Novidades na cardiologia: ACC 2008

Hoje, continua a sessão científica do American College of Cardiology, momento onde há novas revelações importantes. Há alguns anos, as revistas se acertam com os organizadores para lançarem na internet, o artigo referente a uma apresentação de importância.

Estão no The New England Journal of Medicine com acesso livre:

1. comparação dos bloqueadores do receptor de angiotensina com os inibidores de enzima de conversão isolados e, em conjunto (resultado esperado): estudo ONTARGET.

2. tratamento de hipertensão acima de 80 anos (resultado sensacional!!): estudo HYVET.

No JAMA também com acesso livre:

3. comparação da pioglitazona com glimepiride na redução da luz da artéria coronária (há muita água, ou sangue para passar por essa placa aterosclerótica ainda): estudo PERISCOPE.

Se tiver paciência, leia sobre um momento infeliz da Big Pharma.

O caso ENHANCE já foi tratado aqui como mais um "fanfarronice" em Big Pharma cada vez mais criativa. Duas empresas patrocinam um estudo com medicação combinada para reduzir o colesterol, não conseguem atingir o alvo pretendido e, publicam um comunicado na internet. Hoje, na reunião científica do American College of Cardiology houve apresentação do ensaio clínico. Clique aqui para entender o ocorrido com a reportagem da HeartWire. Ao mesmo tempo, The New England Journal of Medicine publicou o artigo "original". (acesso livre)

Heparina:19 mortes

Já discuti o problema da heparina vinda da China nos Estados Unidos. Agora, o The New York Times apresenta novos dados sobre o caso que se associa a 19 mortes no país. Na foto ao lado, o tratamento que os intestinos de porcos são submetidos na China. Moyses Nin, editor de Foreign Affairs comenta que houve somente estimulo ao aumento da quantidade de comércia, com pouca ou nenhuma preocupação com a qualidade e segurança dos produtos comercializados.

A ética do bazar de órgãos: debate na Harvard School of Public Health

The Ethics of the Organ Bazaar
The event, entitled "Markets for Kidneys? The Ethics of the Organ Bazaar," was held on February 8 in Snyder Auditorium. Speakers presented the often harsh realities of the international organ trade. Ethicists, economists, and audience members struggled to define the compelling issues and circumstances that could make selling organs palatable. The event was organized by HSPH Professor Daniel Wikler.
The latest headlines showcase some of the problems with the international organ trade. In India, for example, there appears to be an illicit organ market, despite being outlawed, that includes the participation of some doctors. Some donors appear to be abducted or conned, and many of their organs are sold to people from other countries.
Demand for organs vastly outpaces the supply, said Luc Noël, coordinator of the Clinical Ethics Team for the World Health Organization. The total number of annual kidney transplants, for example, estimated at 66,000 worldwide, far from meets the needs of the 1 million people suffering from end-stage renal disease, even if only one-half of them meet surgical criteria.
The critical shortage of organs has led to "transplant tourism," a term that describes patients, donors, or physicians who travel to other countries to obtain organs through commercial transactions, typically from the poor and vulnerable.
"We must have a global consensus of objection to commercialization of transplantation," said Francis Delmonico, a surgery professor at Massachusetts General Hospital and Harvard Medical School and director of medical affairs for the Transplantation Society.
In the 1990s, the WHO drafted guiding principles on human organ transplantation that prohibited giving or receiving payments for organs. Taking it further, a 2004 World Health Assembly adopted a resolution where delegates agreed to "take measures to protect the poorest and vulnerable groups from ‘transplant tourism' and the sale or trafficking of tissues and organs."
Even with global censure of a commercial organ market, the ultimate solution lies in the willingness and ability of each country to become self-sufficient in organ transplants, providing a fair system within its borders to satisfy the medical demand there, several speakers said.

Uma vez mais, a doação de órgãos

Hoje,um despacho Associated Press. Novamente, a venda de rins.

Philippine Health Chief Orders Eradication of Kidney Black Market
Associated PressMarch 26, 2008 9:55 a.m.
MANILA, Philippines -- A new order aimed at eradicating a thriving black market in kidney sales by desperately poor Filipinos would restrict foreigners traveling to the Philippines in search of donors, the health secretary said Wednesday. Health Secretary Francisco Duque said the order, which he signed Monday, called for the creation of a government board to oversee kidney donations and transplants, ensure proper care of donors and make more transparent and ethical a disturbing practice that has flourished in secrecy.
Kidney trading in the Philippines, involving poor people and prisoners who sell their organs for paltry sums to syndicates catering mostly to foreign clients, has been reported by the local media and reflects the depth of the Southeast Asian nation's poverty. A TV network once featured a Manila slum in which dozens of men sported abdominal scars after giving up their kidneys. The order seeks to provide a more benevolent image to kidney donations by prohibiting the payment of money as a precondition. It says donations must be done "out of selflessness and philanthropy" to save and ensure the quality of life of the beneficiary. "We want to remove this black market," Mr. Duque said. "We want to protect our already poor countrymen from abuse." Health Undersecretary Alexander Padilla said the order, which took more than two years to craft, was sought specifically because of numerous reports of foreign patients traveling to the Philippines in search of kidney donors. "We don't want to be known as the kidney capital of the world," Mr. Padilla said. A 1991 law only regulated transplants of kidneys and other organs from brain-dead donors. One contentious issue was whether to ban foreigners from securing kidneys from local donors -- a move backed by private advocacy groups to prevent the exploitation of the poor in Third World countries, Mr. Padilla said. Authorities eventually decided against such a ban but made it difficult under the new order for foreign patients to obtain kidneys, he said. The order prioritizes Filipino patients in the allocation of donated kidneys and prohibits their export to any other country. About 10,000 to 12,500 Filipinos develop serious renal diseases each year and about half could be saved by kidney transplants, according to the health department. Only about a tenth of those who could have transplants actually do so because kidneys are in short supply and the procedures cost so much. There are no existing statistics on the number of foreigners seeking local kidney donors.

Como o mundo está ficando sem graça: teste de paternidade nas drogarias

Clique aqui ou leia o resumo abaixo em inglês. Machado de Assis não teria mais vez. Bentinho passaria o cotonete na bochecha de Ezequiel ,de Capitolina e dele próprio. O problema estaria resolvido em 3-5 dias úteis por 200 reais....

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Homicídios em Belo Horizonte: aqui, primeiro e mais confiável.

O faroeste da blogosfera está discutindo os homicídios em Belo Horizonte. Os leitores desse blogue estão informados há muito mais tempo, ou seja desde julho, quando os dados do Ministério da Saúde foram liberados. A origem da informação foram as secretarias de estado e dos municípios.

Quarta-feira, 4 de Julho de 2007
Mortalidade 2005 (3): Taxas de homicídio em SamPa, Rio e BH de 2001 a 2005.
O quadro mostra a evolução das taxas de homicídios nos cinco primeiros anos da década nas regiões metropolitanas de São Paulo, Rio de Janeiro e Belo Horizonte. São Paulo começa com os valores mais elevados, mas ano a ano vai apresentando redução impressionante, tanto que hoje a região encontra-se na 18a posição nesse ranking infeliz. Belo Horizonte - em contraste - teve aumento expressivo, passando para a 4a posição, próximo aos valores do Rio de Janeiro. O Rio de Janeiro também vem apresentando taxas declinantes, mas com desacelaração inferior à observada em São Paulo. Mais uma vez, os dados atrapalham as análises com o viés ideológico, político e partidário. Atenção, acadêmicos, vamos estudar a fundo esses dados. Afinal, não servimos somente para escrever artigos indignados na grande imprensa, mas para interpretar o mundo!
Postado por Paulo Lotufo às 15:46 1 comentários

Mortalidade 2005 (2): as maiores taxas de homicídio nas regiões metropolitanas
Os dados de mortalidade de 2005 do Ministério da Saúde permitiram calcular a taxa de homicídios nas regiões metropolitanas do país naquele ano. Utilizei somente a população masculina. Em resumo, dividi o número de óbitos pela população total de cada área. Sempre utilizando os dados disponíveis em http://www.datasus.gov.br Recife continua na liderança desse ranking infeliz, mas está administrando bem a situação vide o post anterior Pacto pela Vida em Pernambuco. No mesmo estado, a região de Petrolina/Juazeiro ocupa a sexta posição. Depois de Recife, temos Vitória, Maceió, Belo Horizonte, Rio de Janeiro, a já citada Petrolina, Curitiba, Salvador, Belém e João Pessoa. Muita gente não gosta desses dados, mas foram disponibilizados pelo Ministério a partir da informação dos próprios estados. Um momento a refletir, no próximo post mais comentários sobre mortes por homicídios.
Postado por Paulo Lotufo às 15:28 0 comentários

Vitória da Autonomia Universitária: Big Pharma não consegue "estourar" a revisão por pares.

Em primeiro de março noticiei aqui o ataque à autonomia univesitária por parte de advogados da Pfizer americana, que a pretexto de municiar a defesa de processos de pacientes no caso "Cox-2" exigiam que as revistas "abrissem" a relação de revisores. JAMA conseguiu sentença judicial contra a demanda da empresa, preservando a confidencialidade do processo de revisão por pares.

Preserving Confidentiality in the Peer Review Process
Catherine D. DeAngelis, MD, MPH; Joseph P. Thornton, JD
JAMA. 2008;299(16):(doi:10.1001/jama.299.16.jed80000).
For the past year or so, JAMA and the Archives of Internal Medicine have been involved in litigation that significantly threatened the integrity of our peer review process. We now inform our reviewers, authors, and readers about the results of this litigation that preserve the confidentiality of our peer review process.
Pfizer Inc is a defendant in more than 3000 lawsuits across the country alleging that Pfizer advertised and marketed the cyclooxygenase 2 inhibitors celecoxib and valdecoxib as likely to provide pain relief without the adverse effects that had accompanied earlier anti-inflammatory medications. The plaintiffs contend that false representations were made to drive demand for these higher-priced prescription drugs, when lower-cost nonsteroidal anti-inflammatory drugs would have been as safe or safer for most patients. The plaintiffs include consumers, health plan providers such as unions, and third-party payers that manage formularies and reimburse claims.
The defense attorneys for Pfizer issued subpoenas to a host of journals, but it appears the first 2 were directed at JAMA and the Archives of Internal Medicine (AIM). On May 9, 2007, Pfizer served federal court subpoenas on JAMA and AIM seeking 4 broad categories of documents and information. In response, JAMA and AIM provided copies of hundreds of pages of published articles regarding celecoxib and valdecoxib. However, the subpoenas sought all documents regarding the decision to accept or reject manuscripts, copies of rejected manuscripts, the identities of peer reviewers and the manuscripts they reviewed, and the comments by and among peer reviewers and editors regarding manuscripts, revisions, and publication decisions.
For months JAMA and AIM consistently argued that the sanctity of the confidential peer review process should not be violated. We asserted privileges and public policy reasons against production, including the Federal Rules of Civil Procedure, which protect nonparties like JAMA and AIM from unreasonable litigation burdens and abuses. On January 17, 2008, JAMA and AIM were served with a Motion to Compel production of confidential editorial judgments, unpublished manuscripts, and unpublished peer review comments. Among other things, JAMA and AIM argued that this unpublished and privileged material could not have been known to Pfizer or played any role in its advertising and marketing decisions. Likewise, the plaintiffs could not have known and relied on them in making purchasing decisions. We asked the federal district court in Chicago to deny the Motion to Compel, essentially quashing the Pfizer subpoenas, and that is precisely what Magistrate Judge Arlander Keys did. In a ruling issued March 14, 2008,1 the Court agreed with JAMA and AIM that information kept confidential from Pfizer, the general public, and the medical community at large was irrelevant to the pending claims. Magistrate Judge Keys observed that the published articles themselves would satisfy the lawyers' needs. When pondering Pfizer's involvement in and responses to scientific publications, Magistrate Judge Keys remarked that "this evidence would seem to be just as easily accessible from Pfizer as from the Journals."1 He concluded that "Especially given the strong policy behind preserving confidentiality in the peer review process, the Court finds any probative value would be outweighed by the burden imposed on the Journals in invading the sanctity of that process."1 We firmly believe that ensured confidentiality of reviews allows reviewers to provide professional critiques of manuscripts without fearing potential repercussions from authors.
To that end, JAMA and our Archives Journals have historically and deliberately kept unpublished manuscripts and peer reviewer comments confidential. This promise to reviewers and authors allows the peer review process to work in an unrestrained environment. Producing any of these documents, with or without names, would seriously compromise the process and the trusting relationship among the editors, authors, and reviewers. The subpoenas attempted to invade the peer review process, and we are delighted that Magistrate Judge Keys said so when he ruled they could not be enforced against us.

Discriminação e doença: dekasseguis no Japão.

American Journal of Public Health publica artigo original mostrando os problemas de saúde dos dekassegui no Japão. Cópia deverá ser solicita ao autor no email abaixo que segue o resumo do estudo. Um bom tema na comemoração dos 100 anos da Imigração Japonesa no Brasil.

Returning to the "Homeland": Work-Related Ethnic Discrimination and the Health of Japanese Brazilians In Japan Takashi Asakura, PhD, Gilbert C. Gee, PhD, Kazuhiro Nakayama, PhD and Sayuri Niwa, MA, RN (e-mail: asakurat@u-gakugei.ac.jp
Objectives. We investigated whether self-reported ethnic discrimination in the workplace was associated with well-being among Japanese Brazilians who had returned to Japan. Further, we examined interactions between discrimination and education on well-being.
Methods. We obtained data from a cross-sectional survey of Japanese Brazilian workers (n = 313) conducted in 2000 and 2001. Outcomes were self-rated health, psychological symptoms as measured by the 12-item General Health Questionnaire (GHQ-12) score, and a checklist of somatic symptoms.
Results. Reports of ethnic discrimination were associated with increased risk of poor self-rated health and psychological symptoms (GHQ-12 score), after we controlled for self-assessed workload, supportive relations at work, physically dangerous working conditions, workplace environmental hazards, shift work, number of working hours, age, gender, marital status, income, education, Japanese lineage, length of residence, and Japanese language proficiency. Further, the relationship between discrimination and self-rated health and somatic symptoms was most robust for those with the least education.
Conclusions. Ethnic discrimination appears to be a correlate of morbidity among Japanese Brazilian migrants. Future research should investigate how educational and workplace interventions may reduce discrimination and possibly improve health.

Enquanto isso, na Semana Santa

Postei

(1) "Medicina do Viajante": acidentes com serpentes e acidentes com relâmpagos.

(2) A formação médica em Boston e São Paulo.

(3) Mestiçagem na América Latina.

(4) O crime em negar vacina a crianças.

(5) "Clínica & Epidemiologia": o mito da síndrome metabólica.

(6) La Ninã e El Niño: explicam a dengue?

Medicina do Viajante: acidentes por serpentes e por raios.

Na série "Medicina do Viajante" (14 tópicos relacionados ao lado) adicionam-se mais dois textos publicados no How Stuff Works do Brasil: "acidentes com serpentes" e "acidentes com relâmpagos". Esse verão tem sido propício a acidentes graves e a mortes por relâmpagos. Até 21 de fevereiro de 2008, houve 22 mortes por raios nos primeiros 50 dias de 2008 em oposição a 46 vítimas em todo o ano anterior (2007), sugerindo um aumento do número de acidentes. A maior parte dos acidentes se concentra no Estado de São Paulo.

A formação médica em Boston e São Paulo.

Abaixo do blogue do Boston Globe, a proporção de vagas para residência em áreas básicas: medicina de família, clínica médica, obstetrícia e ginecologia e pediatria nos hospitais de Boston, o centro nevrálgico da medicina ultra-especializada mundial. Vou verificar a proporção no Brasil, mas na Faculdade de Medicina da USP, 44% das vagas de ingressantes são para essas especialidades. Isso não significará, nem em Boston, nem em São Paulo, que todos terminarão como "generalistas". A maioria irá para especialidades e subespecialidades.

By Elizabeth Cooney, Globe Correspondent
Fourth-year medical students discovered today where they will spend the next stage of their medical training. This year the Match Day formula sorted more than 15,000 US medical school seniors into programs at teaching hospitals. There was a small uptick in family medicine choices nationwide, coming at a time when primary care doctors are in short supply. At the four medical schools in Massachusetts, primary care specialties -- family medicine, internal medicine, obstetrics/gynecology, and pediatrics -- drew almost half the soon-to-be MDs graduating from the three schools in Boston. At University of Massachusetts Medical School in Worcester, the tally was higher, consistent with its mission focusing on primary care. Both levels are similar to previous years. -- Boston University School of Medicine: 46 percent-- Harvard Medical School: 44 percent -- Tufts University School of Medicine: 46 percent -- University of Massachusetts Medical School: 60 percent

Mestiçagem na América Latina

PLOS Genetics traz artigo discutindo o padrão genético de populações mestiças na América Latina. O Brasil foi representado somente pelo Rio Grande do Sul.

The large and diverse population of Latin America is potentially a powerful resource for elucidating the genetic basis of complex traits through admixture mapping. However, no genome-wide characterization of admixture across Latin America has yet been attempted. Here, we report an analysis of admixture in thirteen Mestizo populations (i.e. in regions of mainly European and Native settlement) from seven countries in Latin America based on data for 678 autosomal and 29 X-chromosome microsatellites. We found extensive variation in Native American and European ancestry (and generally low levels of African ancestry) among populations and individuals, and evidence that admixture across Latin America has often involved predominantly European men and both Native and African women. An admixture analysis allowing for Native American population subdivision revealed a differentiation of the Native American ancestry amongst Mestizos. This observation is consistent with the genetic structure of pre-Columbian populations and with admixture having involved Natives from the area where the Mestizo examined are located. Our findings agree with available information on the demographic history of Latin America and have a number of implications for the design of association studies in population from the region.

O crime em negar vacina a crianças

The New York Times traz reportagem sobre a tendência cada vez maior de pais recusarem vacina a seus filhos. Os motivos são os mais variados, mas todos calcados na ignorância com ar de sabedoria extrema. Todo pediatra brasileiro tem uma história triste de crianças mortas por sarampo ou meningite que poderiam estar vacinadas, mas cujos pais eram adaptos de alguma seita alternativa ou foram iludidos por médicos irresponsáveis.

Clínica & Epidemiologia: o mito da síndrome metabólica

Em "Clinica & Epidemiologia" reproduzo o debate disponível no British Medical Journal sobre a assim chamada síndrome metabólica. O histórico da questão diabetes e obesidade encontra-se publicado em outro texto meu: The "common soil" theory: diabetes, coronary heart disease and inflammation.

Minha opinião: a síndrome metabólica teve interesse nos anos 90 porque chegaríamos a um marcador comum para todos os fatores de risco: hipertensão, diabetes e dislipidemia. O que se conseguiu foi um membro da Big Pharma lançar medicamento "teoricamente" dirigido à sindrome metabólica. Mas, esse medicamento não tem qualquer comprovação de segurança em uso continuado, tanto que não foi aprovado nos EUA. Aqui, ainda não foi lançado, apesar da pressa da ANVISA em aprová-lo.

Para o clínicos, a síndrome metabólica traz confusão, para as ações preventivas, despreza o tabagismo, para os pacientes, também confusão. Afinal, confiar em "doença" ou "fator de risco" que tem seis definições!!

La Ninã e El Niño: explicam a dengue?

O Aedes é municipal, estadual ou federal? Em quem bater: César Maia ou Temporão? Esse é o vai e vém dessa epidemia que consegue transtornar o serviço de atendimento de uma grande cidade, como ocorreu em São Paulo há um ano. No entanto, há um debate feroz sobre o determinante maior entre infectologistas e cientistas do ambiente. Para esses, últimos o aumento da temperatura na região explica o avança para o México e na região fronteiriça dos Estados Unidos (que tem casos no Havaí). Leia mais no The Lancet em artigo de acesso livre. (mas, necessita registro de entrada).

Excesso de compromissos, volto na quinta-feira, 20 de março de 2008.

A epidemiologia explicando a economia: ou o "fato social" de Durkheim e o fim da CPMF.

Como The Economist resolveu discutir a epidemiologia da aids no Brasil. Sinto-me confortável em discutir economia e sociologia.

Não me lembro de estar em São Paulo, em janeiro, com tanto movimento e agitação. Nem o período de carnaval "segurou" a cidade. Em março, o movimento está muito maior do que o habitual. Hoje, noticia-se que as compras aumentaram em janeiro em relação a dezembro, fato inédito. Ou seja, minha impressão é fato . Economistas não sabem explicar. Fico tentado a apresentar uma hipótese: o fim da CPMF. Um indivíduo que recebe 2000 mil reais se gastasse todo o salário de imediato pagaria "somente" R$ 7,60 da CPMF. Como ele, deixou de recolher essa quantia, gastou também esse valor. Ou seja, ao invés de recolher a Brasília, ele deixou na sua cidade. Milhões fizeram o mesmo. Esse recurso multiplicou-se na economia real. O indivíduo não percebeu o ganho, mas o impacto social é grande.

A epidemiologia demonstrou que reduzir em 2mm de mercúrio a média populacional da pressão arterial reduzirá em 10% as mortes por doença cerebrovascular. Notem que 2 mm não é a unidade de medida no aparelhos tradicionais, por isso imperceptível ao indivíduo, mas com impacto populacional.

Ou, como definiu Durkheim, o fato social: que é geral na extensão de uma sociedade dada, apresentando uma existência própria, independente das manifestações individuais que possa ter."

Transplantes de órgãos:os pobres de países pobres

Abaixo, mais um relato de uma situação que se estenderá nas próximas décadas: ricos comprando órgãos de pobres em países pobres. Pai vende parte do fígado para custear tratamento de câncer do filho, isto ocorreu no Cairo, Egito. A notícia é do Los Angeles Times, a síntese do blogueiro do The Wall Street Journal. Outros post sobre o comércio de órgãos, situação do transplante no Brasil e sobre a doença renal crônica podem ser lido clicando aqui.

More scenes from the global black market in organs.
In Cairo, the 4-year-old son of a bus driver needs surgery for cancer. The bus driver sells part of his liver on the black market to pay for the procedure. The boy dies. But the bus driver has a new job: black-market organ broker. “I sold part of my liver to save my son,” Mustafa Hamed tells the Los Angeles Times. “But some people who come to me aren’t that desperate. They could find other solutions. Many men I see now want to sell their organs so they can afford to buy an apartment to get married. That doesn’t seem desperate enough to me. I try to tell them: ‘Be patient. You don’t need to do this.’ ” This is what happens when medical technology allows for lifesaving transplants and organ donors are in short supply. The underlying themes are the same around the world — poverty and wealth, life and death — but the story takes on different tones in different countries. In Egypt, geography and religion are drivers. Wealthy residents of oil-rich Persian Gulf countries come to Cairo in need of organs, Mohamed Queita, a legislator who has been trying for years to regulate transplants, tells the LAT. But Queita’s efforts have been slowed by Islamic clerics who argue that transplanting organs, even from brain-dead patients, is forbidden. Religious teachings can cut both ways, though. Looking back to his own operation, when he sold a piece of his liver, Hamed says: “Even if something bad had happened to me during the operation, I would not have minded as long as the objective was to rescue my son. If one dies for the sake of his son, he gets rewarded by God.”

The Economist: uma visão da aids no Brasil.

The Economist dessa semana publicou reportagem no Brasil mostrando que a aids avança no interior e, entre as mulheres. A aids "vai" para o interior, os homicídios também "foram". Ora, a economia também foi para o interior e, parte da população lá se fixou. Nada estranho. Importante ressaltar que a taxa de prevalência no Brasil é baixa, 0,6% como ressalta a revista, isto porque o programa de tratamento é tão efetivo que mantém os infectados vivos. Ao contrário, de outros países.

A portrait in red Mar 13th 2008 SÃO PAULO From The Economist print edition
One of the world's most successful AIDS programmes faces new problems
BRAZIL'S government is accustomed to being lampooned for being wasteful, ineffectual and corrupt. Occasionally, though, it does something really well. Keeping HIV/AIDS under control in a country where sex rivals football as the national sport is an impressive achievement, and over the past 20 years the government has done just that. Now, however, the disease has spread across Brazil (see maps). Although the total number of cases remains low at 620,000, representing 0.6% of those aged 15-49, the change in the profile of sufferers is taking the fight to places where it will be much harder to win. “The epidemic has now taken the contours of the general population,” says Mariângela Simão, who runs the federal government's AIDS programme in Brasília, the capital. “It has become a portrait of Brazil.” Brazil's epidemic began life among gay men in the south-east of the country, probably after travelling south from the United States rather than west from Africa. Had the virus not affected some white men living in the country's most prosperous region, the response might have been less energetic, some suggest under their breath. Thankfully, it was energetic, and it has taken three forms. First, there has always been an insistence on the need to wear condoms, particularly at carnival time (when the usual supply of free prophylactics increases by 40%). The World Bank recently helped the government to buy a billion condoms (for 190m inhabitants)—around a tenth of the world's total supply. It took a year to find factories with sufficient capacity and the right quality controls to fill the order. Second, the government funds free treatment for anyone with AIDS. This has involved side-stepping patents on anti-retroviral drugs to keep the bill down. Brazil saved an estimated $30m last year through the compulsory licensing of Efavirenz, a drug developed by Merck. But this strategy has its limits: the launch onto the market of one new drug has been delayed despite undergoing some clinical trials in Brazil. Third, NGOs have been good at publicising the cause and at holding federal and local governments to their promises. This is particularly important in the north and north-east of the country where the disease is spreading fastest, and where some politicians have a semi-feudal relationship with voters. Cristina Pimenta, head of the Brazilian Interdisciplinary AIDS Association, says that NGOs are also now focused on making sure women know about the disease, get tested and, if necessary, get treated. During this year's carnival in Pernambuco, a poor state in the north-east, a government campaign was aimed almost exclusively at women. (restante clique aqui).

Farmacêuticos e Doenças Crônicas: um bom debate

Uma proposta polêmica que está na agenda da ANVISA, mas que deve e necessita ser avaliada com o cuidado devido: farmacêuticos no controle de doenças crônicas. Podem ser um braço da Big Pharma ou um poderoso agente de saúde pública. Abaixo, post do The Wall Street Journal sobre diabetes e o acompanhamento em farmácias americanas.

Diabetes care is a poster child for much of what’s wrong with our health-care system, which is good at handling acute crises but bad at preventing them. Pharmacists are angling to step into the breach and improve preventive care for diabetics.
In a project described in the March/April Journal of the American Pharmacists Association, employers in 10 U.S. cities agreed to waive copays for employees’ diabetes meds, and to fund regular meetings between pharmacists and diabetic employees. A year after the project launched, 914 patients who had been enrolled for at least three months saw their hemoglobin A1C, a key measure of health for diabetics, fall on average to 7.2% from 7.6%, a significant improvement.
“The pharmacist is really helping people stay on track, just like a coach would for whatever skill you want to choose,” said William Ellis, CEO of the American Pharmacists Association foundation.
Patients typically meet with pharmacists once every few months, Ellis said. Costs vary, but a 30-minute session usually runs somewhere between $60 and $90, Ellis said. GlaxoSmithKline paid for the foundation to conduct the study.
A similar project in Asheville, N.C., a few years back suggested that employers save money in the long run, because improving diabetics’ health on the front end cuts the rate of expensive hospital procedures that are more common when diabetes is poorly controlled.
Ellis said an economic analysis of the 10-city project is expected later this year.

Um testemunho da tuberculose na Índia

Vikram Paralkar é um médico indiano que realiza estágio como médico residente na Filadélfia, Estados Unidos. Citando Keats e, depois Thomas Mann, ele redigiu um texto na primeira pessoa que é simplesmente fantástico mostrando a situação indiana. Ele traz ao ambiente médico, a descrição, o testemunho, uma das bases da clínica e da epidemiologia. O texto foi publicado no The New England Journal of Medicine com acesso livre.

Tuberculose avança na África.

The New England Journal of Medicine destaca o aumento dos casos de tuberculose na África em decorrência da aids. A única boa notícia seria a possibilidade que melhorou a notificação dos serviços de vigilância epidemiológica. Mas, a infecção com o HIV e as péssimas condições dos serviços de saúde, agravado pelo êxodo de profissionais propiciou o aumento descrito na figura.

Integração docente assistencial: a USP e o SUS

Participe com trabalhos originais do I Simpósio Pró-Saúde USP organizado pela Escola de Enfermagem e Faculdade de Medicina.

A página eletrônica é

http://www.pro-saude.hu.usp.br

Local: Centro de Convenções Rebouças

São Paulo SP

data: 08 e 09 de maio de 2008.

Lourdes de Freitas Carvalho, in memoriam

Morreu ontem, 11 de março de 2008, a Professora Lourdes de Freitas Carvalho, de quem sou o quarto sucessor na superintendência do Hospital Universitário.

Abaixo, despacho da Agência Fapesp.
12/03/2008 Agência FAPESP – Faleceu na segunda-feira (10/3), aos 93 anos, a professora aposentada Lourdes de Freitas Carvalho, do Departamento de Prática de Saúde Pública e ex-diretora da Faculdade de Saúde Pública (FSP) da Universidade de São Paulo.
Entre 1980 e 1986, Lourdes também foi superintendente do Hospital Universitário (HU) da USP. Ela tinha pneumonia causada por fibrose pulmonar. O corpo foi velado na FSP e enterrado, na terça-feira (11/3), no Cemitério São Paulo.
Lourdes se formou em medicina na Faculdade de Medicina da USP e, em 1943, quando trabalhava no Hospital das Clínicas (HC), foi aos Estados Unidos, com bolsa de estudos da Fundação Rockefeller, para adquirir conhecimentos sobre o Serviço de Arquivo Médico e Estatística (Same), tendo, em seguida, aplicado esses conhecimentos no próprio HC.
Seus ensinamentos sobre o Same, que tem por finalidade a guarda e preservação do prontuário médico, incluindo dados pessoais, evolução clínica e exames, foram, durante muitos anos, a única referência para todos os que se interessavam pelo assunto. Do Hospital das Clínicas, o Same foi disseminado por todo o Brasil e, atualmente, é utilizado pelos serviços de estatística de diferentes hospitais do país. Em 1951, juntamente com os professores Odair Pacheco Pedroso e José Gabriel Borba, Lourdes foi responsável pela criação do curso de especialização em Organização e Administração Hospitalar na FSP/USP. Obteve, em 1973, o título de professora titular da FSP e, de 1982 a 1986, exerceu o cargo de diretora da faculdade. Foi ainda diretora da Clínica Ortopédica e Traumatológica do HC e superintendente da Irmandade da Santa Casa de Misericórdia de São Paulo. Ainda ao lado do professor Odair Pedroso, criou o Hospital de Cotia, hoje Hospital Dr. Odair Pacheco Pedroso, do qual foi diretora durante 20 anos.

Tailândia bate firme na Big Pharma

Sem qualquer juízo de valor, mas o governo da Tailândia não tem medo da Big Pharma. Vai para cima, contra preços considerados extorsivos. Primeiro, medicamentos para aids com vitória (clique aqui), agora para câncer. O Brasil bateu na Big Pharma somente depois da Tailândia no caso da aids quebrando a patente do efavirenz. Aliás, uma boa pauta a ser cumprida: qual a situação atual da produção, distribuição e prescrição do efavirenz no Brasil. Eu, não tenho a menor idéia. Abaixo, trecho de reportagem do The Wall Street Journal sobre a proposta do governo tailandês.

Thailand's new health minister announced that he would urge the Thai government to continue to ignore patents on several cancer drugs, disappointing big pharmaceutical companies that had hoped Bangkok might roll back a policy of overriding patents in the name of public health.
The drugs' makers include Roche Holding AG and Novartis AG of Switzerland and Sanofi-Aventis of France.
Suphan Srithamma, a spokesman for the Thai health ministry, said that Minister Chaiya Sasomsup has decided to support the previous government's decision to ignore cancer-drug patents in a bid to cut the cost of medicines for the Thai people. The health ministry will make its recommendation to the Thai cabinet today, according to Dr. Suphan. Thailand's previous health minister, Mongkol na Songkhla, decided in early January to issue compulsory licenses (a policy that permits lower-cost generics) for four drugs: Novartis's imatinib, also known as Gleevec; Novartis's breast-cancer drug letrozole, whose brand name is Femara; Sanofi-Aventis's docetaxel, marketed as Taxotere and used to fight lung and breast cancer; and Roche's erlotinib, whose trade name is Tarceva. Novartis proposed that same month to offer Gleevec free to poor Thai patients, possibly making a compulsory license unnecessary, according to the ministry of health. A Novartis spokeswoman wasn't available for comment. It wasn't clear how yesterday's decision would affect Gleevec, given Novartis's apparent earlier concession.

Dica de livro: O Mapa Fantasma

O livro de Steven Johnson, O Mapa Fantasma (no original : The Ghost Map. The Story of London´s Most Terryfying Epidemic - and How It Changed Science, Cities, and the Modern World) editado pela Zahar encontra-se em todas livrarias por R$39,90. Compensa ler uma das sagas mais interessantes da história e, ainda desconhecida de muitos, incluindo aqueles interessados em temas da história da medicina. Quem gostar, poderá continuar lendo The Strange Case of th Broad Street Pump, de Sandra Hempel, editado pela University of California Press, com entrega pela Amazon. Aliás, Zahar, porque não traduzir esse também?

Observação e Experimentação: os dilemas da clínica e epidemiologia no século XXI

Quem não ficou estupefato com as diferenças entre os resultados do Nurses´Health Study (observacional) e os do Women´s Health Initiative sobre a terapia hormonal pós-menopausa? Quem não se cansou de ouvir falar em "medicina baseada em evidências" ? Quem não aceita que estudos de segurança não sejam parte do processo provisório de medicamentos? Essas dúvidas não são dirimidas no texto (advirto para iniciados) Jan Vandenbroucle publicado no Plos Medicine: Observational Research, Randomised Trials, and Two Views of Medical Science.

Medicamentos na água potável: ?!?!

Medicamentos encontrados na água. O texto completo é um despacho da Associated Press (clique aqui) . Abaixo, o comentário do blogueiro do WSJ

It’s not so expensive to get pharmaceuticals after all: Just drink water.
An investigation by the Associated Press found trace amounts of scads of drugs in drinking-water supplies around the country. For a list of what was found in the watersheds of 28 metro areas, click here. Among the water’s offerings were antibiotics, anti-convulsants, mood stabilizers and sex hormones. There were traces of sedatives in water serving the city that never sleeps.
While eyebrow-raising, there’s debate about what this actually means for human health. A microbiologist for PhRMA, the drug industry’s trade group, told the AP there’s little to no risk to humans. But at a conference last summer, Mary Buzby, director of environmental technology for Merck, said: “There’s no doubt about it, pharmaceuticals are being detected in the environment and there is genuine concern that these compounds, in the small concentrations that they’re at, could be causing impacts to human health or to acquatic organisms.”
Recent research found the small amounts of drugs affected human embryonic kidney cells, human blood cells and human breast cancer cells, the AP says, causing cancer cells to proliferate too quickly, for instance. (See this AP story for more on the research.) Wildlife are also being affected: Male fish are being feminized, creating egg yolk proteins. But some scientists caution the research is extremely limited, and there are lots of unknowns. Water providers rarely inform the public about the phenomenon, in part because they fear the fear factor. The head of a group representing major California suppliers told the AP that the public “doesn’t know how to interpret the information” and might be unduly alarmed. How do the drugs get in the water, anyway? Through our own waste, the AP explains. When people take drugs, their bodies absorb some, but not all, of the medication, and the rest goes down the toilet. Wastewater, of course, is treated before it’s discharged into reservoirs, rivers or lakes, and then it’s cleansed before it makes its way to the tap or into bottles. But trace amounts of drug residue remain.

Vacinação para hipertensão (resumo do artigo original)

Publicado hoje, no The Lancet. No site, há um vídeo discutindo o tema. Depois, comento.

Effect of immunisation against angiotensin II with CYT006-AngQb on ambulatory blood pressure: a double-blind, randomised, placebo-controlled phase IIa study
Background : Hypertension can be controlled adequately with existing drugs such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Nevertheless, treatment success is often restricted by patients not adhering to treatment. Immunisation against angiotensin II could solve this problem. We investigated the safety and efficacy of CYT006-AngQb—a vaccine based on a virus-like particle—that targets angiotensin II to reduce ambulatory blood pressure.
Methods :In this multicentre, double-blind, randomised, placebo-controlled phase IIa trial, 72 patients with mild-to-moderate hypertension were randomly assigned with a computer-generated randomisation list to receive subcutaneous injections of either 100 μg CYT006-AngQb (n=24), 300 μg CYT006-AngQb (24), or placebo (24), at weeks 0, 4, and 12. 24-h ambulatory blood pressure was measured before treatment and at week 14. The primary outcomes were safety and tolerability. Analyses were done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00500786.
Findings :Two patients in the 100 μg group, three in the 300 μg group, and none in the placebo group discontinued study treatment. All patients were included in safety analyses; efficacy analyses did not include the five dropouts, for whom no data were available at week 14. Five serious adverse events were reported (two in the 100 μg group, two in the 300 μg group, and one in the placebo group); none were deemed to be treatment related. Most side-effects were mild, transient reactions at the injection site. Mild, transient influenza-like symptoms were seen in three patients in the 100 μg group, seven in the 300 μg group, and none in the placebo group. In the 300 μg group, there was a reduction from baseline in mean ambulatory daytime blood pressure at week 14 by −9·0/−4·0 mm Hg compared with placebo (p=0·015 for systolic and 0·064 for diastolic). The 300 μg dose reduced the early morning blood-pressure surge compared with placebo (change at 0800 h −25/−13 mmHg; p<0·0001 for systolic, p=0·0035 for diastolic).
Interpretation : Immunisation with CYT006-AngQb was associated with no serious adverse events; most observed adverse events were consistent with local or systemic responses similar to those seen with other vaccines. The 300 μg dose reduced blood pressure in patients with mild-to-moderate hypertension during the daytime, especially in the early morning.
Funding Cytos Biotechnology AG.

Big Pharma está criativa: o ENHANCE trial

Passou despercebido por mim, durante as férias, um fato inédito: uma empresa, a Schering-Plough lançou no seu site e na imprensa leiga a suspensão de um ensaio clínico Effect of Ezetimibe Plus Simvastatin Versus Simvastatin Alone on Atherosclerosis in the Carotid Artery (ENHANCE) trial. Procurei o artigo original e, não achei. Descobri, agora que houve uma forma heterodoxa de comunicação científica: somente conclusões. O trial terminou em junho de 2006! JAMA apresentou comentário ácido sobre o ocorrido. (clique aqui)

O tráfico de droga com receita médica

Há muito discuto aqui, o uso e abuso de medicamentos que criam dependência que são comprados com receita médica. Felizmente, médicos estão diminuindo a má-prática de atender ao assédio de amigos, familiares e vizinhos e, já há falsários vendendo receitas devido à dificuldade em conseguir com médico. Nos Estados Unidos, onde o controle de prescrição é muito maior, a situação é muito complicada: 4,4% utilizam medicamentos controlados por razões não médicas. Vejam, o resumo do trabalhos publicado no Archives of Pediatrics and Adolescent Medicine. (março 2008)

Screening for Drug Abuse Among Medical and Nonmedical Users of Prescription Drugs in a Probability Sample of College Students. Sean Esteban McCabe, PhD, MSW Arch Pediatr Adolesc Med. 2008;162(3):225-231.
Objectives To determine the prevalence of medical and nonmedical use of 4 classes of prescription drugs (opioid, stimulant, sleeping, and sedative or anxiety) and to assess probable drug abuse among 4 mutually exclusive groups of medical and nonmedical use of prescription drugs.
Design In 2005, a Web survey was self-administered by a probability sample of 3639 college students (68% response rate).
Setting A large, midwestern 4-year university.
Participants The sample had a mean age of 19.9 years, and respondents were 53.6% female, 67.4% white, 12.1% Asian, 6.0% African American, 4.2% Hispanic, and 10.2% other racial categories.
Main Outcome Measures Medical and nonmedical use of prescription drugs was measured. Probable drug abuse was assessed using a modified version of the Drug Abuse Screening Test, Short Form.
Results A total of 40.1% of respondents reported no lifetime use of at least 1 of 4 classes of prescription drugs, 39.7% reported medical use only, 15.8% reported both medical and nonmedical use, and 4.4% reported nonmedical use only. The odds of a positive screening result for drug abuse were greater among medical and nonmedical users (adjusted odds ratio, 5.5; 95% confidence interval, 3.4-7.3) and nonmedical users only (adjusted odds ratio, 6.5; 95% confidence interval, 4.0-10.6) compared with nonusers. The odds of a positive screening result for drug abuse did not differ between medical users only and nonusers. Conclusions Nonmedical users of prescription drugs are at heightened risk for drug abuse, whereas medical users without a history of nonmedical use are generally not at increased risk. Drug abuse screening should be routine for college students, especially among individuals with any history of nonmedical use of prescription drugs

Um ataque à autonomia universitária: processos contra autores

Notícia do blog White Coats que traz noticias da área médica de Boston. Um exemplo de atentado à autonomia universitária iniciar processos contra autores de artigos que vão contra o interesse de empresas ou de grupos. Aqui, assistimos a campanha contra uma pesquisa patrocinada pela FAPESP sobre uso de drogas e, outra pior, vinda de abaixo-assinado contra um projeto de pesquisa da UFRGS.

Autonomia universitária é a liberdade de pesquisar utilizando o que de melhor existir em termos de metodologia científica. Quem não gostar do resultado que mostre em outro momento como cartas, revisões e, novos estudos, o equívoco apresentado. Se autor e revistas forem levianos ao publicar "artigos difamatórios" perderão o único patrimônio acadêmico: a respeitabilidade.

Em tempo, autonomia universitário não deve ser confundida com o "direito" em não respeitar as leis do país ou não prestar contas do dinheiro gasto.

Posted by Elizabeth Cooney February 28, 2008 06:05 PM
A Harvard physician has been sued by a manufacturer claiming its product was unfairly disparaged in a paper he wrote in a scientific journal, an unusual development in the world of scholarly publishing. Dr. Douglas P. Kiel, a gerontologist at Harvard Medical School and Hebrew Senior Life, wrote an article published in the Journal of the American Medical Association that said hip-protectors did not prevent fractures in nursing home patients. HipSaver Inc. of Canton, which makes hip protectors, filed a suit in Norfolk Superior Court Feb. 15 alleging that Kiel knowingly tested an inferior product and produced results that placed its version in a poor light. A story on the suit appeared in yesterday's Harvard Crimson. “It would have been more appropriate and scientifically accurate for Dr. Kiel to limit his conclusions to the specific hip protector that he studied,” HipSaver president Edward L. Goodwin said in a statement. “As it stands, his JAMA-published conclusions have wrongfully damaged the entire field of hip protection, including the HipSaver brand.” JAMA editors are not commenting on the suit, but stand by the study as published, a spokesman said. Kiel did not return a call from the Globe seeking comment, but Hebrew Senior Life is looking carefully at the charge before responding, spokeswoman Jennifer Davis said in an interview. “The research was published in one of the most prestigious and carefully vetted peer-reviewed journal published in the country,” she said. “Dr. Kiel is a very well respected and accomplished geriatric physician as well as researcher. So we certainly at this point feel we would do nothing other than support him completely in face of the complaint.”

Leitura de domingo: o iluminismo termina no bezerro de ouro.

O professor Leonardo Maurício Diniz, da Universidade Federal de Minas Gerais enviou-me esse texto excelente, com inúmeras referências desde a Bíblia até David Sackett, passando por Goethe e Swift. Uma boa leitura para o fim de semana para compreender a medicina antiga e a atual. "The Era of Enlightenment Ends With the Golden Calf" . Lecture given during The Škrabanek Foundation Colloquium "Medical Utopianism: A Threat to Health" held at the Royal College of Physicians, London, on April 25, 2002. Author: Michael Berger, Clique aqui para ver o texto completo.

Estatísticas de saúde implica imprensa livre e autonomia universitária.

Abaixo, segue reportagem do Estadão sobre a mortalidade por dengue questionando os númeroso do Ministério da Saúde.

Passou despercebido, em pleno Carnaval, mas a Folha de S.Paulo questionou os dados de mortes violentas não especificadas. Não vou entrar na discussão, que não cabe a um blog. Talvez, um texto em "Clínica & Epidemiologia".

Utilizei esse exemplo, mas mostrar que comparar estatísticas entre países implica identificar a existência de liberdade de imprensa, autonomia universitária e ministério público atuante. O restante pode ser, e com grande chance, manipulação de dados. Vide o horror da saúde pública na ex-URSS.
Em 2 anos, dengue matou 45% mais do que o divulgado
Por Fabiane Leite, no Estadão:A dengue no Brasil tem matado muito mais do que mostram os relatórios divulgados pelo Ministério da Saúde e governos estaduais e municipais. O número real de mortes pela doença em 2006 e 2007 - 326 óbitos - é 45% maior do que os 225 óbitos informados nos últimos dois anos em boletins sobre situação epidemiológica da dengue, revelam novos dados da pasta.O ministério, assim como governos estaduais e municipais, só inclui nos relatórios divulgados para o público as mortes por dengue hemorrágica e não informa os óbitos pelas outras formas de manifestação da doença, que também podem matar: a dengue clássica e a dengue com complicações, classificações definidas pela Organização Mundial da Saúde (OMS).Segundo a pasta, a própria OMS trabalha apenas com a divulgação das mortes hemorrágicas, para facilitar a comparação entre os países. A adição dos dados de mortes por outras formas da doença é o que eleva as já significativas estatísticas da dengue no País - no ano passado, o Brasil registrou epidemias em cinco Estados, com mais de 500 mil casos suspeitos e aumento do número de mortes por dengue hemorrágica. Em 2008, já houve diminuição da incidência da doença em 40%, informou o ministério.