretos, não médicos diretos e indiretos foram coletados por meio de uma abordagem de microcustos, realizado entre maio de 2014 e julho de 2016 sob a perspectiva da sociedade. A população do estudo foi composta por mulheres diagnosticadas com CCU invasivo internadas em um hospital terciário em Recife, PE, Brasil. O custo anual por paciente foi estimado emtermos de dólares americanos (US$) para o ano de 2016. Resultados O custo anual do tratamento do CCU invasivo sob a perspectiva da sociedade foi de US$ 2.219,73 por paciente. Os custos médicos diretos foram responsáveis por 81,2% do valor total, dos quais a radioterapia e a quimioterapia ambulatorial tiveram a maior participação. Sob o pressuposto do caso base, o custo estimado para o orçamento nacional de um ano de tratamento do CCU invasivo na população brasileira foi de US$ 25.954.195,04. Conclusão Foi encontrado um alto impacto econômico dos sistemas de saúde para o tratamento do CCU invasivo em uma região pobre do Brasil. Essas estimativas poderão ser aplicáveis emavaliações adicionais do custo-efetividade da prevenção e tratamento do CCU.

Screening for Non-communicable Diseases at a Walk-in Clinic in Trinidad and Tobago: A Time-motion Cross-sectional Study and Net Present Value Analysis / Pruebas de detección de enfermedades no transmisibles en una clínica ambulatoria de Trinidad y Tobago: estudio transversal de tiempos y movimientos y análisis del valor actual neto

ABSTRACT Objective: To determine the feasibility of recommending a screening process for non-communicable diseases (NCDs) and their risk factors, as a national and regional model. Methods: A cross-sectional, six-station process was carried out. It consisted of invitation and consent, history (personal and family history of NCDs), biometrics (waist circumference and body mass index), blood levels (lipids and glycosylated haemoglobin) and urinalysis (microalbuminuria), basic examinations (blood pressure, peripheral neuropathy, presence of acanthosis nigricans and visual acuity), and an exit interview. Net present value (NPV) calculations were carried out for very high-risk patients (those with a > 30% risk of a cardiovascular event (limb amputation) in the next 10 years) for two discount rates: 0.75% (United States of America) and 3.4% (Trinidad and Tobago). Results: A convenience sample of 514 walk-in patients (56.2% recruitment rate) was screened (about 23 patients per day). The median time for a patient attending all stations was 21 minutes (range: 11-59 minutes). Of the six stations, the laboratory took the longest: median 10 minutes (range: 2-50 minutes). The entire project cost US$20 439 (US$39.76 per patient). Between one and seven very high-risk patients (three sub-groups of patients had this risk profile) were identified. The cost of identifying a very high-risk patient ranged from US$2907 to US$20 349. The NPV of identifying these high-risk patients ranged from -US$6748.71 to US$14 725 and was favourable for three of four monetary scenarios. Conclusion: A six-station process to provide rapid screening of walk-in patients for NCDs was found to be feasible and provided monetary value in three of four scenarios in a Trinidad and Tobago setting.

RESUMEN Objetivo: Determinar la viabilidad de recomendar un proceso de cribado de las enfermedades no transmisibles (ENT) y sus factores de riesgo, como modelo nacional y regional. Métodos: Se realizó un proceso transversal de seis estaciones. El mismo consistió en invitación y consentimiento; historia (antecedentes personales y familiares de ENT); biometría (circunferencia de la cintura e índice de masa corporal); niveles sanguíneos (lípidos y hemoglobina glicosilada); y análisis de orina (microalbuminuria); exámenes básicos (presión arterial, neuropatía periférica, presencia de acantosis nigricans y agudeza visual); y una entrevista de salida. Se realizaron cálculos del valor actual neto (VAN) para pacientes de muy alto riesgo - pacientes con riesgo de un 30% de evento cardiovascular (amputación de extremidades) en los próximos 10 años - para dos tasas de descuento: 0.75% (Estados Unidos de América) y 3.4% (Trinidad y Tobago). Resultados: Una muestra de conveniencia de 514 pacientes ambulatorios (tasa de reclutamiento de 56.2%) fue sometida a pruebas de detección (unos 23 pacientes por día). El tiempo promedio para que un paciente asistiera a todas las estaciones fue de 21 minutos (rango: 11-59 minutos). De las seis estaciones, el laboratorio tomó el tiempo más largo: un promedio de 10 minutos (rango: 2-50 minutos). El proyecto entero costó $20 439 USD (39.76 USD por paciente). Entre uno y siete pacientes de muy alto riesgo (tres subgrupos de pacientes tenían este perfil de riesgo) fueron identificados. El costo de identificar a un paciente de muy alto riesgo osciló entre $2907 USD y $20 349 USD. El VAN de identificación de estos pacientes de alto riesgo fluctuó de $6748.71 a $14 725 USD, y fue favorable para tres de cuatro escenarios monetarios. Conclusión: Se halló que un proceso de seis estaciones para pruebas de detección rápidas de ENT a pacientes ambulatorios, es factible y proporciona valor monetario en tres de cuatro escenarios en un contexto de Trinidad y Tobago.

Effectiveness of breast cancer screening policies in countries with medium-low incidence rates

ABSTRACT Chile has lower breast cancer incidence rates compared to those in developed countries. Our public health system aims to perform 10 biennial screening mammograms in the age group of 50 to 69 years by 2020. Using a dynamic programming model, we have found the optimal ages to perform 10 screening mammograms that lead to the lowest lifetime death rate and we have evaluated a set of fixed inter-screening interval policies. The optimal ages for the 10 mammograms are 43, 47, 51, 54, 57, 61, 65, 68, 72, and 76 years, and the most effective fixed inter-screening is every four years after the 40 years. Both policies respectively reduce lifetime death rate in 6.4% and 5.7% and the cost of saving one life in 17% and 9.3% compared to the 2020 Chilean policy. Our findings show that two-year inter-screening interval policies are less effective in countries with lower breast cancer incidence; thus we recommend screening policies with a wider age range and larger inter-screening intervals for Chile.

Association of high-density lipoprotein and apolipoprotein E genetic variants with age-related macular degeneration / Associação de lipoproteína de alta densidade e variantes genéticas da apolipoproteína E com degeneração macular relacionada à idade

Purpose: This study aimed to evaluate the association of age-related macular degeneration (AMD) with apolipoprotein E (APOE) variants and serum lipid profiles, including levels and fractions of total serum cholesterol (TC), low-density lipoprotein cholesterol (LDLc), and high-density lipoprotein cholesterol (HDLc), and triglycerides (TG). Methods: Genotyping of APOE-HhaI was performed in 134 patients (study group, SG) and 164 individuals without AMD (control group, CG), aged 50-89 years. Lipid profiles were analyzed in a subgroup of 30 subjects of both groups, matched according to age and sex. The significance level was set at P<0.05. Results: APOE E3/E3 was more prevalent (SG=74.6%; CG=77.4%), with no difference between both groups (P=0.667). The same result was observed for risk genotypes (APOE E -/2: SG=7.4%; CG=10.3%, P=0.624). Serum levels of TC, LDLc, and TG revealed similar median values between SG (193.5, 116, and 155 mg/dL, respectively) and CG (207.5, 120, and 123.5 mg/dL, respectively; P >0.05). For HDLc, a higher median value was observed in SG (53.3 mg/dL) versus CG (42.5 mg/dL; P=0.016). Logistic regression analysis showed the same value, and the HDLc/TC ratio was -11.423 (P=0.014), as also confirmed by an increase in HDLc in SG. The association between lipid profiles and apolipoprotein E genotypes was similar in both groups (P>0.05). Conclusion: APOE-HhaI is not associated with AMD. However, an increase in serum HDLc level appears to exert a protective effect against the disease, irrespective of the genetic variants of apoE. .

Objetivo: Este estudo teve como objetivo avaliar a associação de degeneração macular relacionada à idade (DMRI) com variantes de alipoproteína E (APOE) e perfil lipídico sérico, incluindo níveis séricos de colesterol total (TC) e frações de proteínas relacionadas a receptor de LDL (LDLc) e HDL colesterol (HDLc), e triglicérides (TG). Métodos: Realizouse genotipagem de APOE-HhaI em 134 pacientes (grupo de estudo SG) e 164 indivíduos sem a doença (grupo controle CG), na faixa etária entre 5089 anos. O perfil lipídico sérico foi analisado em um subgrupo de 30 indivíduos de ambos os grupos, pareados por idade e sexo. Admitiuse nível de significância para valorP<0,05. Resultados: APOE E3/E3 prevaleceu (SG=74,6%; CG=77,4%), sem diferença entre os grupos (P=0,667), o mesmo ocorreu para genótipos de risco (APOE /E2: SG=7,4%; CG=10,3%,P=0,624).Níveis séricos de TC, LDLc e TG mostraram medianas semelhantes entre SG (193,5; 116; 155 mg/dL, respectivamente) e CG (207,5; 120; 123,5 mg/dL respectivamente; P>0,05). Para HDLc notouse valor de mediana elevado em SG (53,3 mg/dL) versus CG (42,5 mg/dL; P=0,016), constatado também na análise de regressão logística, cuja razão HDLc/TC mostrou coeficiente 11,423 (P=0,014), confirmando acréscimo de HDLc em SG. A relação entre perfil lipídico sérico e genótipos de APOE mostrou semelhança entre os grupos (P>0,05). Conclusão: APOE-HhaI não se associa a DMRI, no entanto, o acréscimo no nível sérico de HDLc parece ter efeito protetor contra a doença, independente de variantes genéticas da apoE. .

Adherencia al tamizaje de cáncer cérvicouterino: una mirada desde el modelo de determinantes sociales de la salud / Adherence to cervical cancer screening: a look from the social determinants of health model

ANTECEDENTES: Los Determinantes Sociales (DS) consideran "características del contexto social que afectan la salud, así como también los mecanismos por los cuales las condiciones sociales se traducen en impactos en salud". Las intervenciones cuyo objetivo son reducir la enfermedad serán exitosas solamente cuando consideren adecuadamente los DS de salud. OBJETIVO: Analizar, en base a la literatura existente, el modelo de determinantes sociales de la OMS y su aplicación a la adherencia al tamizaje de cáncer cérvicouterino (CC). RESULTADOS: Son variados los estudios que establecen la relación entre los determinantes estructurales e intermediarios y la adherencia al tamizaje. Si bien hay estudios contradictorios, es relevante la asociación positiva entre determinantes estructurales y mayor adherencia: un mayor nivel educacional, la presencia de empleo y un mayor ingreso familiar determinan una mayor adherencia al tamizaje. Como determinantes estructurales, son varios los factores reportados, entre los que se encuentran las características del hogar, el tiempo de permanencia, las características del sistema de salud, su disponibilidad y contacto con profesionales de la salud, factores de riesgo para CC, conocimiento acerca de la enfermedad así como también las creencias, entre otras. CONCLUSIÓN: Es necesario considerar la prevención de CC desde una perspectiva mucho más amplia, con un enfoque que va mas allá de los fenómenos biomédicos que la falta de adherencia al tamizaje conlleva, sino como una problemática social que explica dicho comportamiento en salud. Se sugiere que las campañas de prevención de CC consideren el enfoque de DS.

BACKGROUND: Social Determinants consider "characteristics of the social context that affect health, as well as the mechanisms by which social conditions translate into health impacts". Interventions aimed at reducing diseases will be successful only when properly considered the social determinants of health. OBJECTIVE: Analyze, based on the existing literature, WHO's Social Determinants of health model and its application to cervical cancer (CC) screening adherence. RESULTS: There are many studies that establish the relationship between structural and intermediate determinants and adherence to screening. Even though there are contradictory studies, it is important the positive association between structural determinants and greater adherence: a higher education, employment and the presence of increased house holding come determine a greater adherence to screening. As structural determinants, several factors are reported, including house hold characteristics, residence time, characteristics of the health system, availability and contact with health professionals, risk factors for cervical cancer, knowledge and beliefs of the disease, among others. CONCLUSION: It is necessary to consider CC prevention from a much wider perspective, with an approach that goes beyond the biomedical phenomena that the lack of screening adherence entails, but as a social problem that explains this health behavior. It is suggested that CC prevention campaigns should consider the Social Determinants approach.

Cost-Utility Analysis of Screening Strategies for Diabetic Retinopathy in Korea

This study involved a cost-utility analysis of early diagnosis and treatment of diabetic retinopathy depending on the screening strategy used. The four screening strategies evaluated were no screening, opportunistic examination, systematic fundus photography, and systematic examination by an ophthalmologists. Each strategy was evaluated in 10,000 adults aged 40 yr with newly diagnosed diabetes mellitus (hypothetical cohort). The cost of each strategy was estimated in the perspective of both payer and health care system. The utility was estimated using quality-adjusted life years (QALY). Incremental Cost Effectiveness Ratio (ICER) for the different screening strategies was analyzed. After exclusion of the weakly dominating opportunistic strategy, the ICER of systematic photography was 57,716,867 and that of systematic examination by ophthalmologists was 419,989,046 from the perspective of the healthcare system. According to the results, the systematic strategy is preferable to the opportunistic strategy from the perspective of both a payer and a healthcare system. Although systematic examination by ophthalmologists may have higher utility than systematic photography, it is associated with higher cost. The systematic photography is the best strategy in terms of cost-utility. However systematic examination by ophthalmologists can also be a suitable policy alternative, if the incremental cost is socially acceptable.

Custo-efetividade de um programa de rastreamento organizado de câncer de mama no Sul do Brasil / Cost-effectiveness of an organized breast cancer screening program in Southern Brazil / Coste-efectividad de un programa organizado para la detección precoz del cáncer de mama en el sur de Brasil

O objetivo deste estudo foi avaliar o custo-efetividade de um programa organizado de rastreamento mamográfico de câncer de mama implementado na cidade de Porto Alegre, Rio Grande do Sul, Brasil (Núcleo Mama Porto Alegre - NMPOA). Foi construído modelo de Markov para estimar a relação de custo-efetividade incremental do NMPOA em comparação à situação atual de atenção ao câncer de mama no SUS, em coorte hipotética de mulheres de 40-69 anos com risco de desenvolver câncer de mama. Os parâmetros foram coletados do NMPOA e da literatura nacional. Na estratégia NMPOA, a efetividade foi modelada levando-se em conta a real adesão da população participante do rastreamento. A efetividade foi medida em anos de vida ajustados para qualidade (QALY). A relação de custoefetividade incremental no caso base foi de R$ 13.426,00 por QALY. Esse resultado foi pouco sensível à variação dos principais parâmetros do modelo nas análises de sensibilidade. Considerando o limiar usualmente sugerido como bastante atrativo do ponto de vista econômico no Brasil, o rastreamento do câncer de mama nos moldes do NMPOA é custo-efetivo em cidades com alta incidência deste tipo de câncer.

The aim of this study was to evaluate the cost-effectiveness of an organized breast cancer mammographic screening program implemented in Porto Alegre (Núcleo Mama Porto Alegre - NMPOA), Rio Grande do Sul State, Brazil. A Markov model was constructed to estimate the incremental cost-effectiveness ratio of NMPOA compared to current BC diagnosis and care in the Brazilian public health system, in a hypothetical cohort of women aged 40-69 years at risk of developing breast cancer. Model parameters were collected from NMPOA and the national literature. In the NMPOA strategy, effectiveness was modeled taking into account the actual observed screening adherence. Effectiveness was measured in quality-adjusted life years (QALYs). Incremental cost-effectiveness ratio in the base case was R$ 13,426 per QALY. This result was not sensitive to variation in the main model parameters in sensitivity analyses. Considering the threshold usually suggested as highly attractive in Brazil, breast cancer screening as performed in NMPOA is cost-effective in cities with high incidence of breast cancer.

El objetivo de este estudio fue evaluar el coste-efectividad de un programa organizado para el diagnóstico precoz con mamografía del cáncer de mama, implementado en Porto Alegre, Rio Grande do Sul, Brasil (Núcleo Mama Porto Alegre -NMPOA). Se utilizó el modelo de Markov, con el fin de estimar la tasa de costeefectividad incremental de NMPOA, comparada con la situación actual en lo referente a la atención del cáncer de mama en el sistema público de salud brasileño. El estudio se realizó en una cohorte hipotética de mujeres entre 40-69 años con riesgo de cáncer de mama. Los parámetros se obtuvieron del NMPOA y literatura nacional. En la estrategia del NMPOA, la eficacia se modeló teniendo en cuenta la adhesión real de la población al programa. La efectividad se midió en años de vida ajustados por calidad (QALY). La tasa de coste-efectividad incremental en el caso base fue R$ 13.426,00 por QALY. Este resultado no fue sensible a la variación de los principales parámetros del modelo en el análisis de sensibilidad. Teniendo en cuenta el umbral frecuentemente aceptado como muy alto económicamente en Brasil, un programa similar al NMPOA es coste-efectivo en ciudades con alta incidencia de cáncer de mama.

Prevention of cervical cancer in women with ASCUS in the Brazilian Unified National Health System: cost-effectiveness of the molecular biology method for HPV detection / Prevenção de câncer de colo uterino em pacientes com ASCUS no Sistema Único de Saúde: custo-efetividade de método de biologia molecular para HPV

This study aimed to assess the performance of PCR as a means of detecting HPV 16/18 compared to the single probe-based PCR for detecting high-risk HPV, and evaluate these methods for detecting cervical intraepithelial neoplasia (CIN) in follow-ups for ASCUS testing. It also compares the costs of cytology, PCR methods, colposcopy and biopsy in the Brazilian Unified National Health System. Of the 81 patients with ASCUS, 41 (50.6%) tested positive for HPV 16/18 in PCR testing and 47 (58.02%) tested positive for high-risk HPV with single probe-based PCR testing. The negative predictive value was 93.75% for HPV 16/18 PCR and 100% for single probe-based PCR in cases that progressed to high-grade CIN. The annual costs of patient referral were the following: R$2,144.52 for referral of patients with ASCUS cytology for colposcopy; R$6,307.44 for referral of patients with ASCUS cytology and PCR positive for HPV 16/18 or colposcopy; R$3,691.80 for referral of patients with ASCUS cytology with single probe-based PCR positive for high-risk HPV. Therefore, cost per user can be reduced by performing single probe-based PCR for high-risk HPV on patients with ASCUS.

Os objetivos deste estudo foram avaliar o desempenho do PCR para detecção de HPV 16/18 versus PCR sonda única para a detecção de HPV de alto risco, avaliar estes métodos na detecção de neoplasia intraepitelial cervical (NIC) no seguimento de ASCUS, e comparar os custos de citologia, métodos de PCR, colposcopia e biópsia no Sistema Único de Saúde. Das 81 pacientes com ASCUS, 41 (50,6%) foram positivas para o HPV 16/18 PCR, e 47 (58,02%) foram positivas para PCR sonda única para HPV de alto risco. O valor preditivo negativo foi de 93,75% para HPV 16/18 PCR e 100% para PCR sonda única em casos que evoluíram para NIC de alto grau. Os custos anuais encaminhando todas as pacientes com ASCUS para a colposcopia, encaminhando à colposcopia as pacientes com ASCUS e PCR positivo para HPV 16/18 e encaminhando à colposcopia aquelas pacientes com ASCUS e PCR sonda única para HPV de alto risco positivo foram de R$2.144,52, R$6.307,44 e R$3.691,80, respectivamente. Considerando eventual redução dos custos para utilização em grandes quantidades, este método poderia ser realizado em ASCUS.

Rastreamento das infecções perinatais na gravidez: realizar ou não? / Perinatal infections screening during pregnancy: perform it or not?

Devido à conhecida importância das infecções adquiridas intraútero, vários serviços médicos em todo o mundo preconizam o rastreio das doenças passíveis de transmissão vertical. Entretanto, há muitos questionamentos na literatura a respeito da real relevância, custo-benefício e aplicabilidade do rastreamento. Corrobora essa assertiva a terapêutica ineficiente, a baixa prevalência para algumas dessas afecções e a reduzida confiabilidade e elevado custo de certos testes laboratoriais usados para o rastreamento. Por outro lado, o rastreio e posterior tratamento de algumas infecções resultam na diminuição da morbimortalidade, o que é de extrema relevância, uma vez que reduz sequelas fetais e auxilia na manutenção da saúde das gestantes. Mais estudos são necessários para o estabelecimento de um panorama completo a respeito do rastreamento das infecções perinatais, pois, além dos impasses expostos, é importante considerar as características epidemiológicas de cada população, o que requer pesquisas mais aprofundadas. Esta revisão da literatura teve como objetivo reunir evidências quanto à recomendação ou não do rastreamento destas doenças durante o pré-natal nas diversas entidades de relevância nacional e internacional.

Due to the importance of intrauterine acquired infections, severalguidelines suggest the screening of diseases that can be vertically transmitted. However, there are questionsabout the real relevance, cost-benefit and applicability of this practice. The absence of an efficient treatmentand the small prevalence of some of these disorders combined with the reduced reliability and high costsof some laboratorial tests used for screening, confirm this statement. On the other hand, the possibility oftreatment associated with the screening and the subsequent reduction of morbimortality are a very relevantpoint, once it attenuates fetal sequelae and helps keeping pregnant women health. More studies are needed toestablish a complete picture of the screening of perinatal infections because beyond the impasses presentedabove, it is important to consider the epidemiological characteristics of each population, which requires moreextensive research. This literature review attempted to gather information about the importance of the prenatalscreening of perinatal infections in different and relevant national and international entities.

International programs for the detection of breast cancer

The benefit of early breast cancer detection is the foundation for programs around the globe to reduce morbidity and mortality related to breast cancer. These programs range from educational programs targeted to women and health professionals to organized or opportunistic screening programs that target specific age groups of women.Modern mammography programs tend to follow the protocols from the randomized clinical trials, but there is variation in key program elements such as the age groups invited to screening, the screening interval, performance indicators, and the uptake rate. Until recently, the emphasis on early breast cancer detection was limited to mammography, but the steady rise in incidence and mortality in low and medium resource countries, where mammography may be unaffordable, has led to a renewal in emphasizing the incremental value of downsizing palpable tumors through physical exams. There is consensus that programs should be designed based on disease burden and available resources, but that even in low resource countries there are opportunities to reduce breast deaths through earlier diagnosis and effective treatment. Screening programs are most effective when they are organized, and program planners should consider WHO criteria and local input data as a basis for tailoring screening programs to the needs of their population.

El beneficio de la detección temprana del cáncer de mama es el fundamento para programas alrededor del mundo que buscan reducir la morbilidad y mortalidad relacionada con este padecimiento. Estos programas abarcan desde los de tipo educativo, orientados a mujeres y profesionales de la salud, hasta programas de monitoreo organizados u oportunistas que tienen como objetivo grupos específicos de edad. Los programas modernos de mastografía tienden a seguir protocolos para estudios clínicos aleatorios,pero hay una variación en elementos clave como los grupos de edad invitados a participar, el intervalo para el monitoreo, indicadores de desempeño, y la tasa de captación. Hasta hace poco, el énfasis en la detección temprana del cáncer estaba limitado a la mastografía, pero el incrementoen la incidencia ymortalidad en países de recursos bajos a medios, donde las mastografías no son asequibles, ha llevado a un renovado énfasis en el valor de los exámenes físicos. Existe un consenso en cuanto a que los programas deben estar diseñados basándose en la carga de la enfermedad y los recursos disponibles, pero incluso los países con recursos más limitados tienen oportunidades para reducir las muertes de cáncer de mama a través de un diagnóstico oportuno y un tratamiento eficaz. Los programas de detección son más eficaces cuando están organizados, y los planeadores del programa deben considerar los criterios de la OMS y la información local como bases para ajustarlos a las necesidades de la población.

Development and analysis of a low-cost screening tool to identify and classify hearing loss in children: a proposal for developing countries

OBJECTIVE: A lack of attention has been given to hearing health in primary care in developing countries. A strategy involving low-cost screening tools may fill the current gap in hearing health care provided to children. Therefore, it is necessary to establish and adopt lower-cost procedures that are accessible to underserved areas that lack other physical or human resources that would enable the identification of groups at risk for hearing loss. The aim of this study was to develop and analyze the efficacy of a low-cost screening tool to identify and classify hearing loss in children. METHODS: A total of 214 2-to-10 year-old children participated in this study. The study was conducted by providing a questionnaire to the parents and comparing the answers with the results of a complete audiological assessment. Receiver operating characteristic (ROC) curves were constructed, and discriminant analysis techniques were used to classify each child based on the total score. RESULTS: We found conductive hearing loss in 39.3 percent of children, sensorineural hearing loss in 7.4 percent and normal hearing in 53.3 percent. The discriminant analysis technique provided the following classification rule for the total score on the questionnaire: 0 to 4 points - normal hearing; 5 to 7 points - conductive hearing loss; over 7 points - sensorineural hearing loss. CONCLUSION: Our results suggest that the questionnaire could be used as a screening tool to classify children with normal hearing or hearing loss and according to the type of hearing loss based on the total questionnaire score.

Cost-effectiveness analysis of colorectal cancer screening methods in Iran

Screening can prevent colorectal cancer from becoming advanced by early detection of precancerous lesions. Cost-effectiveness analysis of colorectal cancer screening methods is highly necessary due to increased prevalence, decreased age at onset and the limited budget in Iran. Methods of screening currently available in Iran were selected. A systematic search revealed the sensitivity and specificity of each method. For this study, a model for a 20 year screening period of a population of 100000 apparently healthy persons of ages 45-65 years in Isfahan Province was used. The cost-effectiveness of each method and the ratio of cost-effectiveness were calculated based on this model. The most and the least effective methods were CT colonography and fecal occult blood test, respectively. The highest and lowest expenditures in the governmental sector were related to fecal occult blood test and flexible sigmoidoscopy and in the private sector, to CT colonography and fecal occult blood test, respectively. The cost per cancer detected in 20 years of screening in the governmental sector was 0.28, 0.22 and 0.42 billion Rials, respectively for screening by colonoscopy, flexible sigmoidoscopy and fecal occult blood test. In the private sector, these were 1.54 [colonoscopy], 1.68 [flexible sigmoidoscopy], and 1.60 [fecal occult blood test] billion and 2.58 billion Rials for CT colonography, respectively. Although CT colonography is the most effective method, it needs a budget of 2.58 billion Rials for each screened patient. If costs in the governmental sector are considered, flexible sigmoidoscopy would be the most cost-effective method for screening the 45-65-year-old population in Iran

[Cost-effectiveness analysis of screening strategies for cervical cancer in Tunisia]

We aimed to identify the most appropriate screening strategy for cervical cancer [periodicity of 3, 5 or 10 years] for Tunisia, taking into consideration the incidence of the disease, costs of screening and economic implications. We simulated follow-up of a fictitious cohort of 1 million women 35-39 years over 30 years. Computation of yearly medical care costs was based on data from medical files of patients diagnosed with cervical cancer in 2004 at the National Institute of Cancer, Tunis. For a 60% coverage level of screening, cervical cancer reduction would be 49.2% for a 3-year periodicity. The reduction would be 40.3% and 33.1% for 5 and 10 years periodicity respectively. Considering cost-effectiveness, 10-year screening gave the lowest annual cost to avoid 1 cervical cancer case

Comparison of fast protein liquid chromatography (FPLC) with HPLC, electrophoresis & microcolumn chromatography techniques for the diagnosis of β-thalassaemia.

Background & objectives: β-thalassaemia is a genetic disorder and an important health problem around the world. Quantitative haemoglobin A2 (HbA2) levels are used for the diagnosis of β-thalassaemia. The conventional methods are high performance liquid chromatography (HPLC), electrophoresis, and microcolumn chromatography techniques. We established a fast protein liquid chromatography (FPLC) method, to measure quantitatively of HbA2 levels, and compared its efficacy with conventional methods. Methods: The FPLC method, using a DEAE Sepharose, Hi Trap anion-exchange column chromatography technique was set up for HbA2 measurement. In this study, 220 blood samples were screened for haemoglobin type by FPLC technique and also using HPLC, microcolumn chromatography and electrophoresis. Results: The FPLC results were highly correlated (r = 0.985, P<0.001) with those of HPLC for quantification of HbA2 as well as cellulose acetate electrophoresis (r = 0.977) and microcolumn chromatography (r = 0.980). The FPLC method showed 100 per cent sensitivity and specificity, positive and negative predictive value for β-thalassaemia diagnosis. In addition, the FPLC method was simple, rapid, low cost and reproducible. The HbA2/E range of FPLC for β-thalassaemia was 6-10 per cent, HbE trait was 10-40 per cent, β-thalassaemia/HbE was 40-60 per cent and homozygous HbE was more than 60 per cent. Interpretation & conclusions: Our findings suggested that FPLC method could be used as a cost-effective method for routine β-thalassaemia diagnosis.