Outubro com tudo: blogue em recesso (ou o Red and Green October)

Amigos: como todos sabem, um blogue não fecha, está sempre aberto. Nesse mês de outubro permanecerá em estado de latência, quase sem sinal de vida.

Motivo: o excesso de compromissos acadêmicos e administrativos assumidos que se acumularam quase todos nesse mês.

Nos anos 70, outubro era mês complicado na Faculdade de Medicina: eleições sempre disputadas no CAOC, Mac-Med e Show Medicina.

Agora, décadas depois, a vida continua apertada nesse mês.

Sem contar, claro que o Boston Red Sox estará defendendo seu título e, o Palmeiras caminha para o pentacampeonato. Ambos, o vermelhão e o verdão me obrigarão a plantões televisivos intensos.

Transfat: o novo alvo

Walter Willett esteve essa semana em São Paulo e Porto Alegre. Ele é um dos assim chamados "figurões" da ciência mais acessíveis e de fácil trato. Publiquei em 2004, um trabalho em conjunto com ele. Agora, ele (na esquerda da foto) começa a campanha pra banir os alimentos com gordura trans.

Nutrition Chair Willett Joins Mayor Menino in Reminding Bostonians of Start of Trans Fat Ban
Walter Willett, chair of the HSPH Department of Nutrition, joined Mayor Thomas Menino at a press conference on Friday, September 12, to remind residents that Boston’s ban on artificial trans fat would begin officially the next day. The press conference was held at local Mission Hill bistro The Savant Project, which stopped using trans fat three months ago.
According to a press release from the Boston Public Health Commission, Boston is the first city in Massachusetts to implement a ban on trans fats. Brookline has passed a similar ban, but it will not go into effect until later this year. Approximately 5,600 restaurants and other food service establishments in the city must start eliminating partially hydrogenated oil from food or beverages. Businesses that violate the ban will receive a citation and fine ranging from $100 to $1,000. Trans fatty acids, or trans fats, raise the level of bad (LDL) cholesterol in the body and lower the good (HDL) cholesterol. Consuming trans fat can increase one’s risk of developing heart disease and stroke. It can also put people at higher risk of developing Type 2 diabetes. Willett has been a leading voice in encouraging the removal of trans fats from foods. His research has helped contribute to the public's understanding of the health detriments of consuming the substance and to federal regulations requiring it be listed on food labels. The Public Health Commission board approved the trans fat ban in March and is implementing it in two phases. As of September 13, food service establishments may no longer use oils, shortenings, and margarines containing partially hydrogenated vegetable oil for frying, sautéing, grilling, or as a spread. Six months later, the ban will apply to baked goods, mixes, partially fried items, and all other foods containing artificial trans fat. The ban affects all food service establishments that are required to hold a permit from Boston’s Inspectional Services Department. These include restaurants, grocery stores, delis, cafeterias in schools and businesses, caterers, senior-center meal programs, children’s institutions, mobile food-vending units and commissaries that supply them, bakeries, park concessions, street-fair food booths, and other establishments. The ban does not apply to food or beverages served in the manufacturer’s original sealed package, such as a package of cookies or a bag of potato chips. It also does not apply to food or beverage items that contain less than 0.5 grams of trans fat per serving.

dicas dos amigos (1): Gapminder

Dica de Vitor Kawabata. O site é o Gapminder.
http://www.gapminder.com/

Consegue atrapalhar um pouca a vida de demógrafos e epidemiologistas, não porque traz pronto uma sériede informações, mas porque permite cruzá-las. Vejam ao lado a relação entre infecção pelo HIV e renda per capital: façam o triângulo Brasil, África do Sul e Estados Unidos e, comparem a capacidade de manusear a epidemia de cada um dos três países.

Bem, o GapMinder é muito interessante. Aguardo comentários dos meus amigos demógrafos plugados na rede do Taquinho.

Um cordão sanitário ao redor da China não será nada mal.

Brinquedos, rações de animais, heparina e agora o leite. Alguém precisa contabilizar o fator chinês na redução de seres humanos e animais somente no último ano. Como a Organização Mundial do Comércio não fará nada para conter a China, e a Organização Mundial da Saúde é dirigida por uma chinesa, resta aos governos de países democráticos e que defendem a saúde dos seus cidadãos tomar a atitude necessária para evitar mais danos. Abaixo, reproduzo a situação na África, descrito em despacho da agência Reuters, onde mostra o comércio entre países africanos e China.
DAKAR (Reuters) - Bans on imports of Chinese milk products by African states fearing contamination have highlighted the growing presence of Chinese goods in Africa's markets and raised worries over depending on them too heavily.
From Ivory Coast in the west to Tanzania in the east, governments have joined the list of countries blocking Chinese milk imports over concerns they could be contaminated with deadly melamine.
Since the start of the decade, African leaders have been keen to strike often controversial deals with China which guarantee supply of oil or metals from Africa in return for billions of dollars in loans and infrastructure projects. These deals have opened the door to imports of cheap Chinese goods, including food, which African consumers have come to rely on as they struggle with high prices. Chinese exports to Africa rose 40 percent to $23 billion year-on-year in the first half of 2008.
Chinese powdered milk laced with industrial chemical melamine has been blamed for causing four deaths in China so far and making thousands more ill.
The health scare means African authorities and shoppers are now also worried about what's in Chinese dairy products. Togo became the latest African country to ban them on Wednesday. Burundi, Gabon and Ghana also have bans.
"Chinese products are all over the place and the prices are very attractive, so we must be careful," said Maame Abdallah, a grandmother in Ghana's capital Accra.
"Chinese milks are the most affordable and they help a lot," said Ghanaian mother Jane Morkeh. "There are a lot of others in the market, but I use the new ones, including those made in China, because I can afford to buy in bulk," she added.

Taquicardia postural ortostática e fadiga crônica

Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome
A. Hoad1, G. Spickett1, J. Elliott2 and J. Newton3
Background: It has been suggested that postural orthostatic tachycardia syndrome (POTS) be considered in the differential diagnosis of those with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). Currently, measurement of haemodynamic response to standing is not recommended in the UK NICE CFS/ME guidelines.
Objectives: To determine prevalence of POTS in patients with CFS/ME.
Design: Observational cohort study.
Methods: Fifty-nine patients with CFS/ME (Fukuda criteria) and 52 age- and sex-matched controls underwent formal autonomic assessment in the cardiovascular laboratory with continuous heart rate and beat-to-beat blood pressure measurement (Task Force, CNSystems, Graz Austria). Haemodynamic responses to standing over 2 min were measured. POTS was defined as symptoms of orthostatic intolerance associated with an increase in heart rate from the supine to upright position of >30 beats per minute or to a heart rate of >120 beats per minute on standing.
Results: Maximum heart rate on standing was significantly higher in the CFS/ME group compared with controls (106 ± 20 vs. 98 ± 13; P = 0.02). Of the CFS/ME group, 27% (16/59) had POTS compared with 9% (5) in the control population (P = 0.006). This difference was predominantly related to the increased proportion of those in the CFS/ME group whose heart rate increased to >120 beats per minute on standing (P = 0.0002). Increasing fatigue was associated with increase in heart rate (P = 0.04; r2 = 0.1).
Conclusions: POTS is a frequent finding in patients with CFS/ME. We suggest that clinical evaluation of patients with CFS/ME should include response to standing. Studies are needed to determine the optimum intervention strategy to manage POTS in those with CFS/ME.

vitamina D e depressão

Effects of vitamin D supplementation on symptoms of depression in overweight and obese subjects: randomized double blind trial
R. Jorde 1,2 , M. Sneve 2 , Y. Figenschau 3,4 , J. Svartberg 1,2 & K. Waterloo 5,6
From the 1Institute of Clinical Medicine, University of Tromsø ; Departments of 2Internal Medicine and 3 Medical Biochemistry, University Hospital of North Norway ; 4 Institute of Medical Biology, University of Tromsø ; 5 Department of Neurology, University Hospital of North Norway ; and 6 Department of Psychology, University of Tromsø, Tromsø, Norway
Correspondence to Rolf Jorde, Medical Department, University Hospital of North Norway, Tromsø 9038, Norway.(fax: + 47 776 26863; e-mail: rolf.jorde@unn.no). J Intern Med 2008;
Objectives. The objective of the present study was to examine the cross-sectional relation between serum 25-hydoxyvitamin D [25-(OH) D] levels and depression in overweight and obese subjects and to assess the effect of vitamin D supplementation on depressive symptoms.
Design. Cross-sectional study and randomized double blind controlled trial of 20.000 or 40.000 IU vitamin D per week versus placebo for 1 year.
Setting. A total of 441 subjects (body mass index 28–47 kg m−2, 159 men and 282 women, aged 21–70 years) recruited by advertisements or from the out-patient clinic at the University Hospital of North Norway.
Main outcome measures. Beck Depression Inventory (BDI) score with subscales 1–13 and 14–21.
Results. Subjects with serum 25(OH)D levels <40 nmol L−1 scored significantly higher (more depressive traits) than those with serum 25(OH)D levels ≥40 nmol L−1 on the BDI total [6.0 (0–23) versus 4.5 (0–28) (median and range)] and the BDI subscale 1–13 [2.0 (0–15) versus 1.0 (0–29.5)] (P < 0.05). In the two groups given vitamin D, but not in the placebo group, there was a significant improvement in BDI scores after 1 year. There was a significant decrease in serum parathyroid hormone in the two vitamin D groups without a concomitant increase in serum calcium.
Conclusions. It appears to be a relation between serum levels of 25(OH)D and symptoms of depression. Supplementation with high doses of vitamin D seems to ameliorate these symptoms indicating a possible causal relationship.

Situação marital e mortalidade

Marital and cohabitation status as predictors of mortality: A 10-year follow-up of an Italian elderly cohort
Emanuele Scafatoa, Lucia Galluzzoa, , , Claudia Gandina, Silvia Ghirinia, Marzia Baldereschib, Antonio Capursoc, Stefania Maggid, Gino Farchia and for the ILSA Working Group1
aPopulation Health and Health Determinants Unit, National Centre for Epidemiology, Surveillance and Health Promotion (CNESPS), Istituto Superiore di Sanità (ISS), Via Giano della Bella 34, 00161 Roma, Italy bInstitute of Neuroscience, Italian National Research Council (CNR), Firenze, Italy cDepartment of Geriatrics, University of Bari, Italy dItalian National Research Council (CNR), Aging Section, Padova, Italy . Available online 31 July 2008.
Abstract
The relationship between mortality and marital status has long been recognized, but only a small number of investigations consider also the association with cohabitation status. Moreover, age and gender differences have not been sufficiently clarified. In addition, little is known on this matter about the Italian elderly population. The aim of this study is to examine differentials in survival with respect to marital status and cohabitation status in order to evaluate their possible predictive value on mortality of an Italian elderly cohort. This paper employs data from the Italian Longitudinal Study on Aging (ILSA), an extensive epidemiologic project on subjects aged 65–84 years. Of the 5376 individuals followed-up from 1992 to 2002, 1977 died, and 1492 were lost during follow-up period. The baseline interview was administered to 84% of the 5376 individuals and 65% of them underwent biological and instrumental examination. Relative risks of mortality for marital (married vs. non-married) and cohabitation (not living alone vs. living alone) categories are estimated through hazard ratios (HR), obtained by means of the Cox proportional hazards regression model, adjusting for age and several other potentially confounding variables. Non-married men (HR = 1.25; 95% CI: 1.03–1.52) and those living alone (HR = 1.42; 95% CI: 1.05–1.92) show a statistically significant increased mortality risk compared to their married or cohabiting counterparts. After age-adjustment, women's survival is influenced neither by marital status nor by cohabitation status. None of the other covariates significantly alters the observed differences in mortality, in either gender. Neither marital nor cohabitation status are independent predictors of mortality among Italian women 65+, while among men living alone is a predictor of mortality even stronger than not being married. These results suggest that Italian men benefit more than women from the protective effect of living with someone.

A necessidade de ambientes livres do cigarro

Mais uma informação sobre tabagismo passivo. Agora, um estudo chines publicado em Circulation revela que mulheres que nunca fumaram, mas que moram ou trabalham em ambientes com fumantes, tiveram risco maior em 60% de doença cerebrovascular, 70% de doença coronariana e em 80% em doença cerebrovascular.

Passive Smoking and Risk of Peripheral Arterial Disease and Ischemic Stroke in Chinese Women Who Never Smoked
Yao He MD, PhD*, Tai Hing Lam MD, Bin Jiang MD, PhD, Jie Wang MD, PhD, Xiaoyong Sai MD, PhD, Li Fan MD, Xiaoying Li MD, Yinhe Qin MD, and Frank B. Hu MD, PhD*
Background—The association between secondhand smoke (SHS) and risk of peripheral arterial disease (PAD) and stroke remains uncertain.
Methods and Results—We examined the relationship between SHS and cardiovascular diseases, particularly PAD and stroke, in Chinese women who never smoked from a population-based cross-sectional study in Beijing, China. SHS exposure was defined as exposure to another person's tobacco smoke at home or in the workplace. Cardiovascular disease events included coronary heart disease, stroke, and PAD. PAD was defined by signs of intermittent claudication as measured by the World Health Organization Rose questionnaire and an ankle-brachial index of <0.90.>

ELSA lançado e, uma nova proposta

Estou no Congresso Internacional de Epidemiologia em Porto Alegre.
Participei de uma atividade sobre o Estudo Longitudinal de Saúde do Adulto, onde juntamente com Isabela Bensenor comparamos o maior estudo brasileiro em epidemiologia cardiovascular e do diabetes com o Study of Latinos, apresentado por Gerardo Heiss, da Universidade da Carolina do Norte. O ELSA foi lançado oficialmente pelo Ministério da Saúde, ontem . (clique aqui)

Ontem, assisti a um mesa-redonda com os ministros da saúde da Comunidade de Países de Língua Portuguesa. Estavam presentes Cabo Verde, Guiné-Bissau, Moçambique, Timor Leste, Portugal e Brasil. Da platéia, apresentei a proposta de estudo multinacional verificando a particular situação da hipertensão arterial e da doença cerebrovascular. O Ministro Temporão elogiou a proposta e, a levará à nova reunião dos ministros da saúde.

MFFIT: 25 anos depois

The Multiple Risk Factor Intervention Trial (MRFIT)—Importance Then and Now
Commentary by Jeremiah Stamler, MD; James D. Neaton, PhD
JAMA. 2008;300(11):1343-1345.

Is Relationship Between Serum Cholesterol and Risk of Premature Death From Coronary Heart Disease Continuous and Graded? Findings in 356 222 Primary Screenees of the Multiple Risk Factor Intervention Trial (MRFIT)
Jeremiah Stamler, MD; Deborah Wentworth, MPH; James D. Neaton, PhD; for the MRFIT Research Group
JAMA. 1986;256(20):2823-2828
The 356 222 men aged 35 to 57 years, who were free of a history of hospitalization for myocardial infarction, screened by the Multiple Risk Factor Intervention Trial (MRFIT) in its recruitment effort, constitute the largest cohort with standardized serum cholesterol measurements and long-term mortality follow-up. For each five-year age group, the relationship between serum cholesterol and coronary heart disease (CHD) death rate was continuous, graded, and strong. For the entire group aged 35 to 57 years at entry, the age-adjusted risks of CHD death in cholesterol quintiles 2 through 5 (182 to 202, 203 to 220, 221 to 244, and 245 mg/dL [4.71 to 5.22, 5.25 to 5.69, 5.72 to 6.31, and 6.34 mmol/L]) relative to the lowest quintile were 1.29, 1.73, 2.21, and 3.42. Of all CHD deaths, 46% were estimated to be excess deaths attributable to serum cholesterol levels 180 mg/dL or greater (4.65 mmol/L), with almost half the excess deaths in serum cholesterol quintiles 2 through 4. The pattern of a continuous, graded, strong relationship between serum cholesterol and six-year age-adjusted CHD death rate prevailed for nonhypertensive nonsmokers, nonhypertensive smokers, hypertensive nonsmokers, and hypertensive smokers. These data of high precision show that the relationship between serum cholesterol and CHD is not a threshold one, with increased risk confined to the two highest quintiles, but rather is a continuously graded one that powerfully affects risk for the great majority of middle-aged American men.
In 1986 in JAMA, we reported findings of the 6-year follow-up of the large cohort screened for the Multiple Risk Factor Intervention Trial (MRFIT).1 The article, challenging existing dogmas about the relationship between cholesterol and coronary heart disease (CHD), generated much interest. Now, the 25-year results are available with almost 7% (23 382) of the men deceased due to CHD.2-4 The 1986 findings and conclusions regarding the relationship of a single measurement of serum cholesterol to premature CHD mortality are verified in depth by the 25-year data with extraordinary precision due to large size of the cohort, long follow-up, and a large number of CHD deaths.
The main finding of our report was that the relationship between serum cholesterol and CHD mortality is continuous, graded, and strong; ie, CHD risk is progressively higher at every cholesterol level from 160 mg/dL and higher levels, with no threshold. This finding prevails with 5-, 10-, 15-, 20-, and 25-year follow-up and for the first, second, third, fourth, and fifth 5-year follow-up periods. These robust results, controlled for age, systolic blood pressure, number of cigarettes smoked per day, diabetes status, race and ethnicity, and study geographic site, prevailed over the 25-year follow-up with only modest attenuation in quantitative strength of relative risk from higher serum cholesterol levels and with increase over time in absolute excess risk from higher serum cholesterol levels as the CHD death rate increased annually.
These findings also held for men of every age 35 to 39, 40 to 44, 45 to 49, 50 to 54, and 55 to 57 years); race and ethnicity (African American, Asian American, Hispanic American, and non-Hispanic white American); lower and higher income strata across the 22 MRFIT centers in 18 US cities; cigarette smokers and nonsmokers; normotensive, prehypertensive, and hypertensive participants; nondiabetic and diabetic participants; and for men stratified into 6 subgroups based on blood pressure and cigarette smoking status; also for the separate cohort of 5362 men with a history of prior myocardial infarction—37% of whom died from CHD.

Data Regarding Other Cohorts
The 1986 findings and conclusions have also been validated for women and men by data from many other prospective studies, eg, on young adult and middle-aged Chicago residents (>35 000 individuals observed for >30 years)2 and on 61 cohorts worldwide (900 000 individuals) observed for an average of 13 years (33 744 CHD deaths [3.7%]) in an Oxford University meta-analysis.5 For the 61 cohorts combined, the relationship between a single serum cholesterol level and CHD mortality, ie, continuous, graded, and strong, was quantitatively similar for men in the MRFIT cohort and men and women of all the other cohorts. The cholesterol and CHD relationship prevailed across geographic locations (on 4 continents), at all blood pressure levels, for smokers and nonsmokers, and across body mass index (BMI) strata (MRFIT lacked BMI data). This further information set is especially relevant given the worldwide obesity epidemic, the consequent unprecedented high prevalence rates of overweight/obesity, and its adverse effects on serum cholesterol and other metabolic CHD risk factors (eg, blood pressure, glycemia/diabetes). With an apparent focus on the potential for CHD prevention and control, the Oxford University report highlighted relative risks with estimated "usual" serum cholesterol lower by approximately 40 mg/dL: CHD risk approximately one-half lower in early middle age (40-49 years), one-third lower in later middle age (50-69 years), and one-sixth lower in older age (70-89 years). Although relative risk was less extreme with older age, absolute excess risk was greater.5
Clearly, these fundamental findings quantitating the relationship between serum cholesterol and CHD are generalizable populationwide. The depth, breadth, and consistency of these findings reflect the fact, recognized throughout the research, public health, medical, and public policy communities, that this is an etiologically significant relationship.
Myths and Dogmas Refuted
The 1986 JAMA article1 helped refute several dogmas and myths that were once influential, eg, that the relationship between serum cholesterol and CHD is a threshold one—with greater risk only at cholesterol levels equal to or greater than 240, 250, or 260 mg/dL; that proper cut point for abnormal serum cholesterol is therefore 240, 250, 260, or even 300 mg/dL; and that serum cholesterol and the other readily measured major CHD risk factors (blood pressure, smoking, diabetes, overweight/obesity) account for no more than 50% of CHD events.6
In presenting MRFIT data rebutting these notions and explicitly rejecting them, the 1986 article1 helped strengthen scientific foundations for the efforts to prevent, control, and eradicate the CHD epidemic. The MRFIT data were powerful underpinnings for the clinical serum cholesterol classification of the National Cholesterol Education Program2, 7-8: for adults, favorable levels are denoted as less than 200 mg/dL; borderline high levels as 200 to 239 mg/dL; and high levels as 240 mg/dL or greater.
Low Coronary Heart Disease Risk
The 1986 MRFIT report for the first time put forward the concept of optimal or low CHD risk, gave a first set of criteria for its definition, emphasized its rarity among US adults, and also emphasized its benefits.1 For participants in the MRFIT cohort without a history of myocardial infarction (N = 356 222), low risk was defined as all of the 5 following criteria: optimal level of serum cholesterol and systolic and diastolic blood pressure, nonsmoking status, and no history of treatment for diabetes. Only 2% of the men in the MRFIT cohort met these criteria, only 6 of these men died from CHD during the 6-year follow-up, and the CHD death rate was 87% lower than for the rest of the cohort.
Correspondingly, among the Chicago Heart Association middle-aged cohort only 2% (men) and 5% (women) were at low risk based on all 6 of the following criteria2: serum cholesterol lower than 200 mg/dL, systolic blood pressure 120 mm Hg or lower, diastolic blood pressure 80 mm Hg or lower, no smoking, no diabetes, and BMI lower than 25.0. For both of these subcohorts and the similarly defined MRFIT low-risk subcohort, the 25- to 30-year CHD mortality rate was lower by 69% to 82% compared with the corresponding rate for all other individuals; the all-cause mortality rate was lower by 52% to 59%; and estimated longevity was greater by 6 to 7 years.2
From 1986 to the present, the findings on low risk have informed public policy on the strategy for ending the CHD epidemic: because for low-risk individuals, CHD ceases to be epidemic and because relatively few individuals are at low risk, vital strategic challenges, tasks, and priorities for medical care and public health are to achieve steady, progressive, and sustained increases year by year in the proportion of all population strata at low risk.
"Disturbances of Human Culture": Causes of Disease Epidemics
Data are extensive regarding what needs to be done to help most adults become low risk for CHD. The essentials derive from a basic law of medicine and public health: epidemics are, as set down by Virchow, due to " . . . disturbances of human culture."9 The first and foremost of the crucial disturbances producing epidemic rates of major CHD risk factors and CHD is populationwide adverse dietary patterns, along with cigarette smoking and sedentary lifestyle at work and leisure. The diets—high in caloric density, total fat, cholesterol, and saturated and trans fats (from fat- and cholesterol-laden red meats, dairy products, egg yolks, visible fats, and commercial baked goods); high in salt and processed sugars; for some, excessive in alcohol intake; and for all too many, relatively inadequate/low in key micro- and macronutrients from vegetables, fruits, whole grains, and legumes (eg, calcium, iron, magnesium, phosphorus, potassium, antioxidant and other vitamins, fiber, vegetable protein, and mono- and polyunsaturated fats)—account for the epidemic occurrences of adverse levels of serum cholesterol, blood pressure, and other metabolic CHD risk factors.
In 2008, the role of high dietary cholesterol intake needs to be emphasized for several reasons: first, high cholesterol intake significantly influences serum cholesterol level2, 10-12; second, high cholesterol intake relates independently to CHD risk over and above its role in increasing serum cholesterol levels2; third, feeding cholesterol (eg, from egg yolks) is and has been since 190813 the sine qua non for experimental production of atherosclerosis in laboratory animals, including nonhuman primates (ie, for replicating the human lesion underlying the CHD epidemic); and fourth, sustained commercial propaganda seeks to obfuscate these facts.
Public Policy and Popular Response
The role of adverse eating patterns as key causes of the CHD epidemic (especially the diet and serum cholesterol relationship) was largely delineated in the 1950s and 1960s and recommendations to modify and improve lifestyles were addressed both to the whole population (generally at risk) and to the sizable strata at higher risk (the 2-pronged strategy).1 The population responded by showing substantial improvements (albeit that fell short of national goals): eg, average intake levels of total fat (as percentage of total kilocalories) decreased from approximately 40% to 45% down to 32%; cholesterol from approximately 700 to 320 mg per day; and percentage of kilocalories from saturated fats from approximately 17% to 12%. Predictably (based on metabolic ward data that enabled precise estimates),10-12 population average serum cholesterol level declined considerably despite the countervailing influence of the obesity epidemic. From a 1950s/1960s level of approximately 235 to 240 mg/dL, it reached 200 mg/dL by the year 2000, a decline that predated mass statin use and that was undoubtedly due to improved dietary composition. A national health goal was achieved, but regrettably, little heralded. Over the decades from 1960 to 1990, the proportion of the population at low CHD risk also increased modestly but then decreased (Paul D. Sorlie, PhD, and Teri A. Manolio, MD, PhD, personal communication, July 2008); this remains a major clinical and public health concern.
Perspective
Much progress has been made since 1948 when one of us (J.S.) began a research career studying classic texts averring that dietary factors had no influence on human serum cholesterol levels. Over the decades, epidemiologic, metabolic ward, animal experimental, clinical trial, anthropologic, and other research modalities have produced extensive concordant knowledge on the disturbances of human culture, first and foremost dietary—that caused epidemic CHD. The MRFIT findings have made an extraordinary contribution. They demonstrate the power of large numbers and hard clinical end points to illuminate public policy. Collected with years-long support from the National Heart, Lung, and Blood Institute, the MRFIT results have been and will continue to be an important national resource for informing public health policy.
The crucial scientific findings to end the CHD epidemic are now available. The challenge and task is to apply them in all appropriate patient contacts and across all population strata to extend the progress to date. One key for achieving this is priority emphasis on primordial prevention, ie, family dedication to favorable lifestyles (nutrition, exercise, nonsmoking) as norms of human behavior. This especially applies to the future mother so that when she conceives and throughout pregnancy, her exposures and those of her fetus are optimal and become primary and lifelong habits for the newborn infant and preschool child. Healthy eating patterns such as the DASH diet are available as models for this crucial aspect of disease.2, 14-15
Author Affiliations: Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (Dr Stamler); Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (Dr Neaton).
REFERENCES
1. Stamler J, Wentworth D, Neaton JD. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? JAMA. 1986;256(20):2823-2828. ABSTRACT
2. Stamler J, Neaton JD, Garside DB, Daviglus M. Current status: six established major risk factors—and low risk. In: Marmot M, Elliott P, eds. Coronary Heart Disease Epidemiology: From Aetiology to Public Health. 2nd ed. London, England: Oxford University Press; 2005:32-70.
3. Stamler J, Neaton JD, Garside DB, Daviglus ML. The major adult cardiovascular diseases: a global historical perspective. In: Lauer R, Burns TL, Daniels RS, eds. Pediatric Prevention of Atherosclerotic Cardiovascular Disease. London, England: Oxford University Press; 2006:27-48.
4. Stamler J, Daviglus ML, Garside DB; et al. Low-risk cardiovascular status: impact on cardiovascular mortality and longevity. In: Lauer R, Burns TL, Daniels RS, eds. Pediatric Prevention of Atherosclerotic Cardiovascular Disease. London, England: Oxford University Press; 2006:49-60.
5. Prospective Studies Collaboration, Lewington S, Whitlock G, Clarke R; et al. Blood cholesterol and vascular mortality by age, sex, and blood pressure. Lancet. 2007;370(9602):1829-1839. FULL TEXT PUBMED
6. Stamler J. Low risk—and the "no more than 50%" myth/dogma. Arch Intern Med. 2007;167(6):537-539. FREE FULL TEXT
7. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: the Expert Panel. Arch Intern Med. 1988;148(1):36-69. ABSTRACT
8. National Cholesterol Education Program; Expert Panel on Population Strategies for Blood Cholesterol Reduction. Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction. Bethesda, MD: US Department of Health and Human Services, Public Health Service; 1990. National Institutes of Health Publication 90-3046.
9. Ackerknecht EH. Rudolf Virchow: Doctor, Statesman, Anthropologist. Madison: University of Wisconsin Press; 1953.
10. Hegsted DM, Austman LM, Johnson JA, Dallal GE. Dietary fat and serum lipids. Am J Clin Nutr. 1993;57(6):875-883. FREE FULL TEXT
11. Clarke R, Frost C, Collins R; et al. Dietary lipids and blood cholesterol. BMJ. 1997;314(7074):112-117. FREE FULL TEXT
12. Food and Nutrition Board. Cholesterol. In: Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2005:542-588.
13. Anitschkow N. Experimental arteriosclerosis in animals. In: Cowdry EV, ed. Arteriosclerosis: A Survey of the Problem. New York, NY: Macmillan; 1933:271-322.
14. Sacks FM, Svetkey LP, Vollmer WM; et al. Effects on blood pressure of reduced sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med. 2001;344(1):3-10. FREE FULL TEXT
15. Appel LJ, Sacks FM, Carey VJ; et al. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA. 2005;294(19):2455-2464. FREE FULL TEXT

Dirigindo um hospital: um blogue diferente

Abaixo, reproduzo um dos posts do blogue Running a Hospital, de Paul Levy, diretor do Beth Israel and Deaconnes Medical Center, localizado em Boston. O texto copiado traz uma mensagem interessante relacionado ao sistema de faturamento. Mas, o mais interessante é o próprio blog.

O autor não poupa os próprios subordinados exigindo decisões mais incisas e rápidas.

Wednesday, September 17, 2008
Some ads I get
Notwithstanding our excellent spam control program, I get tons of broadcast emails sent to me as CEO of a hospital, selling all kinds of services -- but especially services related to coding patient treatments to get the highest payment from insurers and Medicare. I suppose this is just a sign of the times and indicative of the structure of the health care industry.I confess that I do not understand many of these ads. I'm not saying that I don't understand why I get them. I am saying that I literally don't understand most of the terminology. Here are some excerpts from a small sample of those I received yesterday. I guess the one I really need is the last one listed . . .

rastreamento para diabetes em hipertensos

USPSTF Recommends Screening for Diabetes in Adults With Elevated Blood Pressure
Posted 09/11/2008
Richard Saitz, MD, MPH, FACP, FASAMAuthor Information
Summary
The U.S. Preventive Services Task Force (USPSTF) has been releasing new and updated guidelines periodically. The USPSTF grades each of its recommendations according to a system described on the USPSTF website.
In 2003, the USPSTF concluded that the evidence was insufficient to recommend screening asymptomatic adults for type 2 diabetes, but it did recommend diabetes screening for adults with hypertension or hyperlipidemia. In updated recommendations, the task force suggests screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or higher. Recommendation: B (the USPSTF recommends that clinicians provide this service). It also concludes that evidence still is insufficient to assess the benefits and harms of diabetes screening in adults with blood pressure lower than 135/80 mm Hg. Recommendation: I (evidence is insufficient to assess the balance of benefits and harms; if the service is offered [e.g., based on clinical considerations], patients should understand that uncertainty exists about benefits and harms).
The USPSTF guideline cites the American Diabetes Association recommendation that measurement of fasting plasma glucose (≥126 mg/dL, repeated for confirmation) be the test of choice for diagnosing diabetes. In an evidence review, the task force identified no studies that showed whether screening asymptomatic individuals for diabetes altered health outcomes. However, fair evidence suggests that lifestyle and pharmacologic interventions can slow progression of prediabetes to type 2 diabetes. Evidence also suggests that lowering blood pressure (even below conventional targets) lowers the occurrence of cardiovascular events among people with diabetes and hypertension. For people with diabetes, but without hypertension, intensive glycemic control attenuates progression of microvascular disease among those identified clinically, but whether early identification of diabetes by screening and early treatment provide a long-term benefit over waiting until clinical diagnosis occurs is unclear. The short-term harms of diabetes screening (e.g., anxiety) are small, although the USPSTF notes that harms associated with screening and labeling large segments of the population as having diabetes might be unknown.
Comment
The American Diabetes Association recommends diabetes screening in middle-aged or older people (>45) and screening in younger people who have risk factors. But recommendations from generalist organizations (e.g., American Academy of Family Physicians diabetes screening guideline) are similar to those of the USPSTF. So, should we screen for diabetes in adults who don´t have blood pressures of 135/80 mm Hg or higher? The best evidence suggests that we should not, unless it will make a difference in management (e.g., in decisions about lipid-lowering therapy) or unless symptoms of diabetes are evident

pré-hipertensão e risco cardiovascular

Hypertension. 2008;52:652

Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease in a Japanese Urban Cohort
The Suita Study
Few prospective studies have examined the association between high-normal blood pressure and cardiovascular disease (CVD) in Asia. We examined the impact of high-normal blood pressure on the incidence of CVD in a general urban population cohort in Japan. We studied 5494 Japanese individuals (ages 30 to 79 years without CVD at baseline) after completing a baseline survey who received follow-up through December 2005. Blood pressure categories were defined on the basis of the ESH-ESC 2007 criteria. In 64 391 person-years of follow-up, we documented the incidence of 346 CVD events. The frequencies of high-normal blood pressure and hypertension Stage 1 and Stage 2 were 18.0%, 20.1%, and 10.1% for men and 15.9%, 15.6%, and 8.8% for women, respectively. Antihypertensive drug users were also classified into the baseline blood pressure categories. Compared with the optimal blood pressure group, the multivariable hazard ratios (95% confidence intervals) of CVD for normal and high-normal blood pressure and hypertension Stage 1 and Stage 2 were 2.04 (1.19 to 3.48), 2.46 (1.46 to 4.14), 2.62 (1.59 to 4.32), and 3.95 (2.37 to 6.58) in men and 1.12 (0.59 to 2.13), 1.54 (0.85 to 2.78), 1.35 (0.75 to 2.43), and 2.86 (1.60 to 5.12) in women, respectively. The risks of myocardial infarction and stroke for each blood pressure category were similar to those of CVD. Population-attributable fractions of high-normal blood pressure and hypertension for CVD were 12.2% and 35.3% in men and 7.1% and 23.4% in women, respectively. In conclusion, high-normal blood pressure is a risk factor for the incidence of stroke and myocardial infarction in a general urban population of Japanese men

Um relato no WSJ para entender a medicina defensiva

My nurse practitioner came to me with the case of a 40-year-old patient complaining about aches and pains from an auto accident.
Just three days before, he had been released by the trauma center with instructions to see his family doctor. That turned out to be me.
He was new to my practice. What impressed my nurse practitioner more than his injuries was the way he knocked the doctors and the hospital where he had been treated.
Everything he said seemed negative, with a particularly hostile edge. "I wonder what he's going to say about us," my nurse practitioner said. So did I.
An exam of the patient revealed some general soreness and a little extra tenderness in the abdomen. I ordered a CT scan.
I wasn't all that worried about internal injuries. Still, the small chance of missing something on a dissatisfied patient was too big a risk for my professional comfort. His scan came back normal, as I expected. But doctors learn early to play defense.
I've never been sued, but I've seen doctors accused of malpractice when there is a bad outcome, regardless of whether they seemed to have done anything wrong.
There is an expectation after a patient does badly that the doctor should have ordered another test or done something else. But sometimes things go wrong no matter what you do -- or don't do.
Defensive medicine is part of the cost of doing business, and also, unfortunately, a large part of the unnecessary expense of health care. In my experience, I'd estimate it accounts for 10% of the waste. Some days I think that's probably conservative.
Unlike defensive driving where slowing down and being less aggressive saves lives, defensive medicine means doing more tests, ordering more consults from specialists and exposing patients to the risks of radiation, invasive tests and treatments.
It transcends being cautious or careful for the patient's sake. It has everything to due with protecting the practice from the legal system. I try not to order expensive or risky tests to chase down minor lab or X-ray findings.
Some physicians feel compelled to do this. One thing that we doctors hate almost as much as a faulty diagnosis is winding up in court to defend our decisions. Once a doctor has had his judgment questioned in a lawsuit, his documentation and test ordering will never be the same. A typical line of legal attack is that you didn't order a test or refer a patient to a specialist fast enough.
A general surgical colleague used to handle elderly patients with higher medical risks. He was good at his job and never turned anyone away for lack of insurance. After being sued, he transferred many patients with problems he used to take care of himself to bigger hospitals for care. The change was expensive, adding ambulance or helicopter costs, and it delayed some surgeries.
Another sign of the times can be found in patient files, which have become more suited to legal defense than medical communication. The modern medical chart often contains reams of normal data kept to satisfy auditors and show that doctors are comprehensive in taking a history and performing an exam. To ward off critics, we put in comments like, "The patient denies other complaints."
Electronic medical records provide even more opportunities to pack in boilerplate entries. The notes from specialists about my patients are now four to five pages long, and I have to search for the nugget of useful information and advice, usually toward the end.
Patients are defensive, too. They look up their symptoms on the Internet and then insist on testing and consultations for symptoms that can be safely observed and frequently go away on their own.
What can we do? Building better relationships between doctors and patients would help, though that's a tall order given the brief visits that have become the norm.
If you are going into the hospital, think about leaving your most confrontational family member at home. When the family questions every detail of care to the Nth degree, you're going to get more testing, more specialists poking you and more cost. If that type of evaluation and treatment is what you are after, most doctors will oblige. Just make sure to factor in the extra doses of radiation from scans, the extra medication you might be allergic to, and the extra procedures the specialist is likely to recommend.
Speak up if you suspect a test is just being ordered to cover the doctor's derriere. The defensive among us will document your informed refusal and our estimation that your lack of compliance might hurt you. The rest of us would probably agree with you.
Due to his schedule and the volume of email he receives, Dr. Brewer may not be able to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsoffice@wsj.com.

gama gt e risco cardiovascular

Arteriosclerosis, Thrombosis, and Vascular Biology. 2008;28:1857

Change in Serum Gamma-Glutamyltransferase and Cardiovascular Disease Mortality. A Prospective Population-Based Study in 76 113 Austrian Adults

Abstract
Objective— The purpose of this study was to investigate the association of longitudinal change in serum -glutamyltransferase (GGT) with mortality from cardiovascular disease (CVD).
Methods and Results— A population-based cohort of 76 113 Austrian men and women with 455 331 serial GGT measurements was prospectively followed-up for a median of 10.2 years after assessment of longitudinal GGT change during an average period of 6.9 years. Cox proportional hazards regression with time-varying covariates was used to evaluate GGT change as an independent predictor for CVD death. Independently of baseline GGT and other classical CVD risk factors, a pronounced increase in GGT (7-year change >9.2 U/L) was significantly associated with increased total CVD mortality in men (P=0.005); the adjusted hazard ratio (95% confidence interval) in comparison to stable GGT (7-year change –0.7 to 1.3 U/L) was 1.40 (1.09 to 1.81). Similarly, total CVD risk was elevated for increasing GGT in women, although effects were less pronounced and statistically significant only in subanalyses regarding coronary heart disease. Age of participants significantly modified the relation between GGT change and CVD mortality, with markedly stronger associations to be observable for younger individuals.
Conclusion— Our study is the first to demonstrate that a longitudinal increase in GGT, independently of baseline GGT and even within its normal range, significantly increases risk of fatal CVD.
We prospectively investigated the association of longitudinal GGT change with CVD mortality in 76 113 men and women. We found increasing GGT, even within its normal range, to significantly increase risk of fatal CVD, independently of baseline GGT and other classical CVD risk factors.
Key Words: cardiovascular disease mortality • -glutamyltransferase • longitudinal change • risk factor • epidemiology

Atrovent no DPOC: aumento de risco cardiovascular

Risk for Death Associated with Medications for Recently Diagnosed Chronic Obstructive Pulmonary Disease Todd A. Lee, PharmD, PhD; A. Simon Pickard, PhD; David H. Au, MD, MS; Brian Bartle, MPH; and Kevin B. Weiss, MD, MPH, MS
16 September 2008 Volume 149 Issue 6 Pages 380-390
Background: Concerns exist regarding increased risk for mortality associated with some chronic obstructive pulmonary disease (COPD) medications.
Objective: To examine the association between various respiratory medications and risk for death in veterans with newly diagnosed COPD.
Design: Nested case–control study in a cohort identified between 1 October 1999 and 30 September 2003 and followed through 30 September 2004 by using National Veterans Affairs inpatient, outpatient, pharmacy, and mortality databases; Centers for Medicare & Medicaid Services databases; and National Death Index Plus data. Cause of death was ascertained for a random sample of 40% of those who died during follow-up. Case patients were categorized on the basis of all-cause, respiratory, or cardiovascular death. Mortality risk associated with medications was assessed by using conditional logistic regression adjusted for comorbid conditions, health care use, and markers of COPD severity.
Setting: U.S. Veterans Health Administration health care system.
Participants: 32 130 case patients and 320 501 control participants in the all-cause mortality analysis. Of 11 897 patients with cause-of-death data, 2405 case patients had respiratory deaths and 3159 case patients had cardiovascular deaths.
Measurements: All-cause mortality; respiratory and cardiovascular deaths; and exposure to COPD medications, inhaled corticosteroids, ipratropium, long-acting β-agonists, and theophylline in the 6 months preceding death.
Results: Adjusted odds ratios (ORs) for all-cause mortality were 0.80 (95% CI, 0.78 to 0.83) for inhaled corticosteroids, 1.11 (CI, 1.08 to 1.15) for ipratropium, 0.92 (CI, 0.88 to 0.96) for long-acting β-agonists, and 1.05 (CI, 0.99 to 1.10) for theophylline. Ipratropium was associated with increased cardiovascular deaths (OR, 1.34 [CI, 1.22 to 1.47]), whereas inhaled corticosteroids were associated with reduced risk for cardiovascular death (OR, 0.80 [CI, 0.72 to 0.88]). Results were consistent across sensitivity analyses.
Limitations: Current smoking status and lung function were not measured. Misclassification of cause-specific mortality is unknown.
Conclusion: The possible association between ipratropium and elevated risk for all-cause and cardiovascular death needs further study.

O sarampo nos Estados Unidos

Se ocorresse em Terra Brasilis, o que estaria acontecento na imprensa? Falência da Saúde Pública!!!

Mas, é na terra de Tio Sam. Notem que há crianças não vacinadas por crenças dos pais, filosóficas ou religiosas.

Measles Outbreaks Continue at Record Pace
CDC Officials Warn of Increasing Levels of Viral Transmission
By Cindy Borgmeyer 9/12/2008
In May, AAFP News Now reported on a series of measles outbreaks that had racked up a total of 64 cases between Jan. 1 and April 25 -- the most cases seen in the United States since 2001. According to CDC officials, that tally had reached 131 by the end of July -- the highest year-to-date number since 1996. As of the end of April, nine states had reported cases of the disease; now, 15 states and the District of Columbia have reported measles cases.But those figures only begin to scratch the surface of the problem.
This boy with measles displays the characteristic red blotchy rash that typically appears on the third day of the illness.
Of the 131 total cases reported to the CDC, 123 occurred in U.S. residents. Five of these residents had received a single dose of measles-mumps-rubella, or MMR, vaccine; six had received two MMR doses; and 112 were unvaccinated or had unknown vaccination status. Of those 112 cases, 16 occurred in patients who were too young to be vaccinated and one occurred in a patient who was born before 1957 and, therefore, was presumed to have immunity. Finally, of the 95 remaining patients eligible for vaccination, 63 had not been immunized because of their parents' philosophical or religious beliefs

Erros médicos: por que não notificar?

O blogueiro do The Wall Street Journal repercute matéria do Philadelphia Inquirer sobre a notificação de erros médicos. Alguns estados americanos adotaram a notificação de erros hospitalares. Lá, como cá há um pavor em dizer que há problemas nos processos de trabalho que levam a erros. Prova da estúpida onipotência do setor hospitalar e dos médicos.

Pennsylvania and New Jersey, like several other states, have passed laws in recent years requiring hospitals to report serious errors. But lots of important mistakes may still be going unreported, the Philadelphia Inquirer reports this morning.
In New Jersey, for example, five of the state’s 80 hospitals didn’t report any preventable mistakes last year. And some Pennsylvania hospitals didn’t report any errors or near misses, which are also supposed to be reported. It’s unlikely the hospitals operated flawlessly.
“I don’t know how many is enough, but zero is a bad number,” said James Bagian, head of the Department of Veterans Affairs’ National Center for Patient Safety, told the Inquirer. “Anybody that is supposed to report close calls and has zero reports is clueless. … Management is asleep at the switch and just waiting until they kill someone.”
The laws are part of a nationwide push to recognize medical errors and improve patient safety by preventing them. But the laws aren’t in step with another big trend in medicine these days: transparency. In general, the error reports aren’t available to the public, and the agencies wouldn’t tell the Inquirer how many error reports each hospital had filed.
The New Jersey Hospital Association supports reporting but opposes making the reports public. “It may present an unfair picture of what is actually going on . . . when we have some hospitals that are not reporting and other hospitals that are reporting,” a hospital association official told Inquirer.

Cold pressor test e dieta hipossódica

Association Between Blood Pressure Responses to the Cold Pressor Test and Dietary Sodium Intervention in a Chinese Population
Jing Chen, MD, MSc; Dongfeng Gu, MD, MSc; Cashell E. Jaquish, PhD; Chung-Shiuan Chen, MS; D. C. Rao, PhD; Depei Liu, PhD; James E. Hixson, PhD; L. Lee Hamm, MD; C. Charles Gu, PhD; Paul K. Whelton, MD, MSc; Jiang He, MD, PhD; for the GenSalt Collaborative Research Group
Arch Intern Med. 2008;168(16):1740-1746.
Background Blood pressure (BP) responses to the cold pressor test (CPT) and to dietary sodium intake might be related to the risk of hypertension. We examined the association between BP responses to the CPT and to dietary sodium and potassium interventions.
Methods The CPT and dietary intervention were conducted among 1906 study participants in rural China. The dietary intervention included three 7-day periods of low sodium intake (3 g/d of salt [sodium chloride] [51.3 mmol/d of sodium]), high sodium intake (18 g/d of salt [307.8 mmol/d of sodium]), and high sodium intake plus potassium chloride supplementation (60 mmol/d). A total of 9 BP measurements were obtained during the 3-day baseline observation and the last 3 days of each intervention using a random-zero sphygmomanometer.
Results Blood pressure response to the CPT was significantly associated with BP changes during the sodium and potassium interventions (all P < .001). Compared with the lowest quartile of BP response to the CPT (quartile 1), systolic BP changes (95% confidence intervals) for the quartiles 2, 3, and 4 were –2.02 (–2.87 to –1.16) mm Hg, –3.17 (–4.05 to –2.28) mm Hg, and –5.98 (–6.89 to –5.08) mm Hg, respectively, during the low-sodium intervention. Corresponding systolic BP changes during the high-sodium intervention were 0.40 (–0.36 to 1.16) mm Hg, 0.44 (–0.35 to 1.22) mm Hg, and 2.30 (1.50 to 3.10) mm Hg, respectively, and during the high-sodium plus potassium supplementation intervention were –0.26 (–0.99 to 0.46) mm Hg, –0.95 (–1.70 to –0.20) mm Hg, and –1.59 (–2.36 to –0.83) mm Hg, respectively.
Conclusions These results indicate that BP response to the CPT was associated with salt sensitivity and potassium sensitivity. Furthermore, a low-sodium or high-potassium diet might be more effective to lower BP among individuals with high responses to the CPT.

Adiponectina e Risco de Diabetes em Mulheres

Total and High-Molecular-Weight Adiponectin and Resistin in Relation to the Risk for Type 2 Diabetes in Women Christin Heidemann, DrPH, MSc; Qi Sun, MD, ScD; Rob M. van Dam, PhD; James B. Meigs, MD, MPH; Cuilin Zhang, MD, PhD; Shelley S. Tworoger, PhD; Christos S. Mantzoros, MD, DSc; and Frank B. Hu, MD, PhD
2 September 2008 Volume 149 Issue 5 Pages 307-316
Background: Adiponectin and resistin are recently discovered adipokines that may provide a molecular link between adiposity and type 2 diabetes.
Objective: To evaluate whether total and high-molecular-weight adiponectin and resistin are associated with future risk for type 2 diabetes, independent of obesity and other known diabetes risk factors.
Design: Prospective, nested, case–control study.
Setting: United States.
Participants: 1038 initially healthy women of the Nurses' Health Study who developed type 2 diabetes after blood sampling (1989 to 1990) through 2002 and 1136 matched control participants.
Measurements: Plasma concentrations of total and high-molecular-weight adiponectin and resistin.
Results: In multivariate models including body mass index, higher total and high-molecular-weight adiponectin levels were associated with a substantially lower risk for type 2 diabetes (odds ratio [OR] comparing the highest with the lowest quintiles, 0.17 [95% CI, 0.12 to 0.25] for total adiponectin and 0.10 [CI, 0.06 to 0.15] for high-molecular-weight adiponectin). A higher ratio of high-molecular-weight to total adiponectin was associated with a statistically significantly lower risk even after adjustment for total adiponectin (OR, 0.45 [CI, 0.31 to 0.65]). In the multivariate model without body mass index, higher resistin levels were associated with a higher risk for diabetes (OR, 1.68 [CI, 1.25 to 2.25]), but the association was no longer statistically significant after adjustment for body mass index (OR, 1.28 [CI, 0.93 to 1.76]).
Limitation: The findings apply mainly to white women and could be partly explained by residual confounding from imperfectly measured or unmeasured variables.
Conclusion: Adiponectin is strongly and inversely associated with risk for diabetes, independent of body mass index, whereas resistin is not. The ratio of high-molecular-weight to total adiponectin is related to risk for diabetes independent of total adiponectin, suggesting an important role of the relative proportion of high-molecular-weight adiponectin in diabetes pathogenesis.

Mitos da doença diverticular do cólon

Nut, Corn, and Popcorn Consumption and the Incidence of Diverticular Disease
Lisa L. Strate, MD, MPH; Yan L. Liu, MS; Sapna Syngal, MD, MPH; Walid H. Aldoori, MD, MPA, ScD; Edward L. Giovannucci, MD, ScD
JAMA. 2008;300(8):907-914.
Context Patients with diverticular disease are frequently advised to avoid eating nuts, corn, popcorn, and seeds to reduce the risk of complications. However, there is little evidence to support this recommendation.
Objective To determine whether nut, corn, or popcorn consumption is associated with diverticulitis and diverticular bleeding.
Design and Setting The Health Professionals Follow-up Study is a cohort of US men followed up prospectively from 1986 to 2004 via self-administered questionnaires about medical (biennial) and dietary (every 4 years) information. Men reporting newly diagnosed diverticulosis or diverticulitis were mailed supplemental questionnaires.
Participants The study included 47 228 men aged 40 to 75 years who at baseline were free of diverticulosis or its complications, cancer, and inflammatory bowel disease and returned a food-frequency questionnaire.
Main Outcome Measures Incident diverticulitis and diverticular bleeding.
Results During 18 years of follow-up, there were 801 incident cases of diverticulitis and 383 incident cases of diverticular bleeding. We found inverse associations between nut and popcorn consumption and the risk of diverticulitis. The multivariate hazard ratios for men with the highest intake of each food (at least twice per week) compared with men with the lowest intake (less than once per month) were 0.80 (95% confidence interval, 0.63-1.01; P for trend = .04) for nuts and 0.72 (95% confidence interval, 0.56-0.92; P for trend = .007) for popcorn. No associations were seen between corn consumption and diverticulitis or between nut, corn, or popcorn consumption and diverticular bleeding or uncomplicated diverticulosis.
Conclusions In this large, prospective study of men without known diverticular disease, nut, corn, and popcorn consumption did not increase the risk of diverticulosis or diverticular complications. The recommendation to avoid these foods to prevent diverticular complications should be reconsidered.
Author Affiliations: University of Washington School of Medicine, Seattle (Dr Strate); Division of Gastroenterology, Department of Medicine, Harborview Medical Center, Seattle (Dr Strate); Departments of Nutrition (Ms Liu and Dr Giovannucci) and Epidemiology (Dr Giovannucci), Harvard School of Public Health, Boston, Massachusetts; Harvard Medical School, Boston (Drs Syngal and Giovannucci); Division of Gastroenterology (Dr Syngal) and Channing Laboratory (Dr Giovannucci), Department of Medicine, Brigham and Women's Hospital, Boston; Division of Population Sciences, Dana Farber Cancer Institute, Boston (Dr Syngal); and Wyeth Consumer Healthcare Inc, Mississauga, Ontario, Canada (Dr Aldoori).

EUROASPIRE III, más notícias

EUROASPIRE III: Not enough being done in the treatment of high-risk primary-prevention patientsSeptember 3, 2008

Munich, Germany - High-risk individuals in primary-prevention programs are not being managed effectively, with too few of these patients following the European guidelines for the prevention of cardiovascular disease and more than 80% never having received any advice or direction about the importance of following a heart-healthy lifestyle program.
These are the results of the primary-prevention EUROASPIRE III study, a survey of 12 participating countries that was designed to assess lifestyle, risk-factor, and therapeutic management of individuals at high risk of developing cardiovascular disease.
Dr David Wood
"The lifestyle of high-risk patients is a major cause for concern, with high prevalences of persistent smoking and both obesity and central obesity," said lead investigator Dr David Wood (Imperial College School of Medicine, London, UK). "Blood-pressure, lipid, and glucose control are completely inadequate, with most patients not achieving the targets defined in the guidelines."
Presenting the results of EUROASPIRE III here at the European Society of Cardiology (ESC) Congress 2008, Wood said that even among patients with diabetes mellitus, many are not achieving blood-pressure control, and the use of other cardioprotective drugs are not prescribed enough. Ironically, many patients want to be informed about their risk of heart disease, he said. Unfortunately, most being treated believe they are low or moderate risk and falsely assume they have an equivalent risk when compared with others of the same age and sex. Bad news for the primary-prevention patient at high risk
The first EUROASPIRE survey, which was done among patients with established coronary heart disease, showed that there was a substantial potential for risk reduction. Subsequent surveys drawn from the same countries multiple years later, however, indicate the potential for risk reduction had been missed, as many heart-disease patients continue to smoke, are still overweight, and have uncontrolled blood-pressure and cholesterol levels.
These new EUROASPIRE findings now suggest that primary-prevention patients are also drastically undertreated, as well as not adhering to lifestyles that promote cardiovascular health. The investigators studied the medical records of 5687 individuals and conducted interviews in more than 75% of these high-risk patients. High-risk patients are defined as men and women 80 years of age and younger without a history of coronary or other atherosclerotic disease who had been started on one or more of the following: antihypertensive therapy, lipid-lowering drugs, and/or diabetes therapies.
In terms of lifestyle, 16% of patients smoked, with nearly 90% of patients continuing to smoke at the time of the EUROASPIRE interview, a disappointing finding showing that only 1 in 10 patients had quit. Almost 50% of patients were overweight, and in terms of the prevalence of elevated risk factors, almost 80% had blood-pressure, triglyceride, and LDL-cholesterol levels exceeding the recommended European targets. Among diabetic patients, only 27% had fasting glucose levels and 53% had HbA1c levels that met the definition for therapeutic control. The prescription of cardioprotective drugs, including statins, was also underprescribed, report investigators.
Importantly, Wood told the audience that almost 85% of patients wanted to know their risk of heart disease, but very few knew their 10-year risk of developing coronary heart disease, and most assumed they were as healthy as men and women of their own age. More than 80% of those participating in the survey were not provided with a professional lifestyle and risk-factor management program, despite ample evidence that such programs, including the EUROACTION nurse-led multidisciplinary approach, improve lifestyles and patient care and reduce the prevalence of cardiovascular risk factors. Not doing enough
Dr Lars Rydén
Speaking to the audience following the EUROASPIRE III presentation, Dr Lars Rydén (Karolinska Institute, Stockholm, Sweden) said that these patients represent a high-risk group of patients and that the real-world data are likely much worse, as the centers participating in the EUROASPIRE studies include active investigators and dedicated clinicians.
Interestingly, there had been some belief that patients would not want to know if they were going to die prematurely, said Rydén, although this does not appear to be the case. "The vast majority of patients actually wanted to know about their risk, but their [self-] estimated risk was considerably lower, so they are living with the false assumption that they will live forever," he said.
Rydén said it is disappointing that patients are not getting advice about managing risk factors through lifestyle modifications and that clinicians have the ability to do better, especially since the ESC guidelines are available in all European languages. He also emphasized the findings from the EUROACTION investigators and suggested that multidisciplinary efforts can effectively alter patient behavior and modify risk factors. Reimbursement for interventions aimed at primary-prevention patients also needs to be altered for these efforts to be effective, said Rydén.

Medicina: a ciência das verdades transitórias, transformadas em dogmas para fins didáticos

No blogue auxiliar Ensaios Clínicos , postei os dois abstracts publicados hoje no The New England Journal of Medicine. Trata-se da continuidade de dois ensaios clínicos sobre diabetes encerrados e publicados há dez anos, o UKPDS (United Kingdom Prospective Diabetes Study). Agora, eles avaliam o efeito do ensaio sem a intervenção, dez anos depois. Os resultados praticamente mudaram o publicado inicialmente, o que implica discutir cada vez mais o mundo dos ensaios clínicos e o mundo real. Fica para outro momento.

O título do post é homenagem ao filósofo, médico, endocrinologista e diabetólogo, Arnaldo Caleiro Sandoval, autor dessa e de outras máximas.

Quem é mais citado?

Um artigo simples, de fácil realização, publicado no Circulation pela equipe da Harvard Medical School revela que artigos financiados pela indústria são mais citados do que aqueles por outras fontes, independente da qualidade. O mesmo vale para artigo mostrando que a proposta nova é mais efetiva do que a existente.

Leitura obrigatória em seminários de médicos-residentes e pós-graduandos.

Differential Citation Rates of Major Cardiovascular Clinical Trials According to Source of Funding. A Survey From 2000 to 2005

David Conen MD, Jose Torres BA, and Paul M Ridker MD*
Background—Prior work indicates that therapeutic trials funded by for-profit organizations are more likely to report positive findings than trials funded by not-for-profit organizations. What impact, if any, funding source has on subsequent dissemination of trial data is uncertain. To address this issue, we used the number of citations per publication per year to assess differences in trial dissemination according to funding source.
Methods and Results—We assessed 303 consecutive superiority trials of cardiovascular medicine published between January 1, 2000, and July 30, 2005, in the Journal of the American Medical Association, The Lancet, and the New England Journal of Medicine. The primary outcome measure was the number of citations per publication per year up to December 31, 2006. Overall, the median number of citations per publication per year was 46 for trials funded exclusively by for-profit organizations, 37 for trials jointly funded, and 29 for trials funded by not-for-profit organizations (P=0.0007). Higher citation rates for trials funded by for-profit organizations were consistently observed in analyses stratified by journal and various trial design features and were most striking when the new intervention was favored over the standard of care; in this subgroup, the median number of citations per publication per year was 52 for trials funded by for-profit organizations compared with 25 for trials funded by not-for-profit organizations (P=0.0006). In marked contrast, in analyses limited to trials in which the new intervention was significantly worse than the standard of care, an inverse pattern was observed with fewer citations per publication per year for trials funded by for-profit organizations compared with not-for-profit organizations (33 versus 41; P=0.048). Higher citation rates were observed for industry-funded trials than for federally funded trials even when the trials dealt with similar issues and were published back-to-back in the same journal.
Conclusions—Dissemination of clinical trial results is important for clinical practice but appears to be biased in favor of for-profit entities. Consideration should be given to more extensive promotion of clinical trial results that are funded by not-for-profit organizations.

Não fui embora !

Reforma do Pronto-Socorro do Hospital, estrutura nova para ambulatórios de especialidade, relatórios e proposições a agências de pesquisas, aulas e seminários, início do ELSA, submissão de manuscritos... O blog ficou sozinho..

Um idéia excelente: compartilhar banco de dados

Towards a Data Sharing Culture: Recommendations for Leadership from Academic Health Centers. (texto completo, clique aqui)
Sharing biomedical research and health care data is important but difficult. Recognizing this, many initiatives facilitate, fund, request, or require researchers to share their data. These initiatives address the technical aspects of data sharing, but rarely focus on incentives for key stakeholders. Academic health centers (AHCs) have a critical role in enabling, encouraging, and rewarding data sharing. The leaders of medical schools and academic-affiliated hospitals can play a unique role in supporting this transformation of the research enterprise. We propose that AHCs can and should lead the transition towards a culture of biomedical data sharing.
Benefits of Data Sharing for Academic Health Centers
The benefits of data sharing and reuse have been widely reported. We summarize them here, from the perspective of an AHC.
The predominant benefit of data sharing is accelerated scientific progress. Advances are clearly valuable to an AHC when translated into improved patient outcomes, reduced research costs, and decreased time in moving discoveries from the bench to the bedside.
Of more immediate benefit to AHCs and their researchers, sharing data increases the visibility and relevance of research output. Sharing data generates opportunities for additional publications through collaboration, and may increase the citation rate of primary publications. Since publication history and citation impact are often considered in future funding decisions, these benefits are likely to accelerate research programs, and thus enhance the reputation of the academic institutions.
Data sharing can also benefit an AHC in its roles of educator and employer. Health care professionals trained in clinical informatics benefit from exposure to real-world data. By embracing data sharing goals, an AHC becomes more appealing to cutting-edge researchers, and thereby more able to recruit the talent required for future successes.
Finally, the widespread adoption of a data sharing culture needs leaders, and thus provides an opportunity for AHCs to demonstrate excellence.
A Leadership Role
Despite the anticipated benefits, sharing research data has yet to be widely adopted in biomedicine. Through their interwoven roles in education, research, and policy, AHCs can lead the development of best practices for establishing a data sharing culture. Practical steps with potentially powerful impact are discussed below and summarized in Box 1.
Box 1: Recommendations for Academic Health Centers to Encourage Data Sharing
Commit to sharing research data as openly as possible, given privacy constraints. Streamline IRB, technology transfer, and information technology policies and procedures accordingly.
Recognize data sharing contributions in hiring and promotion decisions, perhaps as a bonus to a publication's impact factor. Use concrete metrics when available.
Educate trainees and current investigators on responsible data sharing and reuse practices through class work, mentorship, and professional development. Promote a framework for deciding upon appropriate data sharing mechanisms.
Encourage data sharing practices as part of publication policies. Lobby for explicit and enforceable policies in journal and conference instructions, to both authors and peer reviewers.
Encourage data sharing plans as part of funding policies. Lobby for appropriate data sharing requirements by funders, and recommend that they assess a proposal's data sharing plan as part of its scientific contribution.
Fund the costs of data sharing, support for repositories, adoption of sharing infrastructure and metrics, and research into best practices through federal grants and AHC funds.
Publish experiences in data sharing to facilitate the exchange of best practices.

Agora é polícia que mostra a máfia das ações judiciais.

Ações Judiciais para liberação de medicamentos. Quando ninguém falava, eu denunciei. Recebi de um médico, uma ação no CREMESP que foi arquivada e, outra em Conselho de Ética. Outra ação movida contra mim , na esfera do Judiciário foi retirada de início. Agora, somente cabe ler os jornais e, observar detalhes da maior drenagem de dinheiro público na área da saúde ocorrida nos últimos tempos.

Folha de S.Paulo e Datafolha restauram a geografia em São Paulo

A Folha de S.Paulo publica há cinco domingos, pesquisa do Datafolha e dados demográficos sobre as regiões da cidade de São Paulo. O destaque fica pela reintrodução da geografia em contraposição à definição ideológica de bairros com sotaque carioca. Tudo que é bom seria na zona sul, o que não fosse seria zona norte, leste, oeste etc... A própria Folha, mais Estadão, Vejinha sempre classificavam os Jardins como Zona Sul, o mesmo para o Morumbi e, até o Alto de Pinheiros! O Ipiranga que fica na zona sul era classificado como zona leste. A geografia agradece à Folha de S.Paulo, que aprendeu a não brigar com os mapas.

Agora, será a vez dos cardiologistas brasileiros aprenderem que o Brasil está no Ocidente do planeta. Quem nunca leu "com a ocidentalização dos hábitos dos brasileiros....? "(uma tradução idiota de "life style westernization" aplicada à China, Japão, India).

Ensaios Clínicos: um site de ensino

Quem acessar o site Ensaios Clínicos verá uma seleção de resumos dos mais relevantes ensaios clínicos publicados ou comentários relacionados à terapêutica. Na faixa ao lado, também é possível acessá-lo. Desde o início do ano utilizo a secção Ensaios Clínicos em Cardiologia para orientar os residentes de Clínica Médica no preparo de seminários sobre terapêutica que ocorrem todas segundas-feiras. Agora, o objetivo é incentivar os residentes a postarem comentários sobre os temas por eles desenvolvidos para permitir um debate público, incluindo obviamente a imensa comunidade extra-universitária. Depois disso, como as apresentações estão cada vez melhores, a intenção será disponibilizar os diapositivos no site para conhecimento geral.