Aculturação e Diabetes

Diabetes Care 31:1621-1628, 2008 DOI: 10.2337/dc07-2182© 2008 by the American Diabetes Association of Acculturation Levels and Prevalence of Diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA)

Namratha R. Kandula, MD, MPH1, Ana V. Diez-Roux, MD, PHD2, Cheeling Chan, MS3, Martha L. Daviglus, MD, PHD3, Sharon A. Jackson, PHD4, Hanyu Ni, PHD, MPH5 and Pamela J. Schreiner, MS, PHD6
OBJECTIVE—The prevalence of type 2 diabetes among Hispanic and Asian Americans is increasing. These groups are largely comprised of immigrants who may be undergoing behavioral and lifestyle changes associated with development of diabetes. We studied the association between acculturation and diabetes in a population sample of 708 Mexican-origin Hispanics, 547 non–Mexican-origin Hispanics, and 737 Chinese participants in the Multi-Ethnic Study of Atherosclerosis (MESA).
RESEARCH DESIGN AND METHODS—Diabetes was defined as fasting glucose 126 mg/dl and/or use of antidiabetic medications. An acculturation score was calculated for all participants using nativity, years living in the U.S., and language spoken at home. The score ranged from 0 to 5 (0 = least acculturated and 5 = most acculturated). Relative risk regression was used to estimate the association between acculturation and diabetes.
RESULTS—For non–Mexican-origin Hispanics, the prevalence of diabetes was positively associated with acculturation score, after adjustment for sociodemographics. The prevalence of diabetes was significantly higher among the most acculturated versus the least acculturated non–Mexican-origin Hispanics (prevalence ratio 2.49 [95% CI 1.14–5.44]); the higher the acculturation score is, the higher the prevalence of diabetes (P for trend 0.059). This relationship between acculturation and diabetes was partly attenuated after adjustment for BMI or diet. Diabetes prevalence was not related to acculturation among Chinese or Mexican-origin Hispanics.
CONCLUSIONS—Among non–Mexican-origin Hispanics in MESA, greater acculturation is associated with higher diabetes prevalence. The relation is at least partly mediated by BMI and diet. Acculturation is a factor that should be considered when predictors of diabetes in racial/ethnic groups are examined

Big Pharma caminha para biotecnologia

O fim da química fina como atividade da BigPharma avança. Depois da compra da Genentech pela Roche, agora há outras aquisições previstas no mesmo sentido.Vejam a reportagem abaixo do The New York Times.

Bristol-Myers Offers $4.5 Billion for Rest of ImClone

By STEPHANIE SAUL and ANDREW POLLACK Published: August 1, 2008
Bristol-Myers Squibb said Thursday that it planned an offer of $60 a share, or about $4.5 billion, to acquire the rest of ImClone Systems, the maker of the cancer drug Erbitux.The company said in a regulatory filing that it had delivered the offer by letter to the chairman of ImClone, Carl C. Icahn. Bristol currently owns about 17 percent of ImClone, a biotechnology company. The cash offer represents a premium of about 30 percent over ImClone’s closing share price on Wednesday. But investors apparently believed the sale price of ImClone could go even higher, bidding up the company’s shares by 37 percent, to $63.74, a half-hour before the market close. Shares in Bristol-Myers Squibb were off 1 percent, to $21.28. Global sales of Erbitux in 2007 exceeded $1.4 billion. Bristol’s offer comes little more than a week after another drug giant, Roche, offered to buy the 44 percent of its longtime biotechnology partner, Genentech, that it did not already own for $43.7 billion. And it comes during a period in which big pharmaceutical companies are buying smaller biotechnology players to gain rights to products to replenish their pipelines. Recent deals include Takeda Pharmaceutical’s offer to buy Millennium Pharmaceuticals for $8.8 billion and GlaxoSmithKline’s purchase of Sirtris Pharmaceuticals for $720 million. Companies like Genentech and ImClone sell so-called biologic products, which are made in living cells. Such drugs are particularly attractive because they are not subject to a sudden rush of competition by generic manufacturers. Bristol ’s offer set off speculation on Wall Street that other big drug makers might would seek to acquire biotechnology companies that are already their partners. Share of Onyx Pharmaceuticls, which co-developed a cancer drug with Bayer, were up about 9 percent in midday trading, as were shares of Amylin Pharmaceuticals, which co-developed a diabetes drug with Eli Lilly.

Tio Sam não é bobo, seus bajuladores nacionais são

Divertido lembrar as afirmativas dos adoradores brasileiros da Big Pharma. Há dez anos afirmavam que o programa de genéricos "faria água". Depois, duvidavam do programa brasileiro de terapia antiretroviral. Por último, atacaram o Ministério da Saúde quando quebrou a patente do efavirenz. Agora, o Tio Sam (leia Talvez o único ato bom de George W) resolveu ajudar um pouco a África e, como o dinheiro é deles, comprarão os genéricos da Índia.

Generics Fuel AIDS Program
As U.S. Plan Shifts, Indian Drug Makers Reap the Benefits
By SARAH LUECKJuly 31, 2008
WASHINGTON -- Companies that make generic drugs, many based in India, now dominate President George W. Bush's program to provide AIDS treatment in poor countries.
Generic drugs, copies or combinations of brand-name products, accounted for 57% of the $131 million the U.S. spent on the program in fiscal 2007, according to the Office of the U.S. Global AIDS Coordinator. In 2005, generics accounted for 11% of the program's funding. At that time, the U.S. had approved few generics for the anti-AIDS initiative, so most of the money went to buy brand-name drugs that are often more expensive.
Aurobindo Pharma Ltd., a generic-drug maker in India, was the biggest player in fiscal 2007, which ended Sept. 30. The President's Emergency Plan for AIDS Relief, or Pepfar, spent more than $39 million on Aurobindo Pharma products to fight HIV and AIDS. India's Cipla Ltd. received more than $15 million, and Ranbaxy Laboratories, also in India, received nearly $9 million.
South Africa's Aspen Pharmacare Holdings Ltd. received nearly $13 million from Pepfar. It sells generic AIDS drugs and, in some countries, produces brand-name products in partnership with Gilead Sciences Inc. of Foster City, Calif.
Pepfar's shift to generics in the past two years followed a Bush administration decision to set up a special approval at the Food and Drug Administration for the drugs, which cannot be marketed in the U.S. because of patent and exclusivity laws that protect the brand-name versions.
Pepfar provides treatment to patients in 15 poor countries, mostly in sub-Saharan Africa. Bush officials came under fire when the program began five years ago; activists and some in the generics industry complained that the requirement for FDA approval skewed purchases toward more-expensive brand-name products, meaning fewer people would be treated.
Wednesday, Mr. Bush signed a $48 billion, five-year expansion of the program, which now draws widespread praise and is viewed as a major part of his legacy. Congress must appropriate the funds, which also will go toward treatment and prevention of malaria and tuberculosis.
"It's pretty clear that the system is working well, and it protects African families just like American families are protected," said Ambassador Mark Dybul, the U.S. global AIDS coordinator. "We pretty methodically did what we said we were going to do."
Pepfar's spending on brand-name drugs totaled about $56 million in fiscal year 2007, down from $106 million in 2005. Merck & Co. appeared to be the biggest recipient of funds in 2007, with nearly $16 million going to the Whitehouse Station, N.J.-based company. GlaxoSmithKline PLC of the U.K. received about $12 million from Pepfar, including through licensing agreements it has with makers of generics. Abbott Laboratories of Abbott Park, Ill., received nearly $9 million in 2007.The generics companies have been pleased with the changes over the past two years.
"Earlier, it did not work well because none of our products were approved," said Yusuf Hamied, Cipla's chairman and managing director. "Now, there is competition, and the money will be put to better use." He said the funds Cipla receives from Pepfar aren't significant from a business perspective, but the company participates for humanitarian reasons and has helped build pressure for brand-name-drug companies to lower their prices for poor countries."The key is having affordable and accessible medicines, and I think the generic industry has made a contribution in a very positive way to Pepfar," said Chuck Caprariello, a Ranbaxy spokesman.

Correção do Check Up de Câncer de Pulmão

Há quase dois anos teci loas a um artigo sobre o rastreamento de câncer de pulmão. Apesar do meu ceticismo crônico com os "check-ups" considerei que era algo de novo. Hoje, novamente há uma correção a terceira, feita pelos próprios autores. Confesso que já me perdi na releitura do texto original e das correções. Peço desculpa aos leitores por não ter exercido o direito inalienável ao ceticismo em relação aos "check-ups".

Fim dos livros médicos?

Vem aí a MedPedia. Uma wikipedia médica, mas com colaboradores com currículo e aceitos por um conselho editorial. Apoio de peso:Harvard, Stanford e Michigan. O proponente é Joseph Martin, ex-diretor da escola de medicina Harvard.

Vamos ver o que ocorrerá, mas esse fato lembra o futuro apresentado em um post (25/07/08) recente no Blog do Alon sobre o fim dos livros.

Em Framigham: redução da pressão arterial e melhora do controle em 16 anos

Arch Intern Med. 2008 Jul 14;168(13):1450-7.
Altered blood pressure progression in the community and its relation to clinical events.

Ingelsson E, Gona P, Larson MG, Lloyd-Jones DM, Kannel WB, Vasan RS, Levy D.Framingham Heart Study, 73 Mount Wayte Ave, Ste 2, Framingham, MA 01702-5803, USA.BACKGROUND: Long-term blood pressure (BP) progression and its importance as a predictor of clinical outcome have not been well characterized across different periods. METHODS: We evaluated period trends for 3 BP variables (long-term slope and mean BP during a baseline period of 16 years, and last baseline value) in an earlier period (1953-1971; n = 1644, mean participant age, 61 years) and in a later period (1971-1990; n = 1040, mean participant age, 58 years) in participants in the Framingham Heart Study who initially did not have hypertension. In addition, we explored the relation of BP to cardiovascular disease incidence and all-cause mortality in the 2 periods, each with up to 16 years of follow-up. RESULTS: Long-term slope, mean, and last baseline BP measurements were significantly lower in the later period (P < .001). Rates of hypertension control (BP <140/90 p =" .03;" p =" .04).">

Impacto da Prevenção na Redução da Doença Cardiovascular

(Circulation. 2008;118:576-585) coraçaodobrasil/estrategiasdeprevençao

The Impact of Prevention on Reducing the Burden of Cardiovascular Disease.

Richard Kahn, PhD; Rose Marie Robertson, MD, FAHA; Robert Smith, PhD; David Eddy, MD, PhD
E-mail rkahn@diabetes.org
Objective— Cardiovascular disease (CVD) is prevalent and expensive. While many interventions are recommended to prevent CVD, the potential effects of a comprehensive set of prevention activities on CVD morbidity, mortality, and costs have never been evaluated. We therefore determined the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs in the United States.
Research Design and Methods— We used person-specific data from a representative sample of the US population (National Health and Nutrition Education Survey IV) to determine the number and characteristics of adults aged 20-80 years in the United States today who are candidates for different prevention activities related to CVD. We used the Archimedes model to create a simulated population that matched the real US population, person by person. We then used the model to simulate a series of clinical trials that examined the effects over the next 30 years of applying each prevention activity one by one, or altogether, to those who are candidates for the various activities and compared the health outcomes, quality of life, and direct medical costs to current levels of prevention and care. We did this under two sets of assumptions about performance and compliance: 100% success for each activity and lower levels of success considered aggressive but still feasible.
Results— Approximately 78% of adults aged 20-80 years alive today in the United States are candidates for at least one prevention activity. If everyone received the activities for which they are eligible, myocardial infarctions and strokes would be reduced by 63% and 31%, respectively. If more feasible levels of performance are assumed, myocardial infarctions and strokes would be reduced 36% and 20%, respectively. Implementation of all prevention activities would add 221 million life-years and 244 million quality-adjusted life-years to the US adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Of the specific prevention activities, the greatest benefits to the US population come from providing aspirin to high-risk individuals, controlling pre-diabetes, weight reduction in obese individuals, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing coronary artery disease (CAD). As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years.
Conclusions— Aggressive application of nationally recommended prevention activities could prevent a high proportion of the CAD events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently

Em breve, mais gente vivendo do que morrendo de aids

Com certeza, o título é um exagero. Mas, uma vitória, o controle da aids foi saudado como um problema. Esse é um problema de quem trabalha em algumas áreas como doenças infecciosas, desnutrição e doenças da infância: não sabem vencer!

U.N. Says AIDS Epidemic Stable Amid Fewer Deaths, Infections
Associated PressJuly 29, 2008 4:29 p.m.
LONDON -- Fewer people are dying of AIDS, more patients are on HIV medication and the global AIDS epidemic is stable after peaking in the late 1990s.
But the United Nations AIDS agency warned in its yearly report Tuesday that governments will need to continue setting aside millions of dollars for AIDS in the coming decades as patients live longer on AIDS treatment. "We've achieved more in the past five years than in the previous 20 years," said Peter Piot, the agency's executive director. "But if we relax now, it would be disastrous. It would wipe out all of our previous investments."
UNAIDS estimates the number of AIDS case world-wide at 33 million; its previous estimate of 40 million was revised last year because of changes to how it counts cases.
Countries in sub-Saharan Africa including South Africa, Botswana and Swaziland, remain the center of the AIDS epidemic. The region has about 67% of all people infected with HIV and 72% of all AIDS deaths. Outside sub-Saharan Africa, AIDS mainly affects drug users, gay men and sex workers. Officials estimate that two million people died from AIDS last year, down from approximately 2.2 million in 2005. The most dramatic figures are in treatment: The number of people on AIDS medication jumped by 10 times in the last six years, with some 300,000 taking AIDS drugs in 2003 compared to about 3 million in 2007. AIDS drugs have become much cheaper and more available because of a variety of government and private programs. But millions of others still do not have access to the drugs, and those who do will need to remain on them to stay alive. Still, millions of new cases of HIV infection are reported every year, the agency said. HIV is rising in several countries beyond Africa, including China, Germany, Indonesia, Russia and Britain, according to the report, which was issued in advance of next week's international AIDS conference in Mexico City.
The good news is that the global number of new infections was down to about 2.7 million people in 2007 from a peak of about 5 million new cases annually in the early 2000s.
However, the report -- based on government data from 147 countries -- warned there could be future waves of infection. The agency said it would be difficult to predict whether the AIDS epidemic might spike again. Last week, the U.S. government tripled the amount of money it will spend on AIDS and other diseases around the world to $48 billion over five years.
The slow decline of AIDS-related deaths is "dismally disappointing," said Selina Lo, medical coordinator for Medecins Sans Frontiere's Access to Essential Medicines campaign. The group also is known as Doctors Without Borders.

Estresse, pressão arterial e peso ao nascer: diferenças por gênero

Sex-specific programming of cardiovascular physiology in children

Alexander Jones1,2,*, Alessandro Beda3, Clive Osmond1, Keith M. Godfrey1, David M. Simpson3 and David I. W. Phillips1 Eur Heart J 2008; DOI: 10.1093/eurheartj/ehn292.
Email: aj@mrc.soton.ac.uk
Aims: Increasing evidence suggests that adverse prenatal environments, as indicated by low birth weight, cause long-term changes in cardiovascular physiology that predispose to circulatory disease. The mechanisms are poorly understood, most human studies have been carried out in adults and little is known about early pathophysiological changes. Therefore, we have assessed the relationship between birth weight and cardiovascular physiology in children.
Methods and results: In 140 healthy boys and girls (aged 7–9 years), born at term and followed prospectively, we continuously recorded blood pressure, electrocardiograms and cardiac impedance before, during, and after 10 min of psychosocial stress (Trier Social Stress Test for Children). In boys, an association of lower birth weight with higher resting systemic arterial pressure (β = –6.8 mmHg/kg, P= 0.03) and a trend towards higher vascular resistance (β = –87 dyne s/cm5/kg, ns) were substantially strengthened following stress (β = –9.5 mmHg/kg, P= 0.003 and β = –139 dyne s/cm5/kg, P = 0.02, respectively). In girls, lower birth weight was associated with a shorter pre-ejection period (β = 8.0 ms/kg, P = 0.005) and corrected QT interval (β = 11.9 ms/kg, P = 0.003) at rest and little changed by stress.
Conclusion: Smaller size at birth is associated with sex-specific alterations in cardiac physiology; boys had higher systemic vascular resistance and girls had increased cardiac sympathetic activation.

Qualidade de vida no portador de doença coronariana

Patient-Reported Health Status in Coronary Heart Disease in the United States
Age, Sex, Racial, and Ethnic Differences Circulation. 2008;118:491-497

Jipan Xie, MD, PhD; Eric Q. Wu, PhD; Zhi-Jie Zheng, MD, PhD; Patrick W. Sullivan, PhD; Lin Zhan, MS; Darwin R. Labarthe, MD, MPH, PhD
E-mail jipan.xie@gmail.com
Background— Coronary heart disease (CHD) affects 15.8 million Americans. However, data on the national impact of CHD on health-related quality of life, particularly among people of different age, sex, racial, and ethnic groups, are limited.
Methods and Results— Using data from the 2000 and 2002 Medical Expenditure Panel Survey, we examined various measures of patient-reported health status, including health-related quality of life, in the CHD and non-CHD populations and differences in the measures among demographic subgroups. These measures included short-form generic measures (Short Form 12; Mental Component Summary-12 and Physical Component Summary-12) and EuroQol Group measures (EQ-5D index and EQ visual analog scale). Ordinary least-squares regressions were used to adjust for sociodemographic characteristics, risk factors, comorbidities, and proxy report. The adjusted difference between the CHD and non-CHD populations was –1.2 for Mental Component Summary-12 (2.4% of the score in the non-CHD population), –4.6 for Physical Component Summary-12 (9.2%), –0.04 for EQ-5D (4.6%), and –7.3 for EQ visual analog scale (9.0%) (all P<0.05).>

Adiposidade e Sobrevida pós Infarto do Miocárdio

Circulation. 2008;118:482-490

Relation Between Body Mass Index, Waist Circumference, and Death After Acute Myocardial Infarction

Marianne Zeller, PhD; Philippe Gabriel Steg, MD, PhD; Jack Ravisy, MD; Luc Lorgis, MD; Yves Laurent, MD; Pierre Sicard, PhD; Luc Janin-Manificat, MD; Jean-Claude Beer, MD; Hamid Makki, MD; Anne-Cécile Lagrost, MSc; Luc Rochette, PharmD, PhD; Yves Cottin, MD, PhD, for the RICO Survey Working Group
Background— An elevated body mass index (BMI) has been reported to be associated with a lower rate of death after acute myocardial infarction (AMI). However, waist circumference (WC) may be a better marker of cardiovascular risk than BMI. We used data from a contemporary French population-based cohort of patients with AMI to analyze the impact of WC and BMI on death rates.
Methods and Results— We evaluated 2229 consecutive patients with AMI. Patients were classified according to BMI as normal, overweight, obese, and very obese (BMI <25,>35 kg/m2, respectively) and as increased waistline (WC >88/102 cm for women/men) or normal. Half of the patients were overweight (n=1044), and one quarter were obese (n=397) or very obese (n=128). Increased WC was present in half of the patients (n=1110). Increased BMI was associated with a reduced death rate, with a 5% risk reduction for each unit increase in BMI (hazard ratio, 0.95; 95% CI, 0.93 to 0.98; P<0.001). In contrast, WC as a continuous variable had no impact on all-cause death (P=0.20). After adjustment for baseline predictors of death, BMI was not independently predictive of death. The group of patients with high WC but low BMI had increased 1-year death rate.
Conclusions— Neither BMI nor WC independently predicts death after AMI. Much of the inverse relationship between BMI and the rate of death after AMI is due to confounding by characteristics associated with survival. This study emphasizes the need to measure both BMI and WC because patients with a high WC and low BMI are at high risk of death.

Colesevelam e Complicações do Diabetes

Efficacy and Safety of Colesevelam in Patients With Type 2 Diabetes Mellitus and Inadequate Glycemic Control Receiving Insulin-Based Therapy . Ronald B. Goldberg, MD; Vivian A. Fonseca, MD; Kenneth E. Truitt, MD; Michael R. Jones, PhD Arch Intern Med. 2008;168(14):1531-1540.
Background Poor glycemic control is a risk factor for microvascular complications in patients with type 2 diabetes mellitus. Achieving glycemic control safely with insulin therapy can be challenging.
Methods A prospective, 16-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study conducted at 50 sites in the United States and 1 site in Mexico between August 12, 2004, and December 28, 2005. Subjects had type 2 diabetes mellitus that was not adequately controlled (glycated hemoglobin level, 7.5%-9.5%, inclusive) receiving insulin therapy alone or in combination with oral antidiabetes agents. In total 287 subjects (52% men; mean age, 57 years; with a mean baseline glycated hemoglobin level of 8.3%) were randomized: 147 to receive colesevelam hydrochloride, 3.75 g/d, and 140 to receive placebo.
Results Using the least squares method, the mean (SE) change in glycated hemoglobin level from baseline to week 16 was –0.41% (0.07%) for the colesevelam-treated group and 0.09% (0.07%) for the placebo group (treatment difference, –0.50% [0.09%]; 95% confidence interval, –0.68% to –0.32%; P < .001). Consistent reductions in fasting plasma glucose and fructosamine levels, glycemic-control response rate, and lipid control measures were observed with colesevelam. As expected, the colesevelam-treated group had a 12.8% reduction in low-density lipoprotein cholesterol concentration relative to placebo (P < .001). Of recipients of colesevelam and placebo, respectively, 30 and 26 discontinued the study prematurely; 7 and 9 withdrew because of protocol-specified hyperglycemia, and 10 and 4 withdrew because of adverse events. Both treatments were generally well tolerated.
Conclusions Colesevelam treatment seems to be safe and effective for improving glycemic control and lipid management in patients with type 2 diabetes mellitus receiving insulin-based therapy, and it may provide a novel treatment for improving dual cardiovascular risk factors

Padrão de Dieta, Perda de Peso e Incidência de Diabetes

Low-Fat Dietary Pattern and Risk of Treated Diabetes Mellitus in Postmenopausal Women The Women's Health Initiative Randomized Controlled Dietary Modification Trial Lesley F. Tinker, PhD; Denise E. Bonds, MD, MPH; Karen L. Margolis, MD, MPH; JoAnn E. Manson, MD, DrPH; Barbara V. Howard, PhD; Joseph Larson, MS; Michael G. Perri, PhD; Shirley A. A. Beresford, PhD; Jennifer G. Robinson, MD, MPH; Beatriz Rodríguez, MD, PhD; Monika M. Safford, MD; Nanette K. Wenger, MD; Victor J. Stevens, PhD; Linda M. Parker, DSc Arch Intern Med. 2008;168(14):1500-1511.
Background Decreased fat intake with weight loss and increased exercise may reduce the risk of diabetes mellitus in persons with impaired glucose tolerance. This study was undertaken to assess the effects of a low-fat dietary pattern on incidence of treated diabetes among generally healthy postmenopausal women.
Methods A randomized controlled trial was conducted at 40 US clinical centers from 1993 to 2005, including 48 835 postmenopausal women aged 50 to 79 years. Women were randomly assigned to a usual-diet comparison group (n = 29 294 [60.0%]) or an intervention group with a 20% low-fat dietary pattern with increased vegetables, fruits, and grains (n = 19 541 [40.0%]). Self-reported incident diabetes treated with oral agents or insulin was assessed.
Results Incident treated diabetes was reported by 1303 intervention participants (7.1%) and 2039 comparison participants (7.4%) (hazard ratio, 0.96; 95% confidence interval, 0.90-1.03; P = .25). Weight loss occurred in the intervention group, with a difference between intervention and comparison groups of 1.9 kg after 7.5 years (P < .001). Subgroup analysis suggested that greater decreases in percentage of energy from total fat reduced diabetes risk (P for trend = .04), which was not statistically significant after adjusting for weight loss.
Conclusions A low-fat dietary pattern among generally healthy postmenopausal women showed no evidence of reducing diabetes risk after 8.1 years. Trends toward reduced incidence were greater with greater decreases in total fat intake and weight loss. Weight loss, rather than macronutrient composition, may be the dominant predictor of reduced risk of diabetes.

Ingestão de frutas (vitamina C) e Incidência de Diabetes

Plasma Vitamin C Level, Fruit and Vegetable Consumption, and the Risk of New-Onset Type 2 Diabetes Mellitus
The European Prospective Investigation of Cancer–Norfolk Prospective Study
Anne-Helen Harding, PhD; Nicholas J. Wareham, FRCP, PhD; Sheila A. Bingham, PhD; KayTee Khaw, FRCP; Robert Luben, BSc; Ailsa Welch, PhD; Nita G. Forouhi, FFPH, PhD
Arch Intern Med. 2008;168(14):1493-1499.
Background Epidemiologic studies suggest that greater consumption of fruit and vegetables may decrease the risk of diabetes mellitus, but the evidence is limited and inconclusive. Plasma vitamin C level is a good biomarker of fruit and vegetable intake, but, to our knowledge, no prospective studies have examined its association with diabetes risk. This study aims to examine whether fruit and vegetable intake and plasma vitamin C level are associated with the risk of incident type 2 diabetes.
Methods We administered a semiquantitative food frequency questionnaire to men and women from a population-based prospective cohort (European Prospective Investigation of Cancer–Norfolk) study who were aged 40 to 75 years at baseline (1993-1997) when plasma vitamin C level was determined and habitual intake of fruit and vegetables was assessed. During 12 years of follow-up between February 1993 and the end of December 2005, 735 clinically incident cases of diabetes were identified among 21 831 healthy individuals. We report the odds ratios of diabetes associated with sex-specific quintiles of fruit and vegetable intake and of plasma vitamin C levels.
Results A strong inverse association was found between plasma vitamin C level and diabetes risk. The odds ratio of diabetes in the top quintile of plasma vitamin C was 0.38 (95% confidence interval, 0.28-0.52) in a model adjusted for demographic, lifestyle, and anthropometric variables. In a similarly adjusted model, the odds ratio of diabetes in the top quintile of fruit and vegetable consumption was 0.78 (95% confidence interval, 0.60-1.00).
Conclusions Higher plasma vitamin C level and, to a lesser degree, fruit and vegetable intake were associated with a substantially decreased risk of diabetes. Our findings highlight a potentially important public health message on the benefits of a diet rich in fruit and vegetables for the prevention of diabetes.

Suco de frutas e Incidência de Diabetes

Sugar-Sweetened Beverages and Incidence of Type 2 Diabetes Mellitus in African American Women Julie R. Palmer, ScD; Deborah A. Boggs, MS; Supriya Krishnan, DSc; Frank B. Hu, MD; Martha Singer, MPH; Lynn Rosenberg, ScD Arch Intern Med. 2008;168(14):1487-1492.
Background Type 2 diabetes mellitus is an increasingly serious health problem among African American women. Consumption of sugar-sweetened drinks was associated with an increased risk of diabetes in 2 studies but not in a third; however, to our knowledge, no data are available on African Americans regarding this issue. Our objective was to examine the association between consumption of sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes mellitus in African American women.
Methods A prospective follow-up study of 59 000 African American women has been in progress since 1995. Participants reported on food and beverage consumption in 1995 and 2001. Biennial follow-up questionnaires ascertained new diagnoses of type 2 diabetes. The present analyses included 43 960 women who gave complete dietary and weight information and were free from diabetes at baseline. We identified 2713 incident cases of type 2 diabetes mellitus during 338 884 person-years of follow-up. The main outcome measure was the incidence of type 2 diabetes mellitus.
Results The incidence of type 2 diabetes mellitus was higher with higher intake of both sugar-sweetened soft drinks and fruit drinks. After adjustment for confounding variables including other dietary factors, the incidence rate ratio for 2 or more soft drinks per day was 1.24 (95% confidence interval, 1.06-1.45). For fruit drinks, the comparable incidence rate ratio was 1.31 (95% confidence interval, 1.13-1.52). The association of diabetes with soft drink consumption was almost entirely mediated by body mass index, whereas the association with fruit drink consumption was independent of body mass index.
Conclusions Regular consumption of sugar-sweetened soft drinks and fruit drinks is associated with an increased risk of type 2 diabetes mellitus in African American women. While there has been increasing public awareness of the adverse health effects of soft drinks, little attention has been given to fruit drinks, which are often marketed as a healthier alternative to soft drinks.

Chagas é prioridade?

O tema doença de Chagas já foi tratado várias vezes no blogue . Hoje, há notícia de que estamos na linha de descoberta de novos fármacos para a doença. Tudo bem, ninguém é contra o conhecimento. Mas, e deverá constar vários "más", a doença de Chagas é residual em nosso meio. Ela foi eliminada (ver o post citando o artigo do Prof Eduardo Massad) praticamente do cenário brasileiro. Resta entre os mais idosos que foram expostos ao barbeiro e, em acidentes como o do açaí. A epidemiologia brasileira ainda é um brinquedo para epidemiologistas, afirmo com ceticismo, ainda não serve para o planejamento de serviços, muito menos para prioridades na ciência. A única "salvação" é "anexarmos" a Bolívia, onde há uma prevalência enorme de infectados. Talvez, uma troca com o gás loca.

Excelência brasileira (28/7/2008) Por Fábio de Castr o
Agência FAPESP – Agência FAPESP – A Organização Mundial da Saúde (OMS) acaba de criar, no Brasil, um novo Centro de Referência Mundial em Química Medicinal para Doença de Chagas , formado por grupos de excelência ligados à Universidade de São Paulo (USP) em São Carlos (SP) e à Universidade Estadual de Campinas (Unicamp).
O novo centro atuará diretamente na rede de laboratórios de descoberta de novos fármacos do Programa Especial para Pesquisa e Treinamento em Doenças Tropicais (TDR, na sigla em inglês), da OMS. Depois de uma competitiva seleção internacional, a organização escolheu o grupo brasileiro para formar o centro voltado especificamente para a pesquisa sobre doença de Chagas. (texto completo, clique aqui)

Antibióticos e Longevidade: o primeiro uso da penicilina

No Annals of Internal Medicine há o relato da primeira administração de penicilina a uma mulhere de 33 anos morimbunda por infeçção por estreptococos. Ela morreria de outra causa aos 90 anos.

The first use of penicillin in the United States occurred in 1942 and saved a moribund patient who had [beta]-hemolytic streptococcal sepsis.

The first dose of penicillin given in the United States was administered at Yale–New Haven Hospital on 14 March 1942 to a patient dying of septicemia. As a young Yale house officer, I found myself involved in what few of us then realized was a very profound sequence of events. It was my ninth month of service, and I was an acting assistant resident.
On the private floor of the Yale–New Haven Isolation Building, a very ill 33-year-old patient had [beta]-hemolytic streptococcal sepsis. She had run a steady temperature of 103° F to 106° F for 4 weeks Her private physician, Dr. John Bumstead, persuaded Dr. John F. Fulton, another ill patient of his with a severe pulmonary infection, to try to obtain a new drug—penicillin. The drug was not yet available in the United States. Dr. Howard Florey had reported on the use of penicillin in England in 1941, and Dr. Fulton was aware of Florey’s studies. Since their Oxford days together, Fulton and Florey had remained friends. In fact, Dr. Florey’s children were living with the Fultons in New Haven, Connecticut, to escape the German bombs falling on London in 1941.
-Dr. Fulton, a National Research Council (NRC) Committee on Aviation Medicine member and Sterling Professor of Physiology, and Dr. Francis G. Blake, Sterling Professor of Medicine and a leading member of the National Academy of Science Chemotherapy Committee, used their considerable influence to complete the tortuous route required to release the small amount of penicillin available in the United States. Dr. Florey and his associate, Dr. Norman Heatley, had come to the United States in an effort to increase penicillin production, because England was so busy with the war with Germany.
The first vial was mailed to Dr. Bumstead in New Haven from Merck & Co. in Rahway, New Jersey, and it arrived on Saturday, 14 March 1942. Dr. Bumstead and I took the vial to Dr. Morris Tager, Associate Professor of Bacteriology and Immunology. We discussed what to do with the pungent, brown-red powder. “We decided to dissolve it in saline and pass it through an E.K. Seitz [asbestos] filter pad to sterilize it,” wrote Dr. Tager in 1976. We then returned to the patient, and I injected 5000 U into the intravenous tubing. Rocko Fasanella, a medical student (later a professor of ophthalmology at Yale), gave subsequent doses every 4 hours. By Monday morning, the patient was eating hearty meals, the intravenous treatment was stopped, and she subsequently received 5000 U intravenously every 4 hours. On Monday morning rounds, Dr. Wilder Tileston, a senior consultant, looking at the temperature chart, muttered to those of us close enough to hear, “black magic.” My fellow intern, Dr. Herbert Tabor (later the editor of the Journal of Biological Chemistry for many years), saved all of the patient’s urine because Dr. Heatley had informed us that more penicillin could be purified from it than could be produced by cultivation.
Probably up to 95% of each intravenous dose was excreted unchanged. When Dr. Heatley delivered a subsequent vial, some of which had come from the patient’s urine, he carted the gallons of urine back to Rahway. The patient survived and later died of other causes at the age of 90 years.
Four hundred million units of penicillin were produced in the first 5 months of 1943. In the next 7 months, 20.5 billion units were produced—an increase of more than 500 times. By August 1945, 650 billion units were distributed each month. The subsurface liquid culture technique produced so well that when the structures of penicillin F and G were later established, it was decided that producing penicillin by culture rather than by any chemical synthetic method would be far less costly. Production costs changed so that the cost of an ampoule of 100 000 units was “scarcely more than the cost of material and labour to put it into an ampoule” If any one person is to be credited with the development of penicillin in the United States, it should be Dr. John F. Fulton. The literature does indeed tell about his significant role. His telephone calls from his own hospital bed demonstrated his persistence, perspicacity, patience (when needed), propriety, and personal influence. He recognized a need and a possible fulfillment of this need, and he effectively pushed for the sequence of events that transpired. Fleming, Florey, and Chain received the Nobel Prize in Medicine in 1945 for their contributions. Fulton deserves credit together with Dr. Francis G. Blake for proving the enormous value of penicillin and effecting the birth of the antibiotic era

PSA: nova revisão sistemática

Benefits and Harms of Prostate-Specific Antigen Screening for Prostate Cancer: An Evidence Update for the U.S. Preventive Services Task Force.
Annals of Internal Medicine Volume 149(3) August 5, 2008

Background: Prostate cancer is the most common nonskin cancer in men in the United States, and prostate cancer screening has increased in recent years. In 2002, the U.S. Preventive Services Task Force concluded that evidence was insufficient to recommend for or against screening for prostate cancer with prostate-specific antigen (PSA) testing.Purpose: To examine new evidence on benefits and harms of screening asymptomatic men for prostate cancer with PSA.Data Sources: English-language articles identified in PubMed and the Cochrane Library (search dates, January 2002 to July 2007), reference lists of retrieved articles, and expert suggestions.Study Selection: Randomized, controlled trials and meta-analyses of PSA screening and cross-sectional and cohort studies of screening harms and of the natural history of screening-detected cancer were selected to answer the following questions: Does screening for prostate cancer with PSA, as a single-threshold test or as a function of multiple tests over time, decrease morbidity or mortality? What are the magnitude and nature of harms associated with prostate cancer screening, other than overtreatment? What is the natural history of PSA-detected, nonpalpable, localized prostate cancer?Data Extraction: Studies were reviewed, abstracted, and rated for quality by using predefined U.S. Preventive Services Task Force criteria.Data Synthesis: No good-quality randomized, controlled trials of screening for prostate cancer have been completed. In 1 cross-sectional and 2 prospective cohort studies of fair to good quality, false-positive PSA screening results caused psychological adverse effects for up to 1 year after the test. The natural history of PSA-detected prostate cancer is poorly understood.Limitations: Few eligible studies were identified. Long-term adverse effects of false-positive PSA screening test results are unknown.Conclusion: Prostate-specific antigen screening is associated with psychological harms, and its potential benefits remain uncertain

Função renal e AVC

Impairment in Glomerular Filtration Rate or Glomerular Filtration Barrier and Occurrence of Stroke. Bruce Ovbiagele, MD .Arch Neurol. 2008;65(7):934-938.
Background Chronic kidney disease (CKD) is associated with substantial burden and is a strong risk factor for cardiovascular disease. However, data on the relationship between CKD and stroke are few and are limited by unreliable or inadequate assessment of renal function.
Objective To properly assess the relationship between renal insufficiency and stroke in stroke survivors in the United States by simultaneously examining the effect of guideline-recommended indices of renal disease that measure glomerular filtration rate (creatinine clearance) and glomerular filtration barrier (proteinuria).
Design Cross sectional.
Setting Nationally representative survey of the United States.
Subjects Participants aged 55 or older who participated in the National Health and Nutrition Examination Survey from 1999 to 2004.
Main Outcome Measures Indices of renal disease that measure glomerular filtration rate (creatinine clearance) and glomerular filtration barrier (microalbuminuria).
Results Of 6382 adults who met inclusion criteria, 5624 (88%) had full and complete data, of which 414 (6%) reported having had a stroke. Stroke survivors were older and more likely to have CKD, diabetes, hypertension, coronary artery disease, elevated blood pressure, increased glycohemoglobin concentration, and lower hematocrit compared with respondents who did not report stroke. Multivariate models showed that microalbuminuria (odds ratio, 1.51; 95% confidence interval, 1.02-2.24), decreased glomerular filtration rate (odds ratio, 1.93; 95% confidence interval, 1.28-2.91), and stage 3 CKD (odds ratio, 2.09; 95% confidence interval, 1.38-3.16) were significantly associated with stroke.
Conclusion Stroke is independently associated with impairment in structure and function of the glomerulus, which supports the need to consider screening patients with stroke for CKD and to simultaneously assess for both indices of renal disease

Hipertensão e Calcificação Coronariana

Prehypertension during Young Adulthood and Coronary Calcium Later in Life Mark J. Pletcher, MD, MPH; Kirsten Bibbins-Domingo, PhD, MD; Cora E. Lewis, MD; Gina S. Wei, MD, MPH; Steve Sidney, MD, MPH; J. Jeffrey Carr, MD, MSCE; Eric Vittinghoff, PhD; Charles E. McCulloch, PhD; and Stephen B. Hulley, MD, MPH Annals of Internal Medicine 15 July 2008 Volume 149 Issue 2 Pages 91-99
Background: High blood pressure in middle age is a well-established risk factor for cardiovascular disease, but the consequences of low-level elevations during young adulthood are unknown.
Objective: To measure the association between prehypertension exposure before age 35 years and coronary calcium later in life.
Design: Prospective cohort study.
Setting: Four communities in the United States.
Participants: Black and white men and women age 18 to 30 years recruited for the CARDIA (Coronary Artery Risk Development in Young Adults) Study in 1985 through 1986 who were without hypertension before age 35 years.
Measurements: Blood pressure trajectories for each participant were estimated by using measurements from 7 examinations over the course of 20 years. Cumulative exposure to blood pressure in the prehypertension range (systolic blood pressure of 120 to 139 mm Hg, or diastolic blood pressure of 80 to 89 mm Hg) from age 20 to 35 years was calculated in units of mm Hg–years (similar to pack-years of tobacco exposure) and related to the presence of coronary calcium measured at each participant's last examination (mean age, 44 years [SD, 4]).
Results: Among 3560 participants, the 635 (18%) who developed prehypertension before age 35 years were more often black, male, overweight, and of lower socioeconomic status. Exposure to prehypertension before age 35 years, especially systolic prehypertension, showed a graded association with coronary calcium later in life (coronary calcium prevalence of 15%, 24%, and 38% for 0, 1 to 30, and >30 mm Hg–years of exposure, respectively; P < 0.001). This association remained strong after adjustment for blood pressure elevation after age 35 years and other coronary risk factors and participant characteristics.
Limitation: Coronary calcium, although a strong predictor of future coronary heart disease, is not a clinical outcome.
Conclusion: Prehypertension during young adulthood is common and is associated with coronary atherosclerosis 20 years later. Keeping systolic pressure below 120 mm Hg before age 35 years may provide important health benefits later in life.

Padrões de dieta e Mortalidade: Nurses´Health Study

Dietary Patterns and Risk of Mortality From Cardiovascular Disease, Cancer, and All Causes in a Prospective Cohort of Women. Christin Heidemann, DrPH, MSc; Matthias B. Schulze, DrPH; Oscar H. Franco, MD, DSc, PhD; Rob M. van Dam, PhD; Christos S. Mantzoros, MD, DSc; Frank B. Hu, MD, PhD Circulation. 2008;118:230-237
Background— The impact of overall dietary patterns that reflect actual eating behaviors on mortality caused by cardiovascular or other chronic diseases is largely unknown.
Methods and Results— We prospectively evaluated the relation between dietary patterns and risk of cardiovascular, cancer, and all-cause mortality among 72 113 women who were free of myocardial infarction, angina, coronary artery surgery, stroke, diabetes mellitus, or cancer and were followed up from 1984 to 2002. Dietary patterns were derived by factor analysis based on validated food frequency questionnaires administered every 2 to 4 years. Two major dietary patterns were identified: High prudent pattern scores represented high intakes of vegetables, fruit, legumes, fish, poultry, and whole grains, whereas high Western pattern scores reflected high intakes of red meat, processed meat, refined grains, french fries, and sweets/desserts. During 18 years of follow-up, 6011 deaths occurred, including 1154 cardiovascular deaths and 3139 cancer deaths. After multivariable adjustment, the prudent diet was associated with a 28% lower risk of cardiovascular mortality (95% confidence interval [CI], 13 to 40) and a 17% lower risk of all-cause mortality (95% CI, 10 to 24) when the highest quintile was compared with the lowest quintile. In contrast, the Western pattern was associated with a higher risk of mortality from cardiovascular disease (22%; 95% CI, 1 to 48), cancer (16%; 95% CI, 3 to 30), and all causes (21%; 95% CI, 12 to 32).
Conclusion— Greater adherence to the prudent pattern may reduce the risk of cardiovascular and total mortality, whereas greater adherence to the Western pattern may increase the risk among initially healthy women.

Evitar a obesidade infantil é prioridade de saúde pública

Há quem critique a proposta de controle da propaganda de alimentos dirigidos às crianças e jovens no Brasil. Nos Estados Unidos, a televisão é um mistura de anúncios de redes de restaurantes, de carros e de .....antiácidos para a digestão! Ainda não chegamos ao padrão americano, mas se políticas para evitar o aparecimento da obesidade não sejam estabelecidas desde já chegaremos no padrão descrito pelo The New York Times, na edição dominical.

Weight Drives the Young to Adult Pills, Data Says
By STEPHANIE SAULPublished: July 26, 2008
A growing number of American children are taking drugs for a wide range of chronic conditions related to childhood obesity, according to prescription data from three large organizations.
The numbers, from pharmacy plans Medco Health Solutions, Express Scripts and the marketing data collection company Verispan, indicate that hundreds of thousands of children are taking medication to treat Type 2 diabetes, high blood pressure, high cholesterol and acid reflux — all problems linked to obesity that were practically unheard-of in children two decades ago.
The data, disclosed publicly in recent months or provided at the request of The New York Times, shows that concerns that children will be taking adult medications — heightened recently by a controversial recommendation by a national pediatricians group — are already a reality.
This month, the American Academy of Pediatrics said that more children, as young as 8, should be given cholesterol-lowering drugs. The recommendation was quickly attacked by some experts as a license to put children on grown-up drugs.
While the drugs do help treat the conditions, some doctors fear they are simply a shortcut fix for a problem better addressed by exercise and diet. Even so, some pharmaceutical companies are developing new versions, including flavored ones, of adult medications for children.
While some of the percentage increases in the three analyses are significant, doctors empha-size that prescriptions of these drugs to children still represent less than 1 percent of their sales.
Express Scripts and Medco developed estimates of how many children might be taking such drugs by extrapolating their data — involving a total of more than four million children — across the broader population.
The companies use different assumptions to reach their estimates, but the data suggests that at least several hundred thousand children are on various obesity-related medications.
The greatest increase occurred in drugs for Type 2 diabetes, with Medco’s data showing a 151 percent jump from 2001 to 2007.
Medco’s data, released in May, showed that use of drugs to treat acid reflux problems in children, often aggravated by obesity, increased 137 percent over seven years. Its analysis also showed an 18 percent increase in drugs to treat high blood pressure and a 12 percent increase in cholesterol-lowering medications during the seven-year period.
Express Scripts found a 15 percent increase over three years in drugs to treat cholesterol and other fats in the blood, a category that is primarily statins.
“We were amazed at how quickly the rates of drugs used have climbed,” said Dr. Donna R. Halloran, an assistant professor at St. Louis University who worked on the Express Scripts analysis, presented at a meeting of the American Public Health Association in November.
Verispan data recorded a 13 percent increase in high blood pressure prescriptions in the under 19 age group from 2005 to 2007. Its numbers show, however, a less than 1 percent increase during the period in cholesterol-lowering drugs in children.
Doctors and some financial analysts have said that less pronounced increases in cholesterol drugs compared with some other medications — seen in all three analyses — reflect a wariness by some doctors about using those drugs in children.
Some experts have expressed concern that the increases in many of these obesity-related drugs reflect a systemic failure, with doctors and parents turning to them because they find lifestyle changes too difficult to implement or enforce.
“I think a lot of people in pediatrics, myself included, are struggling with what is the right management to do for these kids,” said Dr. Russell L. Rothman, an assistant professor at Vanderbilt University, who recently surveyed doctors and found wide variations in how children were being treated.
“You see elevated blood pressure, or elevated sugars, or elevated cholesterol and you try exercise and diet and you don’t see any improvement,” Dr. Rothman said. “I worry that some providers and some families are looking for the quick fix, and are going to want to start medication immediately.” Some pediatricians say they have been treating children with statins for several years.

Evitar a obesidade infantil antes que seja tarde

A obesidade aumenta no Brasil, mas ainda estamos distante do padrão americano. Principalmente, entre crianças. Hoje, nos Estados Unidos roupas do tamanho XL (eXtra Large) são vendidas para crianças (!!!) Aqui podemos evitar que isso ocorra com várias políticas como as dirigidas às escolas e, ao controle da propaganda na televisão. Caso contrário, chegaremos ao descrito abaixo, na ediç

Weight Drives the Young to Adult Pills, Data Says
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new_york_times:http://www.nytimes.com/2008/07/26/business/26kidmed.html

By STEPHANIE SAUL
Published: July 26, 2008
A growing number of American children are taking drugs for a wide range of chronic conditions related to childhood obesity, according to prescription data from three large organizations.
Skip to next paragraph
The numbers, from pharmacy plans Medco Health Solutions, Express Scripts and the marketing data collection company Verispan, indicate that hundreds of thousands of children are taking medication to treat Type 2 diabetes, high blood pressure, high cholesterol and acid reflux — all problems linked to obesity that were practically unheard-of in children two decades ago.
The data, disclosed publicly in recent months or provided at the request of The New York Times, shows that concerns that children will be taking adult medications — heightened recently by a controversial recommendation by a national pediatricians group — are already a reality.
This month, the American Academy of Pediatrics said that more children, as young as 8, should be given cholesterol-lowering drugs. The recommendation was quickly attacked by some experts as a license to put children on grown-up drugs.
While the drugs do help treat the conditions, some doctors fear they are simply a shortcut fix for a problem better addressed by exercise and diet. Even so, some pharmaceutical companies are developing new versions, including flavored ones, of adult medications for children.
While some of the percentage increases in the three analyses are significant, doctors empha-size that prescriptions of these drugs to children still represent less than 1 percent of their sales.
Express Scripts and Medco developed estimates of how many children might be taking such drugs by extrapolating their data — involving a total of more than four million children — across the broader population.
The companies use different assumptions to reach their estimates, but the data suggests that at least several hundred thousand children are on various obesity-related medications.
The greatest increase occurred in drugs for Type 2 diabetes, with Medco’s data showing a 151 percent jump from 2001 to 2007.
Medco’s data, released in May, showed that use of drugs to treat acid reflux problems in children, often aggravated by obesity, increased 137 percent over seven years. Its analysis also showed an 18 percent increase in drugs to treat high blood pressure and a 12 percent increase in cholesterol-lowering medications during the seven-year period.
Express Scripts found a 15 percent increase over three years in drugs to treat cholesterol and other fats in the blood, a category that is primarily statins.
“We were amazed at how quickly the rates of drugs used have climbed,” said Dr. Donna R. Halloran, an assistant professor at St. Louis University who worked on the Express Scripts analysis, presented at a meeting of the American Public Health Association in November.
Verispan data recorded a 13 percent increase in high blood pressure prescriptions in the under 19 age group from 2005 to 2007. Its numbers show, however, a less than 1 percent increase during the period in cholesterol-lowering drugs in children.
Doctors and some financial analysts have said that less pronounced increases in cholesterol drugs compared with some other medications — seen in all three analyses — reflect a wariness by some doctors about using those drugs in children.
Some experts have expressed concern that the increases in many of these obesity-related drugs reflect a systemic failure, with doctors and parents turning to them because they find lifestyle changes too difficult to implement or enforce.
“I think a lot of people in pediatrics, myself included, are struggling with what is the right management to do for these kids,” said Dr. Russell L. Rothman, an assistant professor at Vanderbilt University, who recently surveyed doctors and found wide variations in how children were being treated.
“You see elevated blood pressure, or elevated sugars, or elevated cholesterol and you try exercise and diet and you don’t see any improvement,” Dr. Rothman said. “I worry that some providers and some families are looking for the quick fix, and are going to want to start medication immediately.” Some pediatricians say they have been treating children with statins for several years.

TINSAL-T2D

Diabetes Care. 2008 Feb;31(2):289-94.

Salsalate improves glycemia and inflammatory parameters in obese young adults.
Fleischman A, Shoelson SE, Bernier R, Goldfine AB.
Harvard Medical School, Boston, Massachusetts, USA.
OBJECTIVE: Sedentary lifestyle and a western diet promote subacute-chronic inflammation, obesity, and subsequently dysglycemia. The aim of the current study was to evaluate the efficacy of the anti-inflammatory drug salsalate to improve glycemia by reducing systemic inflammation in obese adults at risk for the development of type 2 diabetes. RESEARCH DESIGN AND METHODS: In a double-masked, placebo controlled trial, we evaluated 20 obese nondiabetic adults at baseline and after 1 month of salsalate or placebo. RESULTS: Compared with placebo, salsalate reduced fasting glucose 13% (P <>

Targeting INflammation Using SALsalate in Type 2 Diabetes (TINSAL-T2D)This study is ongoing, but not recruiting participants.
Sponsors and Collaborators:
Joslin Diabetes CenterNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Information provided by:
Joslin Diabetes Center
ClinicalTrials.gov Identifier:
NCT00392678

Uma crônica com pitada epidemiológica explicando a obesidade

Para quem está afeito ao rigor de citações e das evidências de estudos observacionais e de ensaios clínicos, há momentos em que a única resposta convincente a uma pergunta é oriunda das suas reminiscências de infância e juventude. O questionamento que faço como epidemiologista é o seguinte: como as populações vão se tornando cada vez mais obesas? (Rigorosamente: por que há aumento da mé-dia populacional do índice de massa corpóreo no Brasil?) Apesar de já ter decorado todos os dados dos ENDEFs, PNSNs e PPVs brasileiros, além das versões dos NHANEs americanos, a explicação mais convicente vem ainda das memórias do bairro do Ipiranga, na cidade de São Paulo.

Famoso por abrigar o córrego de onde se ouviu um brado retumbante há quase 180 anos, o Ipiranga localiza-se na região sudeste da cidade encostado com a Moóca e as cidades do ABC. Pouco habitado até o início do século XX, tornou-se um dos pólos industriais da então São Paulo de Piratininga. Primeiro as indústrias têx-teis, depois a metalurgia, incluindo o primeiro automóvel montado na rua Vemag. Tantas indústrias estavam instaladas no bairro, que o bonde que se dirigia para a região tinha o nome de “Fábrica”, nome também adotado pelas linhas de ônibus até os anos 80.

Bem, foi nesse bairro, onde nasci em 1957, em uma rua com paralepídedos, sem iluminação, em uma casa geminada sem garagem... Tal como boa parte da cidade, o bairro está localizado em um terreno acidentado, isto é, a quantidade de ladeiras é bem grande, sendo poucos os locais planos, a maioria deles nas várzeas dos rios, o que tornava os moradores daquele pedaço sujeitos a inundações de suas casas.

O número elevado de fábricas garantia emprego a muito moradores, porém boa parte deles necessitava se locomover, principalmente para a “Cidade”, isto é, o Centro. Aí talvez comece a nossa história. Havia nos anos 50 e 60 quatro formas de condução acessíveis: o trólebus na parte alta do bairro, o ônibus a diesel na parte central, o bonde na parte baixa e o subúrbio da Santos-Jundiaí na várzea dos rios.Todas elas eram radiais, isto é, dirigiam-se ao Centro da Cidade. Não havia comunicação dentro do bairro ou com bairros vizinhos, como a Moóca. Por isso, talvez venha ai minha primeira lembrança que mereça destaque nessa revista: como as pessoas andavam naquelas ruas! Desciam e subiam as ladeiras do bairro o tempo inteiro! Bem criança, lembro o périplo intenso de pessoas andando o tempo todo, descendo para o bonde ou subindo para o tróleibus. Havia somente uma exceção: aos domingos, quando toda a família precisa se locomover, utilizava-se então os táxis pretos Ford e Chevrolet. Fora disso, somente andando muito para alcançar a condução. Carro, poucos tinham, por isso não se justificavam casas com garagem. As ruas do bairro eram calçadas, o trânsito era pequeno, “violência”‘ era confundida com algum mendigo perambulante ou bêbados discutindo futebol, ou com ciganos que “roubavam criancinhas”. Assim, as ruas eram ocupadas todas as tardes e inícios de noite pelas crianças com inúmeros jogos de futebol, taco, carrinhos de rolemã, além de pipas, peões e outros jogos. Aos mais crescidos, podia-se oferecer futebol, basquete ou outros esportes nas escolas do bairro que ficavam abertas aos sábados à tarde. Aos adultos, o futebol no sábado à tarde e no domingo de manhã nos campos de várzea (apesar de ficarem no alto da colina) do Sinclair era sagrado. O domínio do espaço público era grande pelos moradores, vide o mês de junho, onde a cada dia uma quadra do bairro era fechada pelas festas caipiras.
Evidente o meu interesse em destacar que o Agita São Paulo seria, na época, coisa muito estranha para aqueles habitantes que anda-vam muito e tinham muita dificuldade em adquir ou mesmo assistir a um programa de televisão. Talvez de maior interesse seja agora lembrar a forma como nos alimentávamos na época.

Não havia quem não tivesse a caderneta da vendinha ou do açou-gue. Já um pouco crescido, com freqüência era incumbido das deman-das maternas para a compra de algo na vendinha da esquina. Lembro que quase tudo era vendido a granel: arroz, feijão, óleo, bolachas, tudo… A feira livre era imensa, porém ficava muito longe de casa, minha mãe se esfalfelava para voltar da feira com o carrinho cheio. Aos sábados íamos à cooperativa da fábrica onde meu pai trabalhava para comprar maiores quantidades a preço mais baixo. Os restaurantes não existiam, exceto uma ou outra pizzaria, exclusiva para os sábados à noite. Interessantes eram as casas de aves ou de animais onde se escolhia o frango a ser abatido (segundo meu avô, deveria ser sempre escolhido a frango mais agitado e esperto). Mais interessante ainda era lembrar a quantidade de animais nos quintais: porcos, cabritos e perus. No Natal e na Páscoa, existiam aqueles que alugavam o quintal para animais de terceiros e também uma figura popular muito procurada, o megarefe, o abatedor desses animais.

O país muda, a cidade se transforma e temos muitas novidades. Primeiro, o carro. Que festa era quando o pai aparecia com o primeiro fusca. Depois, chegou um supermercado com alimentos com rótulos vendidos em pacotes bem embalados, seguidos de lanchonetes com a novidade da rua Augusta: o hambúrguer e o hot dog! O tempo passa e surgem as rotisserias com alimentos prontos e as casas de aves vão diminuindo e se tranformando em açougues e, no futuro, em lojas de alimentos congelados. Os campos de futebol vão dando lugar a prédios de apartamentos e, também, a garagens para os carros. O trânsito de automóveis aumenta e espanta as crianças das ruas, a qualidade dos programas de televisão melhora atraindo mais gente para assistir a grande novidade da TV colorida. As esco-las fecham suas quadras para evitar sei lá o quê.

Esta foi a transição demográfica que vivi. A epidemiológica não consiguiria mostrar, embora fosse um frequentador da sala de inalação do Pronto-Socorro Municipal. Ouvia muito falar em tifo, escarlatina e reumatismo. Sarampo, catapora, rubéola e caxumba eram doenças normais que todas as crianças necessitavam ter para desenvolver imunidade. Violência? Bem, lembro somente de furtos de casas, porém até meados dos anos 70 era comum jovens nas ruas conversando até altas horas.

Como todas reminiscências, estas estão sujeitas aos desvãos da memória. Por mais que evite não supervalorizar as qualidades desse período... e lembro-me do quão duro deveria ser viver naquele tempo em que o banheiro ficava no quintal em várias casas, e quanto era difícil a condição da mulher na administração da casa.
Já se disse que cantando a sua aldeia, descreve-se o mundo. Não sei se consegui. Porém, por uns tempos deixo o rigor do estudo epidemiológico para lembrar a infância e juventude. Não sei se respondi porque as populações estão ficando mais obesas, porém acho que estou mais perto da verdade do que alguns “Pês” menores do que 0,05
publicado na revista da ABESO (agosto de 2002)

Androgenicidade e risco cardiovascular na pós menopausa

Metabolism. 2008 Jul;57(7):961-5.

Relationship between endogenous testosterone and cardiovascular risk in early postmenopausal women.
Maturana MA, Breda V, Lhullier F, Spritzer PM.
Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, 90050-170 Porto Alegre, RS, Brazil.
Cardiovascular disease (CVD) is the leading cause of death among postmenopausal women. Changes in endothelial function play an important role in the pathophysiology of atherosclerosis, and evidence suggests that interventions to improve endothelial function could modify the rates of progression and the risk of cardiovascular events. In addition, a positive association between markers of endothelial dysfunction and androgenicity has been described in women with polycystic ovary syndrome, suggesting a correlation with the early-onset endothelial dysfunction found in these patients. We performed a cross-sectional study to verify whether endogenous testosterone levels are correlated with markers of inflammation and endothelial function and with anthropometric and metabolic profile in 53 postmenopausal women. Serum testosterone, sex hormone-binding globulin, C-reactive protein (CRP), fibrinogen, and plasma endothelin-1 (ET-1) were determined. Patients were stratified into 2 groups (higher or lower than the mean testosterone levels of the studied sample). Mean age was 55 years (+/-5), and median time since menopause was 5.5 years (interquartile range, 3-8 years). Body mass index and waist circumference were significantly higher in the group with testosterone levels >or=0.49 ng/mL. Median CRP levels were greater in the group with higher testosterone levels (1.17 [0.17-2.36] vs 0.17 [0.17-0.61] mg/L, P = .039). Median ET-1 levels were also higher in women with greater testosterone levels (0.84 [0.81-0.97] vs 0.81 [0.74-0.84] pg/mL, P = .023). An association of testosterone with CRP (r = 0.416, P = .004) and ET-1 (r = 0.323, P = .031) was observed. This association was dependent on homeostasis model assessment index for ET-1 but not CRP. Testosterone was also associated with waist circumference and blood pressure (P = .001). These data suggest that endogenous testosterone levels in recently postmenopausal women may be part of a proatherogenic profile. Longitudinal studies are needed to assess if androgenicity represents a risk factor for cardiovascular disease and the clinical relevance of its association with ET-1 and CRP in this population.

Ingestão de Acido Linolênico e Hipertensão

elsa/dieta/aclinolenicohipertensao

Relationship of Dietary Linoleic Acid to Blood Pressure
The International Study of Macro-Micronutrients and Blood Pressure Study

Hypertension. 2008;52:408-414

Findings from observational and interventional studies on the relationship of dietary linoleic acid, the main dietary polyunsaturated fatty acid, with blood pressure have been inconsistent. The International Study of Macro-Micronutrients and Blood Pressure is an international cross-sectional epidemiological study of 4680 men and women ages 40 to 59 years from 17 population samples in China, Japan, United Kingdom, and United States. We report associations of linoleic acid intake of individuals with their blood pressure. Nutrient intake data were based on 4 in-depth multipass 24-hour dietary recalls per person and 2 timed 24-hour urine collections per person. Systolic and diastolic blood pressures were measured 8 times at 4 visits. With several models to control for possible confounders (dietary or other), linear regression analyses showed a nonsignificant inverse relationship of linoleic acid intake (percent kilocalories) to systolic and diastolic blood pressure for all of the participants. When analyzed for 2238 "nonintervened" individuals (not on a special diet, not consuming nutritional supplements, no diagnosed cardiovascular disease or diabetes, and not taking medication for high blood pressure, cardiovascular disease, or diabetes), the relationship was stronger. With adjustment for 14 variables, estimated systolic/diastolic blood pressure differences with 2-SD higher linoleic acid intake (3.77% kcal) were –1.42/–0.91 mm Hg (P<0.05>

A oficialização do "complexo médico-industrial-midiático"

O termo complexo médico-industrial-midiático foi criado por mim há cinco anos. Agora, oficializa-se nesse evento em Chicago descrito no post do The Wall Street Journal.

Drugmakers Fund Journalism Group Posted by David Armstrong
Doctors and medical associations have taken plenty of lumps for relying on drug companies to sponsor continuing medical education courses. Critics say the sessions are often biased in favor of a particular medicine or drugs over alternative treatments for disease. Corporate sponsors abound at the Unity meeting of journalists at Chicago’s McCormick Place Now add journalists to the groups that are getting professional education subsidized by Big Pharma. At the Unity convention in Chicago -– a gathering of thousands of minority journalists -– the diabetes drug maker Novo Nordisk sponsored a lunch yesterday called, “The Diabetes Explosion: A Call to Action for Journalists of Color.” The panelists included doctors from Harvard, Johns Hopkins and the National Institutes of Health, as well as some journalists. Billed as a “Lunch ‘n’ Learn Event,” the promotional material for the session invited attendees to hear from “distinguished experts in diabetes” about the disproportionate effect of type 2 diabetes on people of color and “how journalism can be used to help combat this disease.” An Phan, a spokeswoman for Novo Nordisk, said 274 journalists showed up for the lunch. She said the company selected the speakers and “set the agenda” for what the panelists should talk about, but that the panelists came up with their own presentations. There was no discussion of brand-name drugs, she said, or any effort to promote Novo Nordisk products. She said the lunch was the first time the company had sponsored such an event for journalists. A spokesman for Unity, which takes place every four years, wasn’t immediately available for comment. For comparison’s sake, the Association of Health Care Journalists doesn’t accept funds from manufacturers of health-care products, including drugs and medical devices. Novo isn’t the only pharmaceutical company making a financial contribution to Unity. Eli Lilly is a bronze sponsor of the event. The list of sponsors goes beyond drugmakers and includes McDonald’s and embattled government mortgage giant Freddie Mac, which is underwriting a panel called “Starting out in Business Journalism.”

Novamente, para os adeptos da "falência da saúde pública"

Hoje, no editorial do The Lancet :
Nevertheless, Latin America has a much better infrastructure than Africa and a record of large publichealth successes. Brazil, with its courageous drug policies, has made universal access to antiretroviral drugs a reality. Since the 1990s, the number of Brazilians dying from AIDS-related illnesses has fallen by 50%. The antiretroviral programme currently reaches 80% of the infected population, which is similar to the coverage in wealthier, more developed nations.

Rastreamento de doença coronariana subclínica ou redução de fatores de risco

coracaodobrasil/estrategiasdeprevençao/Conn JACC

Screening for Risk Factors or Detecting Disease? DEBATE Divides the CV Community
from Heartwire — aShelley Wood
ACS Case Study Video Follow the case of a 58-year-old male presenting to the EmergencyDepartment with chest pain, nausea, and diaphoresis. Watch a video presentation.
July 22, 2008 — A new fissure is creeping through the cardiology community, dividing those in favor of risk-factor screening and prevention on one side from those who advocate early screening for the disease itself. The debate is playing out online July 29, 2008 in the Journal of the American College of Cardiology, with Drs Jay Cohn and Daniel Duprez (University of Minnesota Medical School, Minneapolis) arguing in favor of early identification of disease through simple screening tests, and Drs Philip Greenland and Donald Lloyd-Jones (Northwestern University, Chicago, IL) urging clinicians to focus on risk factors and steer clear of unproven tests for identifying early vascular and cardiac disease [1, 2].
The chivalrous war of words is the latest chapter in a debate that has centered chiefly on the newest and most expensive tests such as coronary calcium scans and multislice CT--neither of which Cohn and Duprez champion in their Viewpoint. But the counterargument, in an editorial by Greenland and Lloyd-Jones, takes exception to the cancer-screening analogy made by Cohn and Duprez, pointing out that in the cancer field there is outcomes research to justify the use of mammography and other screening tests. As Greenland and Lloyd-Jones point out, the screening tests for cardiovascular disease, while promising, have been shown to detect only disease: no large-scale, multicenter studies have proven that identifying early disease has any impact on course of treatment or, more important, can improve patient outcomes.
The interesting and curious thing is that we actually have evidence that if you go to the trouble of screening for risk factors and treating them, patients have better outcomes.
"And we do have that evidence for risk-factor screening," Greenland reminded heartwire. "Even though people criticize risk-factor assessment because it is not sensitive enough or not accurate enough, the interesting and curious thing is that we actually have evidence that if you go to the trouble of screening for risk factors and treating them, patients have better outcomes. We do not have that evidence for any of these other tests."
But Cohn insists screening for early disease "is not rocket science."
"They're saying that we can’t identify disease very effectively so let's just stick with risk factors, which we know are very poorly predictive and nonspecific. It boggles my mind as to why they won't open up their minds to the importance of moving forward in finding better strategies to identify the disease that we are treating. It's very strange. They criticize these disease markers because they are not predictive of events, but they are looking at very short-term outcomes. We're interested in lifetime risk. We're screening people in their 40s who are concerned about morbid events in their 60s and 70s, and no trials are going to track them that long."
At some point, Cohn continues, "you have to accept the pathophysiologic reality that heart attacks don't occur in the absence of coronary disease, and coronary disease doesn't occur in the absence of endothelial dysfunction and vascular disease, all of which now can be identified."
A 10-Test Screening Algorithm
Cohn and Duprez, in their Viewpoint, describe a 10-test screening algorithm they have started using at their center. Named for the center's benefactor, the Rasmussen score includes tests for large and small artery elasticity (compliance), resting blood pressure, blood-pressure response to moderate treadmill exercise, optic fundus photography, carotid intimal-media thickness (IMT), microalbuminuria, electrocardiography, left ventricular (LV) ultrasonography for LV volume and mass, and brain natriuretic peptide (BNP). Each test results is scored out of 10 for low, intermediate, or high risk, and the combined results yields a score that Cohn et al believe is more predictive than any of the existing standalone tests.
It boggles my mind as to why they won't open up their minds to the importance of moving forward in finding better strategies to identify the disease that we are treating. It's very strange.
To heartwire, Cohn emphasized that these 10 tests were chosen as the "most comprehensive and effective tests" that could all be easily performed in an hour, in a single room, by a single technologist. Each has been individually validated as predictive of morbid events, he says, and outcomes data--not yet published--that he and his coinvestigators have collected suggest that the Rasmussen score is more highly predictive of subsequent morbid events than Framingham or levels of cholesterol or blood pressure.
"We're just saying, can we as a society and as a profession accept the idea that there is a link between the vascular abnormalities and the events?" Cohn says. "And that that linkage is tight enough that it should allow us to accept slowing of progression of the vascular abnormalities as an adequate marker for slowing disease progression, without waiting for events to occur? As soon as you use the word surrogate, people jump up and say we have all these markers that we know don't work well--things like premature ventricular contractions [PVCs] on the electrocardiogram, LDL, HDL--but those are not the markers we're talking about. We’re talking about structural and functional changes in the blood vessel and in the heart."
Cohn continued: "There's so much that needs to be done in terms of evaluating this. Greenland and Lloyd-Jones, instead of conceding that what we're claiming is exceedingly rational and that we now really need to investigate this in the most effective way we can, they're essentially saying, no, this isn't important, let's go back to risk factors. Which is really foolish."
Major Problems, Unknown Benefits
Greenland, in response, says that the composite tests in the tool Cohn is proposing haven't been validated for improving outcomes, they've been validated as measures of vascular disease. "That's not to say that these technologies are poor for certain uses, but we think that they're untested in a screening situation," he says. The algorithm "has reasonable base solidity," Greenland acknowledged, "but I can tell you it has major problems, too." He points out that Cohn and Duprez do not explain who should undergo testing, how regularly the test would need to be repeated, or what to do if certain tests came back high risk and others low or no risk.
He points to Tim Russert, whose medical tests prior to his death were the subject of so much recent media scrutiny. "That's a perfect example of how people who are on the screening bandwagon have sort of missed the point," Greenland argues. "Russert actually had multiple tests that were abnormal, including a coronary calcium test, but he had an exercise test that was normal. So there is an example where you have discrepancies between two test results--and what do you do?"
Polarizing Effects
Where Cohn and Greenland appear to agree is on the need for large-scale outcomes studies and on the fact that, in the meantime, the screening debate is carving the community in two.
"When I speak on this topic," says Cohn, "the response I get veers widely between people who are fascinated and say oh my God, that's the way to do this, and those who are highly critical and immediately say, we already measure blood pressure and cholesterol--there's nothing more to do here. And I would disagree."
Greenland too, acknowledged: "This area has definitely polarized the cardiology community, and it's rather interesting, in my view, how this has happened. Because it's not always the case that the most invasive cardiologists are in favor of screening. There are many, many people on the invasive side who say, wait a second, this is bad. So I think the only way that this issue is going to get resolved is not by editorials or opinions like mine or Jay Cohn's but by more data, and the data that are needed are clinical trials."
Cohn believes too much circumspection will hold the field back and hints that opinions like Greenland's are harming, not helping, the cause. "They're not really embracing the idea that yes, this is a wonderful idea, that's go out and prove it. I think their view represents that of the AHA, which has aggressively focused on risk-factor identification and treatment: that approach is outmoded. . . . This whole research agenda will take us years to work through, but the sooner we start it, the sooner we can achieve a more effective preventive strategy."
Greenland, for his part, respectfully disagrees. "There are those, like Drs Cohn and Duprez and others, who feel that the new test options are sufficiently mature to justify their routine application. There are many others, and I am one of them, who feel that screening unselected people or even a moderately targeted group of people requires evidence and careful analysis, which to date, we do not have for any of the 'new tests,' including coronary artery calcium and carotid IMT, etc."
He points to classic cases--hormone-replacement therapy, antiarrhythmic drugs for PVCs--where intuition and the best intentions have produced more harm than good.
"Debate is healthy," Greenland says. "Acting without evidence is not necessarily unhealthy but certainly can be wrong."
Cohn is a director of and holds equity in Cohn Prevention Centers, LLC.
Cohn JN, Duprez DA. Time to foster a rational approach to preventing cardiovascular morbid events. J Am Coll Cardiol 2008; 52:327-329.
Greenland P, Lloyd-Jones D. Defining a rational approach to screening for cardiovascular risk in asymptomatic patients. J Am Coll Cardiol 2008; 52:330-332.