Em recesso, mas atento: a mística de 1968

Muito bom o texto de Élio Gáspari na Folha de S. Paulo (26/12/2007) sobre os acontecimentos de 1968. (assinante da Folha, clique aqui). Um trecho segue a a seguir: A brutalidade da ditadura militar cobriu com um manto sagrado a natureza autoritária dos projetos de quase toda a esquerda brasileira.Passado o tempo, essas militâncias são explicadas a partir da idéia de que aquela foi uma geração que correu atrás de um sonho. Tudo bem, pois ninguém pode discutir com uma pessoa que teve um sonho há 40 anos.A sacralização do 1968 brasileiro tem seu melhor momento na gloriosa passeata dos Cem Mil, ocorrida no Rio de Janeiro, na tarde de 26 de junho de 1968. É pena, mas por mais que ela tenha assustado os generais, foi outro fato quem levou todas as águas do São Francisco para a moenda da ditadura escancarada. Naquela madrugada, um comando da VPR jogara um veículo com explosivos contra o portão do QG do 2º Exército, em São Paulo, matando o sentinela Mário Kozel Filho.No Brasil, 1968 foi o ano de um terrível desencontro provocado pela radicalização política. Talvez não pudesse ser evitado mas, ao contrário de 1989, teria sido melhor que não tivesse existido.

Em outubro, esse blogue em Os vitimizados de 68 já acordaram advertia sobre o porre que será no próximo ano, a louvação ao ano de 1968.

Domingo, 7 de Outubro de 2007
Os vitimizados de 68 já acordaram
Pensei que iria comentar sobre o risco do "ataque de vitimização da geração 68" somente em janeiro, talvez fevereiro de 2008. Mas, começou com o Che, agora no Estadão, o fótografo da passeata dos cem mil está procurando onde estão os participantes. Haja paciência, simplesmente muita paciência com esses mimados com sessenta anos de idade. Essa geração clama ao mesmo tempo os créditos por heroísmo e a recompensa por vítimas. Os eventos de 68 foram somente fotográficos (quantas vezes veremos a foto do carro queimado na Ipiranga com São João ou a briga da Maria Antônia no próximo ano?) mas pouco efetivos em termos de ganhos. Não há como negar a guerrilha urbana e rural foi uma enorme irresponsabilidade que ceifou vidas e justificou o que existia de pior no estamento militar. Quando da promulgação do AI-5 em dezembro, várias organizações "saudaram o fato", porque assim a "ditadura mostrava a sua real face".
Os acontecimentos de 1977 - nos quais participei ativamente - tinham objetivos como anistia, amplas liberdades democráticas e convocação de uma assembléia constituinte. Ganhamos o jogo.
A repressão ao movimento em 77 como a invasão das Faculdades de Medicina da UFMG e USP e da PUC não mereceram nenhuma reportagem. No caso da PUC, mesmo as vítimas reais (queimaduras graves) não se portaram como "vítimas".
Voltando ao fotógrafo de 68, aposto que o número de presentes na passeata dos cem mil chegará a um milhão! Vários com certeza vão entrar com pedidos de indenização ou semelhante.

Blogue em recesso

O final de ano obriga a muitas coisas: entregar relatórios, enviar textos atrasados, corrigir teses e, como não poderiam faltar: as festas, os almoços, e as confraternizações.

As coisas no Brasil esfriam, mas se mantém acesa no hemisfério norte. Mesmo assim, é o momento do recesso.

Um momento de reflexão, de ler aquela montanha de livros e textos que li apressadamente e, recomendei.

Agradeço a atenção da minha quase duas centenas de leitores diários nesse ano de 2007. Em fevereiro de 2008 voltarei normalmente, exceto algo muito excepcional ocorra, tal como um novo caso Avandia que rendeu a maior audiência do blogue em 2007.

Até o final do ano farei uma postagem com um balanço do ano.

Feliz Natal e Ótimo 2008.

Juiced, finalmente o beisebol

A Major League Baseball confirmou o que todo o mundo esportivo sabia: há doping no beisebol. Na gíria, “juiced”. Um esporte sem qualquer controle de doping. Ontem, foi liberado um relatório imenso sobre jogadores com alta performance envolvidos no uso de testosterona e hormônio do crescimento. (clique aqui para ver a versão completa) Aproveitando o post anterior, por enquanto – acredito eu, na minha ingenuidade – o doping está somente na química fina, mas quando chegar na biotecnologia....
Quem quiser aprofundar o tema, Charles Yesalis publicou vários livros sobre o tema. Basta procurar na Amazon. Pena que o tema ainda não se difundiu no Brasil. Por enquanto somente o caso Rebeca e, o ridículo “doping” com finasterida de Romário. Na figura, charge de Barry Bonds, o recordista de home run, mas visivelmente “juiced”.
NEW YORK -- Former Sen. George Mitchell said on Thursday that performance-enhancing drug use has been pervasive in the sport for more than a decade as he released his findings in the shape of a 311-page report, which was fashioned during the past 20 months of investigations. "Everyone involved in baseball shares responsibility," Mitchell said during a news conference at the Grand Hyatt Hotel. "Commissioners, club officials, the Players Association and players. I can't be any clearer than that." In all, 89 players were named in the report, including free agent Roger Clemens, Andy Pettitte of the New York Yankees, Miguel Tejada of the Houston Astros, Eric Gagne of the Milwaukee Brewers and Paul Lo Duca of the Washington Nationals, as well as a list of players like Barry Bonds who have already been publicly associated with steroid use. The report itself is posted at MLB.com and is available to read in its entirety.

Sai a química fina, entra a biotecnologia.

The Wall Street Journal apresenta relato impressionante da queda de empregos na Big Pharma. (vejam a figura) A causa é o fim da química fina no ramo inovador e de marca. Assiste-se a sua transformação em commodities e, consequentemente em genéricos. O futuro está com a biotecnologia. Saem os químicos, entram os biólogos. Aqui, temos a CNTBio .....bem, o que faz a CNTBio?

PARADIGM LOST

As Drug Industry Struggles,Chemists Face Layoff Wave
Lipitor Pioneer Is Out At Doomed Pfizer Lab;A Blockbuster Drought
By AVERY JOHNSON See Corrections & Amplifications belowDecember 11, 2007; Page A1
ANN ARBOR, Michigan -- In January, Pfizer Inc. announced it was closing its storied research laboratories here, laying off 2,100 people. Among the casualties: Bob Sliskovic, a 23-year lab veteran who helped create the world's most successful drug.
The closure and Dr. Sliskovic's abrupt change of circumstances are emblematic of the pharmaceutical industry's declining fortunes. It was at the Ann Arbor facility in the late 1980s that Dr. Sliskovic first assembled the chemicals that make up Lipitor, the cholesterol-lowering drug that has generated about $80 billion in sales since its launch and ranks as the bestselling pharmaceutical product ever. Today, Lipitor is nearing the end of its patent life, and Pfizer hasn't been able to come up with enough promising new drugs to replace it.
Following that initial breakthrough some 20 years ago, Dr. Sliskovic worked on several other research projects, but none panned out. His losing streak mirrors the industry's. A byproduct of the late-19th-century chemical business, pharmaceutical research thrived for more than a century by finding chemical combinations to treat diseases. But after contributing substantially both to human health and drug-industry profits, it has failed to produce significant innovations in recent years.
igh failure rates have long plagued chemistry-based drug research. Between 5,000 and 10,000 compounds are tested for every drug that makes it to market. In recent years, the problem seems to have gotten worse. Despite spending tens of billions of dollars more on research and development, pharmaceutical companies have fewer and fewer drugs to show for it. In 2006, the industry received Food and Drug Administration approval for just 18 new chemical-based drugs, down from 53 in 1996. Moreover, many of those drugs are variations of existing medicines.
Robert Massie, president of the American Chemical Society's database of chemistry research, says some researchers are questioning how many more chemical combinations there are that are useful against diseases. "It's like how coming out with metal drivers in golf was a huge innovation, but now it's incremental. You're just coming out with drivers that are a little longer or rounder," he says.

No ar, RECIIS

No ar, a Revista Eletrônica de Comunicação, Informação & Inovação em Saúde da Fundação Oswaldo Cruz.

Clique aqui para acessar o site e, leia o manifesto de lançamento abaixo.

RECIIS é uma revista pluralista, bilíngüe, não-doutrinária, voltada para a compreensão da dinâmica do presente da arena da saúde, aberta a contribuições que entendam a ciência, a tecnologia e a inovação como expressões, geograficamente situadas, de processos culturais, políticos, econômicos, sociais e históricos, e passíveis de questionamentos e transformações. A revista publica, semestralmente, após avaliação pelos pares, conteúdos críticos sobre informação, comunicação e inovação em saúde. Os manuscritos poderão ser enviados em português ou inglês. Todos os textos aprovados serão traduzidos pela RECIIS e publicados em ambos os idiomas.

Wal-Mart põe consulta médica na prateleira

Esse é o título da reportagem de Valor Econômico de hoje, 12/12/07, sobre a disposição da Wal-Mart de oferecer consulta médica a R$20,00 na rede de supermercados Todo Dia, em Olinda, Pernambuco. Os consultórios serão gerenciados pela Intermédica (que não recebeu a reportagem do jornal para maiores explicações). O laboratório Lavoisier já utiliza locais como shopping-centers para coleta de exames. Nos Estados Unidos, as Rede Clinic funcionam muito bem, mas sem a presença de médicos, mas dependem da legislação de cada estado. Bem, vamos ver o acontecerá.

Harvard adapta anuidades

A Harvard University está atraindo alunos de classe média com descontos de acordo com a renda familiar. Altruísmo? Não exatamente, somente a necessidade de não perder os melhores alunos. Bem, aqui a discussão andou um pouco com a visita da Ministra da Educação da China e a "excelente" performance dos formandos em medicina no exame do CRM.
Harvard announces sweeping middle-income initiative
Cambridge, Mass. – Harvard President Drew Faust and Dean of the Faculty of Arts and Sciences Michael D. Smith today (Dec. 10) announced a sweeping overhaul of financial aid policies designed to make Harvard College more affordable for families across the income spectrum. The new initiative focuses on ensuring greater affordability for middle- and upper-middle-income families through major enhancements to grant aid, the elimination of student loans, and the removal of home equity from financial aid calculations.
This initiative builds on Harvard’s recent pathbreaking policies to ensure that families with incomes below $60,000 are not asked to contribute to the cost of sending their children to Harvard. The new policy has three major components: • The “Zero to 10 Percent Standard”: Harvard’s new financial aid policy dramatically reduces the amount families with incomes below $180,000 will be expected to pay. Families with incomes above $120,000 and below $180,000 and with assets typical for these income levels will be asked to pay 10 percent of their incomes. For those with incomes below $120,000, the family contribution percentage will decline steadily from 10 percent, reaching zero for those with incomes at $60,000 and below. For example, a typical family making $120,000 will be asked to pay approximately $12,000 for a child to attend Harvard College, compared with more than $19,000 under existing student aid policies. For a typical family with $180,000 of income, the payment would be approximately $18,000, compared with more than $30,000 today. The new standard reduces the cost to families by one-third to one-half, making the price of a Harvard education for students on financial aid comparable to the cost of in-state tuition and fees at the nation’s leading public universities. The new initiative also establishes a standard that students and their families can easily understand. • No Loans: In calculating the financial aid packages offered to undergraduates, Harvard will not expect students to take out loans. Loan funds will be replaced by increased grants from the University. Of course, students will be permitted to cover their reduced cost of attendance through loans if they wish. • Eliminate Home Equity from Consideration: Under the new policy, Harvard will no longer consider home equity in determining a family’s ability to pay for college. This will reduce the price by an average of $4,000 per year for affected families as compared with current practice. “We want all students who might dream of a Harvard education to know that it is a realistic and affordable option,” said Faust. “Education is fundamental to the future of individuals and the nation, and we are determined to do our part to restore its place as an engine of opportunity, rather than a source of financial stress. With no loans, no consideration of home equity, and a dramatic increase in grant aid, we are not tinkering at the margins, we are rebuilding the engine. “This is a huge investment for Harvard,” Faust continued, “but there is no more important commitment we could make. Excellence and opportunity must go hand in hand.” (restante da matéria, clique aqui)

Beber e Dirigir:um estudo brasileiro.

DUAILIBI, Sérgio, PINSKY, Ilana e LARANJEIRA, Ronaldo.
Prevalência do beber e dirigir em Diadema, estado de São Paulo.

Rev. Saúde Pública, dez. 2007, vol.41, no.6, p.1058-1061. ISSN 0034-8910.
Problemas decorrentes do consumo de álcool em motoristas têm sido amplamente estudados no mundo e indicam elevadas taxas de morbidade e mortalidade relacionadas à bebida e direção. Existem poucos estudos nacionais a respeito. Assim, realizou-se estudo com o objetivo de estimar a prevalência do uso de álcool por motoristas conduzindo veículos e testar a aceitabilidade dos bafômetros ativos e passivos. Foram avaliados 908 motoristas nas principais vias de trânsito de Diadema, estado de São Paulo, de fevereiro de 2005 a março de 2006. A metodologia adotada foi do tipo pontos de fiscalização de sobriedade. Em 23,7% dos motoristas foi encontrado algum traço de álcool no ar expirado; 19,4% estavam com níveis de álcool iguais ou acima dos limites permitidos pela legislação. O bafômetro passivo mostrou-se confiável e com resultados comparáveis aos do ativo. Esses achados foram seis vezes superiores aos encontrados internacionalmente, sugerindo a relevância desse problema. São necessárias políticas específicas para combater esse problema, além de outras pesquisas em âmbito nacional.

Dirigir embrigado: lá, como cá,mal motoristas há. Mas, impunidade......

O ator Kiefer Sutherland – o Jack Bauer de “24 horas” - ficará preso 48 dias por dirigir embriagado. Em Phoenix, Arizona há um site (clique aqui) com legislação de trânsito, descrição de vítimas e, principalmente, nome e foto de culpado por dirigir embriagado. Nos Estados Unidos, além das penalidades criminais, há indenizações cíveis pesadas e, não há seguradora que aceite um infrator que dirigiu bêbado como cliente.

Aqui, Edmundo bate um bolão no Palmeiras, Alexandre Pires ganha muito dinheiro em shows e, brevemente o comentarista da Globo retornará, talvez somente para os jogos da segunda divisão.

A regulamentação dos propagandistas farmacêuticos (nos EUA)

The Washington Post (reportagem completa) divulgou ontem reportagem sobre projeto de lei restrita ao Distrito de Colúmbia regulamentando a profissão e atividade do representante farmacêutico. Se aprovada a lei, a implicação será o estabelecimento de código de ética e de um board (conselho regional). Uma das implicações será o controle das atividades de vigilância da prescrição médica em prática lá como cá.
Leiam o final da reportagem, onde há sempre a questão dos médicos.
Barry is particularly critical of the legislation's licensing rules. "If you regulate detailers, so what?" he asked. "The doctors don't need to be protected from detailers." Christopher McCoy disagrees. McCoy, a physician in internal medicine in Minnesota, is a member of the prescription privacy committee of the National Physicians Alliance. The group of doctors, formed two years ago, does not accept money from pharmaceutical companies. There has been controversy recently over doctors receiving money from drug companies for speaking engagements and other activities, which critics say influences doctors' prescription choices.
"Our self-confidence makes us believe we are immune to marketing," McCoy said. "Why would the drug companies spend $12 billion if it didn't work?" The industry actually spends an average of $25 billion a year on marketing, and 60 percent of that is for pharmaceutical samples, Powell said. Last year, it also spent $55.2 billion on research and development of new medicines, she said.
McCoy said his group is most worried about data mining. "They have more information than we do. Most doctors I talk to are offended by this," he said. A U.S. District judge blocked New Hampshire this year from enforcing its law prohibiting data mining on the grounds that it restricts commercial free speech. State Rep. Cindy Rosenwald (D) said the state is appealing. "There's no question that using doctors' prescriptions to fine-tune your marketing plan has an impact on drug sales," she said. "There's no other industry that has such detailed information of their customers without their permission." Powell said data mining has benefits for patients because sales representatives can learn more about which drugs doctors are prescribing and better inform them of their effects.

A eliminação da Doença de Chagas no Brasil.

Abaixo, resumo de artigo excelente de Eduardo Massad, meu colega na Faculdade de Medicina da USP sobre a eliminação da Doenças de Chagas no Brasil. Alerto que cálculos e fórmulas são meio indigestos aos não iniciados. Mas, o autor pode fornecer o artigo original e informar mais em edmassad@dim.fm.usp.br

The elimination of Chagas' disease from Brazil.Epidemiol Infect. 2007 Dec 4;:1-12
Massad E.School of Medicine, The University of São Paulo, LIM 01/HCFMUSP, Brazil, and London School of Hygiene Tropical Medicine London, UK.
SUMMARYOn 9 June 2006 the Pan American Health Organization (PAHO) presented the Minister of Health of Brazil with the International Elimination of Transmission of Chagas' Disease Certificate. This act was the culmination of an intensive process that began in 1991 with the Southern Cone Initiative, a joint agreement between the governments of Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay and Peru, to control Chagas' disease by the elimination of the main vector, Triatoma infestans. This initiative has been highly successful and the prevalence area of the vector diminished rapidly in the last years. As a consequence, the current seroprevalence in children aged between 0 and 5 years is of the order of 10-5, a clear indication that transmission, if it is occurring, is only accidental. In this review I calculate the basic reproduction number, R0, for Chagas' disease and demonstrate that its relatively low value (1.25) explains why vectorial transmission was interrupted relatively easily. In addition, I used a mathematical model to forecast how long the remaining cases of the disease, as well as the additional vertically transmitted cases will last.

Uma nova perspectiva para a prevenção cardiovascular

No The Lancet, o cálculo da estratégia da polipílula para prevenção primária e secundária da doença cardiovascular. A proposta é administrar aspirina+estatina+hidroclorotiazida+enalapril a indivíduos com risco elevado de doença cardiovascular. Para aqueles que já sofreram infarto do miocárdio se acrescentaria o atenolol. O estudo apresentado é um simulação para países de baixa e e média renda, mas poderá ser também um bom exercício para uma política ampla de prevenção cardiovascular. Infelizmente, o texto no The Lancet é somente para assinantes.
Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs
Stephen S Lim, Thomas A Gaziano, Emmanuela Gakidou, K Srinath Reddy, Farshad Farzadfar, Rafael Lozano, Anthony Rodgers
In 2005, a global goal of reducing chronic disease death rates by an additional 2% per year was established. Scaling up coverage of evidence-based interventions to prevent cardiovascular disease in high-risk individuals in low-income and middle-income countries could play a major part in reaching this goal. We aimed to estimate the number of deaths that could be averted and the fi nancial cost of scaling up, above current coverage levels, a multidrug regimen for prevention of cardiovascular disease (a statin, aspirin, and two blood-pressure-lowering medicines) in 23 such countries. Identifi cation of individuals was limited to those already accessing health services, and treatment eligibility was based on the presence of existing cardiovascular disease or absolute risk of cardiovascular disease by use of easily measurable risk factors. Over a 10-year period, scaling up this multidrug regimen could avert 17·9 million deaths from cardiovascular disease (95% uncertainty interval 7·4 million–25·7 million). 56% of deaths averted would be in those younger than 70 years, with more deaths averted in women than in men owing to larger absolute numbers of women at older ages. The 10-year financial cost would be US$47 billion ($33 billion–$61 billion) or an average yearly cost per head of $1·08 ($0·75–1·40), ranging from $0·43 to $0·90 across low-income countries and from $0·54 to $2·93 across middle-income countries. This package could effectively meet three-quarters of the proposed global goal with a moderate increase in health expenditure.

Quase tudo sobre tuberculose no Brasil

A Revista de Saúde Pública lançou edição especial sobre a tuberculose no Brasil. Com acesso livre (clique aqui) há quase tudo que “você-gostaria-de-saber-sobre-tuberculose-no-Brasil-mas-tem-vergonha-em-perguntar”. Abaixo, a apresentação dessa edição com o panorama histórico.
A tuberculose (TB) afeta a humanidade há pelo menos cerca de 8.000 anos. Até a metade do século XIX o caráter infecto-contagioso da tuberculose não era reconhecido; a doença era atribuída a diversas causas como a hereditariedade, aos miasmas e a outros determinantes ambientais e sociais. Em 1882, Robert Koch identificou a Micobacteria tuberculosis, definindo assim a TB como uma doença infecciosa. Isto permitiu que a florescente pesquisa biomédica iniciasse a busca por vacinas e tratamentos medicamentosos. A vacina BCG foi, em 1921, usada pela primeira vez em humanos. Anos mais tarde, em 1944, a estreptomicina foi utilizada com sucesso no tratamento da TB, sendo o primeiro de uma série de medicamentos utilizados na terapêutica anti-TB. Essas descobertas trouxeram renovadas possibilidades para prevenção e tratamento da TB. Porém, não se deve esquecer que a mortalidade por esta doença na Europa no século XIX era mais alta do que é hoje na África. Entretanto, naquele continente, a mortalidade começou a declinar de maneira vertiginosa já no final do século XIX, portanto muitas décadas antes da existência dos modernos recursos preventivos e terapêuticos, possivelmente, em razão das mudanças ocorridas nas condições de vida da sua população. Na atualidade, nos países mais desenvolvidos a tuberculose continua sendo um problema quase restrito aos imigrantes dos países pobres e outras populações marginalizadas (desabrigados, alcoólatras, prisioneiros, e outros).

Big Pharma ameaçada pelos genéricos

The Wall Street Journal apresenta hoje uma reportagem bem objetiva, acompanhada de quadro mostrando que todos os grandes produtos da Big Pharma em cinco anos poderão ser vendidos como genéricos. Entende-se a nova linha de "pesquisa-marketing" de remédios combinados, p.ex. hipertensão e dislipidemia, como um jeito de aumentar o período de patente.

Big Pharma Faces Grim Prognosis
Industry Fails to FindNew Drugs to ReplaceWonders Like Lipitor
By BARBARA MARTINEZ and JACOB GOLDSTEIN

December 6, 2007; Over the next few years, the pharmaceutical business will hit a wall.
Some of the top-selling drugs in industry history will become history as patent protections expire, allowing generics to rush in at much-lower prices. Generic competition is expected to wipe $67 billion from top companies' annual U.S. sales between 2007 and 2012 as more than three dozen drugs lose patent protection. That is roughly half of the companies' combined 2007 U.S. sales. At the same time, the industry's science engine has stalled. The century-old approach of finding chemicals to treat diseases is producing fewer and fewer drugs. Especially lacking are new blockbusters to replace old ones like Lipitor, Plavix and Zyprexa.
The coming sales decline may signal the end of a once-revered way of doing business. "I think the industry is doomed if we don't change," says Sidney Taurel, chairman of Eli Lilly & Co. Just yesterday, Bristol-Myers Squibb Co. announced plans to cut 10% of its work force, or about 4,300 jobs, and close or sell about half of its 27 manufacturing plants by 2010. Between 2011 and 2012, annual industry revenue will decline, estimates Datamonitor, a research and consulting firm. That would be the first decline in at least four decades. Patent expirations are a big problem. Drugs are granted 20 years of patent protection, although companies often fail to get a product to market before half of that period has elapsed. Once it hits the market, however, the patent-protected drug is highly profitable: Typical gross margins are 90% to 95%. When patents expire, generic makers offer the products at a price much closer to the cost of production. Pfizer Inc. will be particularly hard-hit when the patent expires as early as 2010 on Lipitor, the cholesterol-lowering blockbuster that ranks as the most successful drug ever. Pharmacists and managed-care companies will aggressively fill prescriptions with generics, reducing annual Lipitor sales to a fraction of last year's $13 billion.

Como é difícil aceitar que a poção mágica não é mágica

Somente nosso pensamento é mágico. A natureza segue seu rumo, com lógicas próprias que deixo para Edward Wilson, Stephen Jay Gould, Richard Dawkins e outros discutirem. Destaco hoje, pesquisa publicada em JAMA que avalia informações oriundas de estudos observacionais: vitamina E e doença cardiovascular, beta-caroteno e câncer e estrógeno e doença de Alzheimer. Todas essas associações não se comprovaram em ensaios clínicos, porém a maioria dos artigos abordando o tema, ainda consideram que vitamina E, beta-caroteno e estrógeno têm utilidade na prevenção da doença cardiovascular, do câncer e da demência, respectivamente.
Persistence of Contradicted Claims in the Literature Athina Tatsioni, MD; Nikolaos G. Bonitsis, MD; John P. A. Ioannidis, MD JAMA. 2007;298(21):2517-2526.
Context Some research findings based on observational epidemiology are contradicted by randomized trials, but may nevertheless still be supported in some scientific circles.
Objectives To evaluate the change over time in the content of citations for 2 highly cited epidemiological studies that proposed major cardiovascular benefits associated with vitamin E in 1993; and to understand how these benefits continued being defended in the literature, despite strong contradicting evidence from large randomized clinical trials (RCTs). To examine the generalizability of these findings, we also examined the extent of persistence of supporting citations for the highly cited and contradicted protective effects of beta-carotene on cancer and of estrogen on Alzheimer disease.
Data Sources For vitamin E, we sampled articles published in 1997, 2001, and 2005 (before, early, and late after publication of refuting evidence) that referenced the highly cited epidemiological studies and separately sampled articles published in 2005 and referencing the major contradicting RCT (HOPE trial). We also sampled articles published in 2006 that referenced highly cited articles proposing benefits associated with beta-carotene for cancer (published in 1981 and contradicted long ago by RCTs in 1994-1996) and estrogen for Alzheimer disease (published in 1996 and contradicted recently by RCTs in 2004).
Data Extraction The stance of the citing articles was rated as favorable, equivocal, and unfavorable to the intervention. We also recorded the range of counterarguments raised to defend effectiveness against contradicting evidence.
Results For the 2 vitamin E epidemiological studies, even in 2005, 50% of citing articles remained favorable. A favorable stance was independently less likely in more recent articles, specifically in articles that also cited the HOPE trial (odds ratio for 2001, 0.05 [95% confidence interval, 0.01-0.19; P < .001] and the odds ratio for 2005, 0.06 [95% confidence interval, 0.02-0.24; P < .001], as compared with 1997), and in general/internal medicine vs specialty journals. Among articles citing the HOPE trial in 2005, 41.4% were unfavorable. In 2006, 62.5% of articles referencing the highly cited article that had proposed beta-carotene and 61.7% of those referencing the highly cited article on estrogen effectiveness were still favorable; 100% and 96%, respectively, of the citations appeared in specialty journals; and citations were significantly less favorable (P = .001 and P = .009, respectively) when the major contradicting trials were also mentioned. Counterarguments defending vitamin E or estrogen included diverse selection and information biases and genuine differences across studies in participants, interventions, cointerventions, and outcomes. Favorable citations to beta-carotene, long after evidence contradicted its effectiveness, did not consider the contradicting evidence.
Conclusion Claims from highly cited observational studies persist and continue to be supported in the medical literature despite strong contradictory evidence from randomized trials.

Avandia: agora osteoporose

Quando uma empresa força demais a indicação de um medicamento, ocorre uma reação inversa, que muitas vezes é desproporcional ao potencial dano do medicamento. Um exemplo é o relatado abaixo pela Associated Press e, repetido em todos os jornais do planeta. Apesar, da empresa reconhecer a possibilidade de aumento de fraturas, o objeto de discussão - osteoporose - não é objeto de preocupação em termos clínicos. Primeiro, os dados foram obtidos em animais. Segundo, o risco cardíaco é mais importante do que o aumento de risco de osteoporose. Por último, notem que o pesquisador que identificou o mecanismo em ratos de forma súbita já indica ações médicas a longo prazo.

Popular Diabetes Drug May Increase Osteoporosis
Associated PressDecember 2, 2007 1:29 p.m.
WASHINGTON -- The popular diabetes drug marketed as Avandia may increase bone thinning, a discovery that could help explain why diabetics can have an increased risk of fractures. New research raises the possibility that long-term treatment with rosiglitazone, as Avandia is also called, could lead to osteoporosis. The diabetes drug is used to improved response to insulin. While bones seem solid, they constantly are being broken down and rebuilt by the body. Researchers found that in mice, the drug increased the activity of the cells that degrade bones, according to a report in this week's online issue of Nature Medicine. Avandia recently was labeled with warnings about the risk of heart failure in some patients. GlaxoSmithKline, which markets the drug, already has acknowledged that a study found a higher risk of fractures among women who take the drug. But this report is the first to attempt to explain the link between the drug and fractures.
The finding "has led to a better understanding of the challenges associated with long-term treatment of patients with Type II diabetes," said Ronald M. Evans of the Salk Institute for Biological Studies in La Jolla, Calif., lead author of the report. "It also provides a basis for the development of a "next generation" of drug that can specifically dial out this side effect and a new insight into a previously unrecognized aspect of bone physiology that has important medical consequences," he said in an interview via e-mail. Nearly 21 million people in the United States have diabetes. Rosiglitazone is widely used in people with Type II, or adult onset diabetes, the most common form of the disease. Evans said the discovery was fortuitous. Researchers were looking at different aspects of the diabetic mice and did not realize they would be able to change the bone-removing activity. The assumption had been that more brittle bones in diabetics were the result of a reduced bone-building activity, not increased bone removal. "Considering the widespread use of these drugs and the known action in people it is surprising that such a key observation had been missed," he said. "The long-term use of rosiglitazone should be cautious in patients with higher risk of fractures such as older women," he added. Using it in combination with anti-osteoporosis drugs could be beneficial, he said. The research was funded by the Howard Hughes Medical Institute and the National Institutes of Health.

Vacinação para gripe e redução das desigualdades: pesquisa da USP no IJE

Professores da USP publicam no International Journal of Epidemiology pesquisa mostrando o impacto da vacinação para gripe na cidade de São Paulo. Mais um dado que vai contra os famosos detratores do SUS, aqueles da "falência da saúde pública", "má utilização de recursos" etc etc

Effectiveness of influenza vaccination and its impact on health inequalities de José Leopoldo F. Antunes, Eliseu A. Waldman, Carme Borrell and Terezinha M. Paiva. O artigo completo pode ser solicitado a leopoldo@usp.br , o resumo é apresentado abaixo.

Background Since 1998, annual publicly funded campaigns for mass vaccination against influenza of the population aged 65 years or older have been performed in the city of São Paulo, Brazil. The effectiveness of the intervention was not assessed for its contribution to the reduction of influenza-attributable mortality. This study sought to compare the age-specific mortality (65 years or older) before and after the onset of yearly vaccination, and to assess the impact of the intervention on health inequalities in relation to inner-city areas.
Methods Official information on deaths and population allowed assessment of overall pneumonia and influenza mortality. Monitoring of outbreaks and the estimation of mortality attributable to influenza peaks used Serfling and ARIMA models. Rates were compared between 1998 and 2002, when vaccination coverage ranked higher than 60% among individuals aged 65 years or older, and 1993–97 (prior to vaccination).
Results Overall mortality due to pneumonia and influenza fell by 26.3% after vaccination. An even higher reduction was observed for mortality specifically attributable to influenza epidemics; the number of peaks of influenza mortality also decreased. Deprived areas of the city had a higher decrease of mortality by pneumonia and influenza during the vaccination period.
Conclusions Influenza vaccination contributed to reduce influenza-attributable mortality in this age group, and was associated with the reduction of inequalities in the burden of the disease among social groups. The concurrent promotion of health and social justice is feasible when there is political will and commitment to implement public health interventions with prompt and effective universal access.

Os precursores da epidemiologia moderna

Abaixo, os comentários de MichaelMarmot publicados no The Lancet sobre o livro mostrado ao lado.

When I joined Epidemiology at the London School of Hygiene and Tropical Medicine, in 1976, I was told: this School is run by upper-class Englishmen and lower-class Scotsmen—my informant was a Scotsman. He went on: it reflected the old Colonial Medical Service; the Englishmen went to the tropics to run the empire, and the Scots to escape their lousy weather. In the USA, I had been told, it was surprising how many of the older generation of epidemiologists had a father who was a preacher, or were of Jewish background. It reflected their social concern.
Of course, the London School has Hygiene as well as Tropical Medicine in its title and there were motivations, other than noblesse oblige or the weather, that brought people into epidemiology. One of the attractions of The Development of Modern Epidemiology is the insight it gives into these motivations. It brings together contributions from many who have been centrally involved in the International Epidemiology Association (IEA) during the 50 years of its existence.
So many of the key figures came to epidemiology because they wanted to improve health in society. John Pemberton, the co-founder of the IEA, was a member of the Socialist Medical Association that was started in 1930. Many of their members believed that poverty was an important cause of ill-health and that some solutions to health problems required political action. In the same vein, Mervyn Susser was aroused to hope and commitment to a socially useful occupation. He, and Zena Stein, saw the practice of socially oriented medicine as an important form of activism. As always, such commitment does not arise, prosper, or otherwise in a vacuum. The pioneers of this approach in South Africa, among them Sydney Kark, as well as Susser and Stein, had to leave because they fell foul of the political regime promoting apartheid. Jerry Morris, in the UK, stated it clearly: “Society largely determines health; ill-health is not a personal misfortune due often to personal inadequacy but a social misfortune due, more commonly, to social mismanagement and social failure.”
The commitment to improving health for the whole of society runs through many of the contributions in this volume. Ian Prior's great grandfather was a missionary in Fiji whose public-health contribution was to convince his parishioners to give up cannibalism. Henry Blackburn, the master of the ECG in epidemiology, was influenced by experiences in Cuba, in 1949, that taught him of the limitations of medicine to deal with mass disease due mainly to poverty and ignorance. Lester Breslow, slightly coy, says that friendly advice was that “with my ideology, I consider public health”. Public Health is grateful that he heeded this advice.
I am in awe of these pioneers. Today, rightly, we expect our students to do Master's degrees and PhDs, to get accredited, pass exams. That is as it should be. But it does not stop me worshipping at the shrine of these founders of our discipline who had none of these qualifications. It may be social concern that motivated these pioneers of epidemiology, but they brought methodological rigour to their enquiries and they had to make it up as they went along. Richard Doll, in a characteristically pithy piece, does not suggest that he chose to go into “epidemiology” as such. Rather, he used his mathematical bent to help a distinguished clinician, Avery Jones, to investigate variations in the occurrence of peptic ulcer. A short course in medical statistics with Bradford Hill (what, no PhD!) and he was put to work to figure out why lung cancer was on the rise. He reports that there were a few early case-control studies of cancer that had come in for methodological criticism. Doll and Hill, therefore, designed their case-control study of lung cancer and smoking to be better. They published in 1950, concluding, with no messy understatement or qualification: “that cigarette smoking is an important cause of cancer of the lung”.
The pioneers developed their investigations with rigour and, in part because of shortage of funds, with precision. Archie Cochrane is justly famous for effectiveness and efficiency and has been immortalised in the Cochrane collaboration. He also did so much to develop observational epidemiology. Nearly 30 years ago I made a pilgrimage to south Wales to see Archie at work, then in his 80s. He drove me in his little car out into the Rhondda where he was still following a cohort of miners. We called on a miner's cottage and a woman took a death certificate off the mantelpiece with the words that her husband had died 3 years previously and she kept the certificate because she knew that Professor Cochrane would call. We then drove back to Cardiff. “That's it”, I asked, “just the death certificate, no questionnaire to the widow?” “What would you want to ask?”, said Archie, “I got all the information I needed.”
Archie Cochrane's personal contribution sums up another theme running through the volume: the different uses of epidemiology, to borrow Jerry Morris' 1957 phrase. Breslow and Detels are clear: epidemiology is the basic science of public health. Richard Heller and Kerr White are equally clear: epidemiology can be used to improve clinical practice and the evaluation and, hence, operation of health services. When we discover that some non-infectious diseases are infectious in origin it makes clear that there should not be two epidemiologies—infectious and non-infectious.
There is surprisingly little whingeing in this volume. There is the occasional allusion to sneering reactions from the medical establishment to the pursuit of epidemiology. These pioneers cannot have had it easy, yet they focus on getting the job done rather than dwelling on their critics. Richard Doll says simply: “epidemiology has contributed more than any other branch of science to our knowledge of the causes of cancer”.
There is some allusion to the political nature of a concern with the health of populations. Adapting this to contemporary debates, a critic, exercising his prejudices, might read the accounts by John Pemberton and others of their social concerns and see not a group motivated by the highest ideals but a bunch of do-gooders who are out to provide ammunition to the nanny state to control people's lives.
Rodolfo Saracci puts this another way. In a thoughtful chapter he suggests that, in the period 1945–75, the rise in epidemiology reflected the impulse of postwar reconstruction and a sense of social solidarity. Accepting health as the right of everybody meant that epidemiology with its focus on whole populations had a ready political acceptance and results had some chance of influencing policy. At the start of the millennium, says Saracci, a neoliberal climate will pay more attention to economics than to a political desire to improve the lot of all sectors of society. Saracci's implications are plain: we need high-quality epidemiological research and we need the political commitment to implement findings to improve population health.
In: Walter W Holland, Jørn Olsen and Charles du V Florey, Editors, The Development of Modern Epidemiology: Personal Reports From Those Who Were There, Oxford University Press (2007) ISBN 0-19856-954-8 Pp 472. US$110·00