Evaluación económico ambiental de productos médicos de uso corriente en un hospital público de la Ciudad de Buenos Aires / Economic-environmental evaluation of commonly used medical devices in a public hospital of the City of Buenos Aires

INTRODUCCIÓN: Los establecimientos de atención de la salud utilizan sustancias y productos potencialmente peligrosos para la salud de los pacientes, los trabajadores, la comunidad o el entorno, ya sea en forma directa o transformados en residuos con potencial impacto ambiental. En el marco de la estrategia de Hospitales Sostenibles, se tiende a limitar la exposición a estos insumos minimizando su uso o reemplazándolos gradualmente por equivalentes de riesgo menor. Sin embargo, y con independencia de los márgenes de seguridad establecidos, la evaluación del impacto ambiental a lo largo de la cadena de valor no forma parte constitutiva del análisis costo-beneficio que antecede a la decisión de su adquisición y empleo. Este trabajo se propuso evaluar una herramienta de análisis económico-ambiental que permita seleccionar la alternativa más sostenible. MÉTODOS: Se utilizó el Proceso de Análisis Jerárquico para incorporar atributos ambientales en la evaluación de múltiples criterios aplicables a productos de similares propiedades e intención de uso con materiales potencialmente peligrosos. RESULTADOS: Se relevaron 125 productos o familias de productos médicos, y 93 cumplían los criterios de inclusión. Se observó una alta prevalencia de productos fabricados en PVC. DISCUSIÓN: La herramienta, que introduce criterios ambientales en el proceso de evaluación, es un instrumento eficaz para decidir una adquisición o incorporación al activo tecnológico de un establecimiento sanitario.

Mortalidad Asociada a Eventos Extremis de Frio en Argentina, 2005-2015 / Mortality Associated to Extreme Cold Events in Argentina, 2005-2015

La mortalidad guarda relación con las temperaturas diarias y los eventos extremos. Este estudio buscó analizar los efectos de las bajas temperaturas sobre la mortalidad en las principales ciudades de Argentina en el período 2005-2015. MÉTODOS: Se realizó un estudio de series temporales con modelos aditivos generalizados, modelando la relación entre bajas temperaturas y mortalidad para 21 ciudades de Argentina entre 2005 y 2015. Se analizó la mortalidad general y por grupos de sexo, edad y causa de muerte, en días fríos y días de olas de frío, así como los rezagos de 7 y 14 días posteriores a dichos eventos. RESULTADOS: En los 7 días posteriores a un día frío, el riesgo de muerte aumenta en la mitad de las ciudades entre un 1,04 [IC95%: 1,00-1,08] y un 1,14 [IC95%: 1,06-1,23] según la ciudad. El grupo de 65 años y más es el que muestra mayor impacto, con un incremento de hasta el 1,20 [IC95%: 1,05-1,39]. Las olas de frío se asocian con un aumento más pronunciado en el riesgo de morir en los siguientes 7 días en 8 ciudades (1,05 [IC95%: 1,03-1,08] a 1,30 [IC95%: 1,03-1,65]), y en 10 ciudades en los siguientes 14 días, aunque con valores algo más bajos. CONCLUSIONES: Con diferencias en magnitud y robustez estadística según las ciudades, la población de las áreas urbanas presenta un riesgo aumentado de muerte durante los 7 y 14 días posteriores a un evento de frío extremo

Environmental and health risks related to waste incineration.

The article presents a mini review of the published research focused on understanding environmental and human health impacts nearby waste incineration plants. We found no studies indicating that modern-technology waste incineration plants, which comply with the legislation on emissions, are a cancer risk factor or have adverse effects on reproduction or development. There are several factors in favor of this affirmation: (a) the emission levels of the plants currently built in the developed countries are several orders of magnitude lower than those of the plants in whose environments epidemiological studies have been carried out and which have found some kind of negative association in terms of health; (b) risk assessment studies indicate that most of the exposure is produced through the diet and not by a direct route; and (c) monitoring dioxin level studies in the population resident in the environment of incineration plants did not reveal increases of these levels when compared with a population living in reference areas. A necessary condition for the development of a waste incineration plant is to generate the conditions to prevent any impact that activates or potentially carries damage or risks to the environment and, in particular, to health. This makes it imperative to use a preventive strategy through the implementation of a previous environmental impact assessment and the establishment of emissions standards and an emissions monitoring program in order to ensure the prevention of environmental damage.

Hospitales sostenibles frente al cambio climático: Huella de carbono de un hospital público de la ciudad de Buenos Aires / Sustainable Hospitals Facing Climate Change: Carbon Footprint of a Public Hospital in Buenos Aires City

El cambio climático es una cuestión de salud pública. La huella de carbono constituye parte esencial de la huella ecológica de una entidad, que mide la superficie biológica necesaria para producir los bienes y servicios consumidos por la misma, así como la capacidad para asimilar los residuos que genera, por lo que es importante su estimación como indicadora del impacto ambiental que generan las actividades del establecimiento. OBJETIVOS: Estimar la huella de carbono del Hospital General de Agudos Enrique Tornú de la Ciudad Autónoma de Buenos Aires en 2015. MÉTODOS: estudio cuali-cuantitativo descriptivo, de tipo transversal, que incluyó las fuentes emisoras de gases con efecto invernadero para calcular las emisiones de las actividades del hospital desde la perspectiva de una organización. RESULTADOS: La huella de carbono obtenida en toneladas de dióxido de carbono equivalente fue 1526,47. El 43% fueron generadas por emisiones directas, 29% por emisiones indirectas por consumo de energía y el 28% restante por otras emisiones indirectas. Indicador obtenido: I2015 = 9,09 tCO2e/cama. CONCLUSIONES: Los resultados muestran el impacto ambiental generado por el funcionamiento del hospital y su contribución al calentamiento global. Los aportes de cada actividad permiten identificar las fuentes de emisión de mayor peso como áreas de oportunidad para la implementación de estrategias de reducción y/o mitigación. El indicador de desempeño permitirá medir avances en términos de reducción programada de emisiones

Accidentes y muertes por animales venenosos en Argentina durante el período 2000- 2011 / Accidents and deaths by venomous animals in Argentina during the period 2000-2011

En Argentina los accidentes causados por animales venenosos constituyen un problema de salud pública. En este estudio analizamos los accidentes y muertes por envenenamientos por mordedura o picadura de serpientes, escorpiones y arañas, y las muertes causadas por abejas- avispas-avispones, centípedos, animales marinos, otros artrópodos y otros animales venenosos en Argentina, recibidos por las autoridades sanitarias nacionales. Se analizó la información sobre accidentes y muertes producidas por este tipo de animales que fueron recibidas por el Ministerio de Salud de la Nación durante el período 2000-2011. Debido al tipo de sistema de notificación solo se pudieron calcular tasas de morbilidad y letalidad en los accidentes por arañas, escorpiones y serpientes. Contrariamente a lo que se suponía, no fueron estos los grupos que mayor cantidad de muertes causaron en el período de estudio, sino los himenópteros (abejas-avispas- avispones). El actual esquema de notificación de envenenamiento por animales venenosos provee información importante para el sistema sanitario. Sin embargo, deben realizarse modificaciones a fin de mejorar el conocimiento epidemiológico referente a envenenamientos por la mordedura o picadura de animales venenosos. De esta manera, se podrá progresar en la implementación de las medidas de prevención de estas patologías, su atención a nivel del primer nivel asistencial y la planificación de la producción de antivenenos.

In Argentina, accidents by venomous animals are a problem of public health. In this study we analyzed the envenomation caused by the bite or sting of snakes, scorpions and spiders and the deaths produced by the envenomation caused by this animals and the deaths caused by bees-wasp-hornet, centipedes, marine animals, other arthropods and other venomous animals in Argentina, recorded by the National Ministry of Health in the period 2000 ­ 2011. Most of the accidents were caused by scorpions nevertheless the highest lethality was observed in snakebites envenomation. Contrary to the general suppositions, hymenoptera (bee-wasp- hornet) were the responsible for the highest number of deaths. The present system of information of envenomation by venomous animals gives important information. However some modifications should be done to achieve a best knowledge of the epidemiological situation of the envenomation caused by bites or sting of the different venomous animals, in order to improve the prevention measures as well as the attention at the first level of sanitary assistance and the planning of antivenom production.

Toxicity of the venom of Latrodectus (Araneae: Theridiidae) spiders from different regions of Argentina and neutralization by therapeutic antivenoms.

"Black widow" spiders belong to the genus Latrodectus and are one of the few spiders in the world whose bite can cause severe envenomation in humans and domestic animals. In Argentina, these spiders are distributed throughout the country and are responsible for the highest number of bites by spiders of toxicological sanitary interest. Here, we studied the toxicity and some biochemical and immunochemical characteristics of eighteen venom samples from Latrodectus spiders from eight different provinces of Argentina, and the neutralization of some of these samples by two therapeutic antivenoms used in the country for the treatment of envenomation and by a anti-Latrodectus antivenom prepared against the venom of Latrodectus mactans from Mexico. We observed important toxicity in all the samples studied and a variation in the toxicity of samples, even in those from the same region and province and even in the same Latrodectus species from the same region. The therapeutic antivenoms efficiently neutralized all the venoms studied.

Lethality and histopathological alterations caused by Phoneutria nigriventer spider venom from Argentina: Neutralization of lethality by experimental and therapeutic antivenoms.

Although the spiders of the genus Phoneutria cause envenomation and their presence has been described in several provinces of the north of Argentina, they are not as common as other spiders of sanitary importance. In the present work, we studied the toxicity of samples of venom of Phoneutria spiders from the provinces of Misiones (where severe envenomation and deaths by Phoneutria have been recorded) and Jujuy (where no deaths have been recorded and severe envenomations are not frequent). To this end, we assessed the lethal potency in mice and guinea pigs and the histopathological alterations caused by both venoms, as well as the neutralization by the commonly used therapeutic antivenom produced by the Butantan Institute in Brazil and by an experimental antivenom developed with venom of P. nigriventer from Misiones. There were no differences in the lethality of the venoms of spiders from both regions. Post mortem examination showed that the heart and lungs were the most affected organs, while important pulmonary edema was seen macroscopically. Histological analysis showed edema, atelectasis, emphysema and cardiac lesion in both experimental models. The antivenoms assayed showed good neutralization of the venoms in the two experimental models. Despite the different geographic origins, the venoms showed similar toxicity and both the experimental antivenom and therapeutic antivenmos were able to neutralize the venoms of Argentinean P. nigriventer.

Análisis de las normativas de residuos biopatogenicos en la Republica Argentina / Analysis of biopathogenic waste regulations in the Argentine Republic

Esta publicación tiene como objetivo analizar la situación de la normativa relacionada con la gestión interna de los residuos biopatogénicos en los establecimientos de atención de la salud. Se realizó una revisión comparativa de las leyes provinciales y de sus decretos reglamentarios a fin de identificar los criterios empleados como base para proponer una adecuación de la normativa nacional con un criterio integrador. La descripción de situaciones particulares obedece a la necesidad de poner de manifiesto las diversidades y coincidencias o los hallazgos en algunas jurisdicciones que son interesantes de replicar en otras o que por el contrario ameritan una revisión local en el contexto del avance del conocimiento y de la disponibilidad de tecnologías. La omisión de una jurisdicción en una descripción no implica necesariamente la ausencia de ese tema su marco legislativo.

[Distribution of findings of scorpions in Buenos Aires city in the period 2001-2012 and their sanitary implications]. / Distribución de los hallazgos de escorpiones en la Ciudad de Buenos Aires en el período 2001-2012 y sus implicancias sanitarias.

Scorpion stings and their associated mortality increased in the last years in Argentina, with a cumulative record of 73,617 cases and 30 deaths during the period 2001-2012, occurring almost all the deaths in pediatric patients. However, deaths due to severe envenoming by scorpion stings have not been recorded in Buenos Aires city and suburban regions, although the presence of scorpions in this city has been increasingly reported. We studied the temporal and geographical distribution of Tityus trivittatus findings in Buenos Aires city from the database of the Research and Development Area from the National Institute for Production of Biologics of the National Ministry of Health during the period 10/01/2001 to 31/12/2012 in order to correlate these findings with the distribution of health centers in the city. In this period 385 consults with identification of scorpions were recorded. Annual records showed a growing trend. Georeferenced data showed that findings appeared to increase in the surroundings of metro and train stations, mainly at the east of the city with expansion to the west. Although Toxicology services are geographically related to the zones with higher density of finding of scorpions, the accessibility to the centers with antivenom may hinder its application in the recommended time; some measures to avoid possible delays in the application of the treatment are suggested.

En Argentina, las picaduras de alacrán (escorpión) y la mortalidad asociada aumentaron en los últimos años. Durante el período 20012012, se registraron 73 617 accidentes y 30 óbitos, casi todos en pacientes pediátricos. A diferencia de otras latitudes del país, en la Ciudad de Buenos Aires y su Conurbano, no se registraron envenenamientos graves o muertes por estos arácnidos. El objetivo fue describir la distribución temporal y geográfica de los hallazgos de Tityus trivittatus en la Ciudad de Buenos Aires desde el 10/1/2001 al 31/12/2012 y su relación con la distribución de los centros asistenciales. Hubo 385 consultas con identificación de escorpiones. Los registros anuales mostraron una tendencia creciente. El georreferenciamiento mostró áreas con mayor frecuencia de hallazgos y densidad en proximidades de ciertas estaciones de ferrocarril y subterráneos, principalmente al este de la ciudad con expansión hacia el oeste. Si bien los centros con servicios de Toxicología coinciden geográficamente con estas zonas, la accesibilidad a centros que disponen del antiveneno puede dificultar su aplicación en el tiempo recomendado. Se sugieren medidas para prevenir demoras en los tratamientos.

Epidemiology of snakebite and use of antivenom in Argentina.

BACKGROUND: The incidence and case fatality rate of snakebite in Argentina are poorly known. METHODS: The authors used questionnaires provided with antivenoms by the primary manufacturer of anti-venoms in Argentina. RESULTS: A total of 8083 completed questionnaires was collected between 1978 and 1998. The annual incidence of snakebite was 1.8 bites per 100,000 inhabitants, with a high geographical heterogeneity; in the northern provinces of the country, the incidence can exceed 150 snakebites per 100,000 people per year. Bothrops (pit viper) bites predominated, accounting for 96.6% (6720/6957) of envenomations, bites from Crotalus (rattlesnake) accounted for 2.8% (195/6957), and bites from Micrurus (coral snake) for 0.6% (42/6957). Most patients were young men, who were generally bitten during agricultural activities, i.e. while working in the fields. Most snakebites (78.9%, 5852/7419) were to the lower limb, including 58.3% (4322/7419) to the foot. The case fatality rate was <0.04% (3/8083). Most envenomations (90%, 7275/8083) were treated with specific antivenom during the first 4 h after the bite. The median dose of antivenom was two vials for viper bites (Bothrops and Crotalus) and three vials for Micrurus bites. CONCLUSION: These preliminary results should enable manufacturers to increase the availability of appropriate antivenom and health authorities to improve the management of snakebites where they are most common.

Envenoming by coral snakes (Micrurus) in Argentina, during the period between 1979-2003 / Envenenamento por cobras corais na Argentina durante o período 1979-2003

Envenomation by coral snakes (Micrurus sp.) is one of the most dangerous injuries in America and it is considered as a serious medical emergency, however bites by these snakes appear to be rare. We analyzed epidemiological data, clinical signs and antivenom use in Argentina during the period between 1979-2003. During this period of study 46 non-fatal Micrurus bites were reported. The majority of cases were men from 31 to 40 years old. Bites occurred primarily in spring and summer. Most cases were reported from the northeast and northwest provinces of the country. The bites were mostly located on hands or feet and occurred mostly during agricultural activities and so mainly involved farmers. Only four cases occurred as a result of handling snakes. The median time it took for antivenom to be administrated was 60 minutes after the bite, and the median number of vials applied was 2. Local pain was mentioned and edema was reported in 41% of patients. All patients recovered without sequelae. This study showed a low incidence of Micrurus bites and low severity of envenomation. However, although no deaths have been reported during the last 30 years, given the toxicity of the venom of Micrurus snakes, the risk of severe envenomation should be considered.

O envenenamento por corais (Micrurus sp.) é um dos mais perigosos na América e considerado uma emergência médica grave ainda que acidentes por estas serpentes pareçam raros. Analisamos dados epidemiológicos e clínicos e o uso de soro antiofídico, durante o período de 1979-2003. As comunicações indicam 46 acidentes por Micrurus, aproximadamente dois casos anuais, sem registro. A maioria dos casos ocorreu em homens de idade entre 31 e 40 anos, principalmente no período de primavera e verão e provenientes do noroeste e nordeste do país. Os acidentes na sua maioria ocorreram em mãos e pés, durante atividades agrícolas envolvendo trabalhadores rurais. Apenas quatro acidentes foram relacionados a manejo dos animais. Em todos os casos analisados houve descrição de dor local e em 41% dos pacientes houve edema. Por paciente foram administradas, em média, duas ampolas. O tempo médio de aplicação do soro foi de 60 minutos. Em todos os casos a recuperação foi favorável sem presença de sequelas. Neste estudo foi possível observar uma baixa incidência de acidentes e baixa severidade nos envenenamentos. Apesar de que não aconteceram mortes nos últimos 30 anos, dado a toxicidade do veneno das cobras corais, o risco de envenenamento severo deveria ser considerado.

Envenoming by coral snakes (Micrurus) in Argentina, during the period between 1979-2003.

Envenomation by coral snakes (Micrurus sp.) is one of the most dangerous injuries in America and it is considered as a serious medical emergency, however bites by these snakes appear to be rare. We analyzed epidemiological data, clinical signs and antivenom use in Argentina during the period between 1979-2003. During this period of study 46 non-fatal Micrurus bites were reported. The majority of cases were men from 31 to 40 years old. Bites occurred primarily in spring and summer. Most cases were reported from the northeast and northwest provinces of the country. The bites were mostly located on hands or feet and occurred mostly during agricultural activities and so mainly involved farmers. Only four cases occurred as a result of handling snakes. The median time it took for antivenom to be administrated was 60 minutes after the bite, and the median number of vials applied was 2. Local pain was mentioned and edema was reported in 41% of patients. All patients recovered without sequelae. This study showed a low incidence of Micrurus bites and low severity of envenomation. However, although no deaths have been reported during the last 30 years, given the toxicity of the venom of Micrurus snakes, the risk of severe envenomation should be considered.

[Use of indicators of geographical accessibility to primary health care centers in addressing inequities]. / Indicadores de accesibilidad geográfica a los centros de atención primaria para la gestión de inequidades.

OBJECTIVE: Characterize geographical indicators in relation to their usefulness in measuring regional inequities, identify and describe areas according to their degree of geographical accessibility to primary health care centers (PHCCs), and detect populations at risk from the perspective of access to primary care. METHODS: Analysis of spatial accessibility using geographic information systems (GIS) involved three aspects: population without medical coverage, distribution of PHCCs, and the public transportation network connecting them. RESULTS: The development of indicators of demand (real, potential, and differential) and analysis of territorial factors affecting population mobility enabled the characterization of PHCCs with regard to their environment, thereby contributing to local and regional analysis and to the detection of different zones according to regional connectivity levels. CONCLUSIONS: Indicators developed in a GIS environment were very useful in analyzing accessibility to PHCCs by vulnerable populations. Zoning the region helped identify inequities by differentiating areas of unmet demand and fragmentation of spatial connectivity between PHCCs and public transportation.

Epidemiological and clinical aspects of scorpionism by Tityus trivittatus in Argentina.

This is a descriptive study of epidemiological and clinical aspects of stings caused by the scorpion Tityus trivittatus in Argentina. We analyzed 511 cases recorded from different health centers in 22 provinces. Most accidents took place during the period November-April (76%), in or nearby houses (86%). Over 50% of the accidents involved children and teenagers. Envenomation by T. trivittatus was mainly characterized by local symptoms: pain (85%), edema (26.6%), burning sensation (24.7%), erythema (20.7%), local hyperthermia (13.1%), paresthesia (9.8%) and general manifestations such as vomiting (25%), paleness (18.8%), headache (11.4%) and sweating (8.2%). Neurological, cardiovascular and respiratory disorders were uncommon. Almost 90% of the injured people got treated with specific antivenom within 2 h, 6% were treated 2-h after the accident and only 2 people were treated 12 or more hours after being stung. The global mortality recorded was 6 per 1000 cases. Scorpionism in Argentina is a public health problem under control due to the relatively low incidence and the accessibility of specific antivenom.

Risk of recurrence in patients with surgically resected stage I non-small cell lung carcinoma: histopathologic and immunohistochemical analysis.

STUDY OBJECTIVE: To evaluate the prognostic value of histopathologic variables and molecular markers in a group of patients with stage I non-small cell lung cancer (NSCLC). SETTING: "María Ferrer" Hospital of Buenos Aires, Argentina. PATIENTS: Pathologic stage IA and IB patients who underwent radical surgery and nonneoadjuvant therapy for NSCLC between January 1985 and December 1999. MEASUREMENTS AND RESULTS: Fifty-three patients fulfilling the inclusion criteria were identified. The overall survival was 52.8%, and 28% of patients had recurrent disease. We found significant differences between squamous cell carcinoma (SCC) and adenocarcinoma in mitotic counting (p = 0.001) and lymphatic permeation (p = 0.01). SCCs showed higher proliferation (MIB-1 grades 2 and 3) [p = 0.001], Bcl-2 expression (p = 0.038), and CD44 expression (p = 0.019) than adenocarcinomas. The log-rank test showed that mitosis count, necrosis, MIB-1, and Bcl-2 were predictive factors for relapse. All of them were associated with increased relapse and a shorter time to recurrence. Multivariate analysis using the Cox proportional hazards regression model showed that mitosis count, Bcl-2 expression, and grade 3 of MIB-1 emerged as independent prognostic factors of recurrence. CONCLUSIONS: We found that mitosis count and MIB-1 expression had significant value to predict recurrence, reflecting the aggressiveness of high-rate proliferative tumors. We could also show that patients with positive Bcl-2 tumors had a poor outcome, probably related to the uncontrolled cell growth that the expression of Bcl-2 promotes. Our observations are of potential interest for the development of rational postresection treatment strategies based on the estimated risk of recurrence of patients with NSCLC.

Control y vigilancia de la calidad del agua de consumo humano en la Republica Argentina

El abastecimiento de agua potable a la poblacion ha sido desde el siglo XIX uno de los compromisos mas fuertes del Estado Nacional. En la actualidad en nuestro pais, la poblacion tiene un nivel de cobertura de este servicio del orden del 80 por ciento. El documento ha sido elaborado con el objetivo de presentar la situacion actual, en relacion con el control y la vigilancia de la calidad del agua, destacar sus limitaciones y proponer un mecanismo para superarlas