blog do Paulo Lotufo

Uma experiência interessante.

2009-10-17T17:52:00.000-03:00

Interessante foi a palavra mais utilizada nesse blogue para valorizar notícias.

Mas, desde 01 de maio esse blogue não foi atualizado e, provavelmente não será nos próximos meses até que se consiga criar uma nova estrutura que garanta ao mesmo tempo amplitude e profundidade dos temas abordados.

O blogue tinha uma audiência entre 200-300 internautas por dia, pouco se comparado a outros, mas atingia exatamente o público a que se destinava: imprensa, formadores de opinião e acadêmicos.

Parei o blogue porque:

(1) falta de tempo:

porque não assumir que esse é o nosso maior problema e deixar de culpar tudo e a todos?

(2) controle de qualidade deficiente:

Erros de digitação e de concordância que me irritavam.

mas, principalmente a insatisfação em não conseguir conferir a fundo várias informações veiculadas;

(3) contradição entre a atividade acadêmica e a liberdade de expressão:

Parece uma bobagem imensa a frase acima, mas estar na Universidade, no meio científico implica controlar-se o tempo inteiro, limitar sua expressão ao mínimo para evitar revides contundentes.

Sempre tentei ser o mais transparente possível nas relações com a indústria e governo, mas como ser "independente" com tantos compromissos assumidos - de forma legal e legítima - tanto com o poder público como com empresas?

A proposta que lanço a quem se interessar é criar uma página eletrônica com conteúdo jornalístico acompanhado de blogues com diversidade de opiniões, onde o Blog do Paulo Lotufo, poderá retomar suas atividades.

O caso Vioxx e autores fantasmas: quase dez anos de história

2009-05-01T01:23:00.001-03:00

O caso Vioxx já deu muito o que falar. Um medicamento excelente para uso por curto período, o rofecoxib, foi empurrado goela abaixo para uso crônico pelo fabricante. No Brasil, Vioxx pela Merck-Sharp Dohme. O artigo inicial publicado em novembro de 2000 chamado VIGOR mostrava a que o rofecoxib e, um medicamento tradicional, naproxeno eram tão efetivos quanto no tratamento da artrite reumatóide. Mas, os efeitos gastrointestinais eram raros no grupo que usou o rofecoxib. Inicou-se a febre Vioxx..

Menos de um ano após a publicação, uma revisão dos próprios dados do VIGOR e de outros dois menores apontava o risco maior de infarto do miocárdio.

A empresa abafou o fato de acordo com a capacidade de reação de cada comunidade acadêmica.

Para isso publicou um artigo na revista Circulation contradizendo a análise que apontava risco.

Hoje, publica-se extensa reportagem - impossível de reproduzir aqui - sobre o processo de montagem do artigo e, da escolha de um professor da Tufs University que seria um autor fantasma. O link da reportagem é http://www.theheart.org/article/965721.do#bib_3

O governo do Irã é mais do que está na imprensa

2009-04-28T07:14:00.001-03:00

Entidades médicas e ONG de ação contra a aids bem que poderiam enviar uma moção ao presidende do Irã na visita que fará ao país.

Treating AIDS is NOT a Crime
Drs. Kamiar and Arash Alaei are well-known Iranian HIV/AIDS physicians who have made breakthroughs in harm reduction and stood up for the health and human rights of the people of Iran. Instead of being rewarded for their groundbreaking work, they’ve been thrown into prison in Iran—and they need your help.
The Alaeis were tried on charges of with communicating with an enemy government in late 2008, and in January 2009 were sentenced to 3 years (Kamiar) and 6 years (Arash) in Tehran’s notorious Evin prison. Their crime: practicing good medicine and sharing public health knowledge with colleagues across the globe—including in the US.
Their arrest robs the world of two great physicians and has a chilling effect on public health dialogue and diplomacy worldwide.
Help free the Alaeis: Take action on May 12, the Global Day of Action fo

The Economist: Health Care and Technology

2009-04-21T20:07:00.000-03:00

The Economist nessa edição (18 a 24 de abril) traz um encarte com 14 páginas sobre o tema Assistência Médica e Tecnologia. Não traz muita novidade. Mas, o enfoque dessa revista, maior ou menor, acaba pautando o restante da imprensa e, mesmo os setores acadêmicos e industriais da saúde em todo o mundo.

Aproveitando o ensejo, a capa de The Economist mostra o virtual presidente eleito da África do Sul: Jacob Zuma. Quem será o seu ministro da saúde? Há possibilidade da "doutora beterraba "voltar? Ativistas da aids estão temerosos.

Um excelente texto, mas com uma citação errada.

2009-04-20T11:45:00.000-03:00

Naomar de Almeida Filho expressou ontem na Folha de S.Paulo a angústia e o sufocamento existente entre aqueles que desejam que o Estado brasileiro e, principalmente a Universidade cumpra a sua missão. Um crítica de conteúdo ao "controlismo" atual que impede qualquer inovação.

Distribui o texto a vários amigos, um deles respondeu que concordava com o texto, já tinha lido pela manhã no jornal. No entanto, ele informou que a citação a um "intelectual paulista" como crítico áspero da autonomia universitária tal como feita por Naomar foi equivocada. Fui conferir agora, o meu amigo estava certo.

O intelectual em questão é Roberto Romano.

Bem, o Brasil tem poucas inteligências, duas delas atendem pelos nomes de Naomar de Almeida Filho e Roberto Romano.

Por favor, não se deixem levar por mal entendidos.

Sol faz bem à saúde!

2009-04-08T06:48:00.000-03:00

Novamente, a crimininalização do Astro-Rei. O VIGITEL não precisava entrar nessa fria...oops! Já mostrei que americanos já abandonam a fobia ao sol. Mas, ainda morremos de doença cardiovascular, cânceres de próstata e de cólon, de fraturas mas pálidos. Abaixo, reportagem da Folha de S.Paulo.

Os brasileiros passaram a se proteger menos do sol, mostra pesquisa do Ministério da Saúde, divulgada ontem. O índice de proteção contra radiação ultravioleta no país caiu de 53,3% para 43,9% de 2007 para 2008.Para medir a taxa de proteção, os pesquisadores levaram em conta a resposta dos entrevistados à seguinte pergunta: "Quando fica exposto ao sol, por mais de 30 minutos, seja andando na rua, seja no trabalho, seja no lazer, costuma usar alguma proteção?"O estudo considerou como proteção eficaz contra raios ultravioleta "o uso de filtro solar e/ou chapéu/sombrinhas e roupas adequadas".Um dos principais erros dos brasileiros está em achar que proteção solar se resume ao uso do filtro em forma de creme, diz Marcus Maia, professor da Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo e coordenador da última campanha contra câncer de pele da Sociedade Brasileira de Dermatologia."Camiseta de trama mais grossa e cor escura, chapéu e sombrinha é muito interessante e é uma solução para a população", diz o médico.CapitaisEntre as capitais, a que apresentou melhor resultado em relação à taxa de proteção foi Florianópolis.A cidade de São Paulo apareceu em penúltimo lugar no ranking, só perdendo para o Rio de Janeiro. De acordo com a dermatologista Flávia Addor, há uma cultura de tomar sol e de bronzeamento em cidades como Rio que é preocupante. "Os critérios têm que ser vistos com atenção. É preciso tomar menos sol e ter atitude de proteção. O ideal é passar o protetor sempre que sair de casa, ainda mais em cidades ensolaradas."O filtro solar deve ser aplicado em partes expostas ao sol, na proporção de 2 ml para cada centímetro cúbico, o que equivale a cerca de 40 ml de produto em todo o corpo para uma pessoa de 70 kg.O câncer de pele é o tipo de tumor mais incidente no Brasil e está diretamente relacionado à exposição ao sol. Para 2009, o Instituto Nacional de Câncer estima 62.090 novos casos em mulheres e 58.840 em homens.A pesquisa do Ministério da Saúde também revelou que as mulheres se protegem mais do que os homens -52,5% das entrevistadas disseram usar protetor solar e/ou chapéu/sombrinha contra 33,8% deles.Ontem, ao apresentar os resultados da pesquisa, o ministro José Gomes Temporão (Saúde) aconselhou os homens "a ouvirem as mulheres". "Eu diria aos homens o seguinte: escutem as mulheres, copiem as mulheres", afirmou. "Os homens fumam mais, bebem mais, comem alimentação com mais gordura, fazem menos atividade física", completou.A Folha publicou reportagem na última segunda-feira mostrando outros dados do mesmo estudo relativos aos hábitos e à saúde do brasileiro.A pesquisa Vigitel 2008 (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico) foi realizada por amostragem com cerca de 54 mil pessoas, nas capitais e no Distrito Federal, entre junho e dezembro do ano passado. As entrevistas foram feitas por telefone, sistema parecido com o adotado nos Estados Unidos.

Inédito: Sindicato de trabalhadores defende a saúde de seus associados e, não o interesse dos patrões.

2009-04-07T22:42:00.000-03:00

Sindicato contraria setor de bares e restaurantes e apoia lei antifumo de Serra
colaboração para a Folha Online
Os membros da Sinthoresp (sindicato de trabalhadores no setor de bares e restaurantes de São Paulo) comemoraram nesta terça-feira a aprovação na Assembleia Legislativa de São Paulo da lei antifumo proposta pelo governador José Serra (PSDB). Em reunião na tarde de hoje com diretores, a entidade contrariou a maioria dos representantes do setor e decidiu apoiar a lei.
A entidade justifica o apoio com a preocupação sobre a saúde tanto de quem fuma quanto dos fumantes passivos. Por meio de sua assessoria, o presidente do sindicato, Francisco Calasans, afirma que "é preciso respeitar trabalhos científicos da medicina que comprovam o mal que o fumo faz".

War and Medicine

2009-03-29T20:13:00.000-03:00

Um livro fascinante da Wellcome Collection publicado pela BlackDog Publishing: War and Medicine. A edição é primorosa.

Traz artigos sobre várias guerras começando na Criméia indo até a Guerra até o Iraque.

Uma síntese da redução da letalidade (proporção de mortes por feridos) das tropas americanas. Variou de 79% na guerra hispano-americana 1898-99 para 11% na guerra do Iraque.

Estadão: leituras de fim de semana.

2009-03-29T20:05:00.000-03:00

O Estadão trouxe nesse fim de semana:

1. uma excelente reportagem seguida por entrevista do diretor-presidente da ANVISA sobre o programa de desconto de medicamentos patrocinado pela indústria farmacêutica. Merece destaque;

2. entrevista com o pesquisador Antonio Carlos Camargo, do Instituto Butantan mostrando a dificuldade em transformar a descoberta científica em produto.

Não publico mais comentários anônimos. É constitucional.

2009-03-29T19:56:00.000-03:00

Esse blogue é propriedade particular, quem não gostar, não leia, nem divulgue.

Restrijo comentários indevidos e, há um tempo não publico nada anônimo. Liberdade de expressão tal como manifestada na Carta Magna implica identificação.

TÍTULO II

Dos Direitos e Garantias Fundamentais

CAPÍTULO IDOS DIREITOS E DEVERES INDIVIDUAIS E COLETIVOS
Art. 5º Todos são iguais perante a lei, sem distinção de qualquer natureza, garantindo-se aos brasileiros e aos estrangeiros residentes no País a inviolabilidade do direito à vida, à liberdade, à igualdade, à segurança e à propriedade, nos termos seguintes:
IV - é livre a manifestação do pensamento, sendo vedado o anonimato;

De novo, a confusão entre internação e incidência de doença

2009-03-27T06:43:00.000-03:00

Folha de S.Paulo repercute hoje, mais uma matéria equivocada sobre doença cardiovascular em mulheres. Os dados publicados pelo Hospital Laranjeiras do Rio de Janeiro confunde internações com pessoas internadas. Simplesmente, uma mesma pessoa pode ser internada mais de uma vez pelo mesmo motivo. No caso, pode ser o infarto do miocárdio, depois uma complicação, cirurgia.

Além do viés óbvio que alguns diagnósticos são anotados em preferência a outros pelo fato que a remuneração é maior. Em suma, esquecer.

JULLIANE SILVEIRADA REPORTAGEM LOCAL O número de internações de mulheres por infarto agudo do miocárdio subiu 46% (de 15.672 para 22.910) entre 1997 e 2007, segundo levantamento realizado pelo INC (Instituto Nacional de Cardiologia) nos hospitais conveniados ao Sistema Único de Saúde em todo o país. Os dados foram retirados do Datasus (banco de dados do Ministério da Saúde).De acordo com o trabalho, o tempo de internação é de sete dias, em média, e a taxa de mortalidade em decorrência do ataque cardíaco chega a 16,8%.Segundo dados do Ministério da Saúde, o infarto é a segunda causa de morte entre as brasileiras -a primeira é o AVC (acidente vascular cerebral). (Assinante da Folha, clique aqui)

Churrasco: nada a declarar

2009-03-24T07:01:00.000-03:00

Ontem, nos Archives of Internal Medicine e, não no JAMA foi publicado artigo original mostrando associação entre ingestão de carne vermelha e mortalidade. A associação de um determinado alimento com risco de doença cardiovascular ou câncer necessita ser vista com muito, mas muito cuidado.

Afoitos já tentam desvendar as causas possíveis com ilações sem sentido, para quem não conhece a metodologia complexa de um questionário de frequência alimentar. O Estudo Longitudinal de Saúde do Adulto (ELSA) está aplicando essa metodologia em 15 mil pessoas e, poderemos saber o impacto na população brasileira. Não basta considerar somente o consumo de carne, mas o tipo de carne consumida e, como é preparada. Por isso, mais cautela na leitura rápida de artigos de epidemiologia.

Abaixo, matéria da Folha de S.Paulo sobre o tema.

Reduzir carne vermelha diminui mortalidade
Pesquisa publicada no "Jama" acompanhou 500 mil pessoas durante dez anosPara pesquisadores, 11% das mortes em homens e 16% em mulheres poderiam ter sido adiadas com a redução de carne vermelha JULLIANE SILVEIRACLÁUDIA COLLUCCIDA REPORTAGEM LOCAL
Um estudo divulgado hoje no "Jama" (revista da Associação Médica Americana) aponta relação entre o consumo de carne vermelha e carnes processadas e maior número de mortes por câncer e problemas cardiovasculares. A pesquisa, uma das maiores já realizadas, analisou dados de 500 mil norte-americanos de 50 a 71 anos de idade.Em dez anos de acompanhamento, morreram 47.976 homens e 23.276 mulheres. Para os pesquisadores, 11% das mortes em homens e 16% das mortes em mulheres poderiam ser adiadas se houvesse redução do consumo de carne vermelha para 9 g do produto a cada 1.000 calorias ingeridas -o grupo que mais ingeriu carne vermelha (68 g a cada 1.000 calorias) foi o que apresentou maior incidência de morte.No caso das doenças cardiovasculares, a diminuição dos riscos chegaria a 21% nas mulheres se houvesse redução. "A carne processada tem mais sal e gordura saturada, o que aumenta chances de doenças cardiovasculares", diz Daniel Magnoni, nutrólogo e cardiologista do Hospital do Coração.Para o cardiologista Marcos Knobel, coordenador da unidade coronária do hospital Albert Einstein, além da gordura da carne, o problema é o preparo e os outros alimentos que são somados à refeição. "Se a pessoa come um bife à milanesa ou um bife com ovo frito, já estourou de longe a cota de colesterol."Além disso, ele alerta para os condimentos. "O sal aumenta o risco de hipertensão arterial sistêmica. Se a carne for processada, é pior porque, além do sódio, geralmente tem óleos para a conservação

Um comentário sobre o artigo de Ferreira Gullar

2009-03-23T06:58:00.000-03:00

1. Ferreira Gullar não acusa o SUS de nada, somente constata má fama. Correto.

2. Descreve paciente com dor há 3 horas sem atendimento. O problema não é do plano, mas do hospital.

3. Toca no ponto mais importante: os idosos. O custo da assistência médica aumenta exponencialmente depois dos 65-70 anos. Esse é um problema que vale para o SUS e os planos de saúde privados e, encontra-se na pauta de todos os países com sistemas organizados e, desorgnizados como os Estados Unidos.

4. Que parte dos planos de saúde são verdadeiras "pirâmides", poucos duvidam. Mas, há possibilidade dos planos serem de fato suplementares ao SUS. Para isso a legislação deveria permitir planos baratos com atendimento ao nível primário e secundário, sem obrigar aos atendimentos dispendiosos em nível terciário como câncer, transplantes e cirurgia cardíaca. Com isso, muitos pacientes sairiam das portas dos pronto-socorros públicos e, o SUS poderia organizar melhor a atenção especializada concentrando-a em poucos e bons hospitais com qualidade melhor e custo menor.

Ferreira Gullar e os Planos de Saúde

2009-03-22T10:01:00.000-03:00

Na Folha de S.Paulo, um desabafo de Ferreira Gullar sobre os planos de saúde. A íntegra pode ser lida aqui por assinante do jornal. Transcrevo parte abaixo, a qual intenciono discutir nos próximos posts.

Os planos de saúde estão se tornando um problema grave para quem deles depende. A má fama do SUS -que obriga os pacientes a filas intermináveis e esperas frustrantes- faz com que as pessoas todas, com algum recurso, procurem os planos de saúde. Como os planos melhores são caros, surgem planos baratos que são verdadeiras arapucas: você paga a mensalidade, mas, quando procura o médico, descobre que ele já não atende porque o plano não o pagou.Só que os problemas não ficam nisso, pois mesmo os planos mais caros têm se mostrado incapazes de atender seus clientes. É que esses planos aceitam mais clientes do que têm capacidade de atender. Entre os numerosos casos de que tenho conhecimento, o mais recente é o de uma amiga que sofreu fratura no pé, foi para uma casa de saúde e lá ficou durante três horas num corredor, gemendo de dor, sem que fosse atendida. A explicação da funcionária do hospital foi que o traumatologista estava atendendo a outro paciente. Já imaginou se mais alguém torce o pé naquele dia?A situação pior é a dos idosos. Como adoecem com frequência, têm que pagar mensalidades altíssimas. Sei do caso de um senhor que, em pouco mais de um ano, teve sua mensalidade aumentada de R$ 1.200 para R$ 1.800. Queixou-se ao corretor, que lhe disse: "Eles estão aumentando exageradamente a mensalidade dos idosos para expulsá-los do plano". Tem lógica: clientes que adoecem com frequência dão pouco lucro ou, pior, dão prejuízo, e os planos de saúde estão aí para obter lucros. O objetivo principal é ganhar dinheiro, claro. O cliente ideal é o que não adoece. O nome do troço é "plano de saúde", não "plano de doença". O capital governa o capitalista e o resto

Índice de massa corpórea e mortalidade

2009-03-21T15:05:00.000-03:00

O índice de massa corpórea (IMC) que é calculado dividindo o peso em kilogramas pelo quadrado da altura em metros continua a ser o melhor preditor de mortalidade dentre os indicadores de adiposidade. Abaixo, resumo de artigo publicado no The Lancet com 56 estudos em conjunto e 900 mil participantes.

Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies
Prospective Studies Collaboration ‡
Background
The main associations of body-mass index (BMI) with overall and cause-specific mortality can best be assessed by long-term prospective follow-up of large numbers of people. The Prospective Studies Collaboration aimed to investigate these associations by sharing data from many studies.
Methods
Collaborative analyses were undertaken of baseline BMI versus mortality in 57 prospective studies with 894 576 participants, mostly in western Europe and North America (61% [n=541 452] male, mean recruitment age 46 [SD 11] years, median recruitment year 1979 [IQR 1975—85], mean BMI 25 [SD 4] kg/m2). The analyses were adjusted for age, sex, smoking status, and study. To limit reverse causality, the first 5 years of follow-up were excluded, leaving 66 552 deaths of known cause during a mean of 8 (SD 6) further years of follow-up (mean age at death 67 [SD 10] years): 30 416 vascular; 2070 diabetic, renal or hepatic; 22 592 neoplastic; 3770 respiratory; 7704 other.
Findings
In both sexes, mortality was lowest at about 22·5—25 kg/m2. Above this range, positive associations were recorded for several specific causes and inverse associations for none, the absolute excess risks for higher BMI and smoking were roughly additive, and each 5 kg/m2 higher BMI was on average associated with about 30% higher overall mortality (hazard ratio per 5 kg/m2 [HR] 1·29 [95% CI 1·27—1·32]): 40% for vascular mortality (HR 1·41 [1·37—1·45]); 60—120% for diabetic, renal, and hepatic mortality (HRs 2·16 [1·89—2·46], 1·59 [1·27—1·99], and 1·82 [1·59—2·09], respectively); 10% for neoplastic mortality (HR 1·10 [1·06—1·15]); and 20% for respiratory and for all other mortality (HRs 1·20 [1·07—1·34] and 1·20 [1·16—1·25], respectively). Below the range 22·5—25 kg/m2, BMI was associated inversely with overall mortality, mainly because of strong inverse associations with respiratory disease and lung cancer. These inverse associations were much stronger for smokers than for non-smokers, despite cigarette consumption per smoker varying little with BMI.
Interpretation
Although other anthropometric measures (eg, waist circumference, waist-to-hip ratio) could well add extra information to BMI, and BMI to them, BMI is in itself a strong predictor of overall mortality both above and below the apparent optimum of about 22·5—25 kg/m2. The progressive excess mortality above this range is due mainly to vascular disease and is probably largely causal. At 30—35 kg/m2, median survival is reduced by 2—4 years; at 40—45 kg/m2, it is reduced by 8—10 years (which is comparable with the effects of smoking). The definite excess mortality below 22·5 kg/m2 is due mainly to smoking-related diseases, and is not fully explained.

Homicídios em queda no Rio

2009-03-20T16:50:00.000-03:00

Finalmente, a Secretaria de Estado do Rio de Janeiro assumiu que os homicídios estão com taxas declinantes na cidade.

Esse blogue identificou há quase dois anos essa tendência.

Leia em Taxas de Homicídios em SamPa, Rio, BH: 2001 a 2005.

Prevenção do Câncer de Próstata: muitas novidades e a discussão continua.

2009-03-20T16:34:00.000-03:00

Imperdível, dois artigos publicados no The New England Journal of Medicine sobre rastreamento para câncer de próstata. Trata-se de dois ensaios clínicos, um americano e outro europeu com delineamento de ensaio clínicos. Os resultados são aparentemriente contraditórios.

O acesso é gratuito em http://www.nejm.org.

De volta da clínica de desintoxicação da blogosfera

2009-03-20T16:25:00.000-03:00

Meia quaresma completa, estou saindo da clínica de desintoxicação da blogosfera. Aparentemente, recuperado.

Desânimo com a blogosfera.

2009-02-25T14:00:00.000-03:00

A blogosfera que poderia ser local de troca de informação e debate tornou-se um local de embates ideológicos dos mais ridículos. Todo fato é imediatamente atribuído ao seu grupo se, positivo ou ao do adversários, se negativo.

Difícil conviver com um ambiente desses porque, acredito que blogue será rapidamente sinônimo de leviandade. Há uma legião de especialistas que entendem de aviação civil, obras do metro, política do Oriente Médio, situação da Itália nos anos 70, ataques neonazistas na Suíça.

Para mim, nada pior do que os comentários sobre sepse depois de um caso exageradamente divulgado que obrigaram até o Ministro da Saúde se manifestar.

Bem, para continuar na brincadeira, vou parar para assistir a apuração de uma crônica decadência: as das Escolas de Samba do Rio de Janeiro. Que como todos sabem, tal como a USP, o futebol brasileiro e os Estados Unidos, o Carnaval do Rio se desviou dos seus objetivos e se encontra decadente.

Vive la décadence!

Epigenética: Lamarck não merece a fama

2009-02-08T17:16:00.000-02:00

Marcelo Coelho na Folha de S.Paulo ressalta que Lamarck não merece a fama que lhe é atribuída em aulas no segundo grau. Com certeza. Anexo, uma revisão atualíssima sobre o tema epigenética: Epigenetics and human disease: translating basic biology into clinical applications.

Rodenhiser D, Mann M.
EpiGenWestern Research Group, Children's Health Research Institute, London, Ont. drodenhi@uwo.ca
Epigenetics refers to the study of heritable changes in gene expression that occur without a change in DNA sequence. Research has shown that epigenetic mechanisms provide an "extra" layer of transcriptional control that regulates how genes are expressed. These mechanisms are critical components in the normal development and growth of cells. Epigenetic abnormalities have been found to be causative factors in cancer, genetic disorders and pediatric syndromes as well as contributing factors in autoimmune diseases and aging. In this review, we examine the basic principles of epigenetic mechanisms and their contribution to human health as well as the clinical consequences of epigenetic errors. In addition, we address the use of epigenetic pathways in new approaches to diagnosis and targeted treatments across the clinical spectrum.

HU USP: pesquisa e inovação em cicatrização

2009-01-30T21:46:00.000-02:00

O Jornal Nacional divulgou a pesquisa do médico Fábio Kamamoto do Hospital Universitário da USP sobre cicatrização. Clique aqui para ver a matéria apresentada por Graziela Azevedo.

Meus cumprimentos a ele, ao seu mentor professor Marcus Castro Ferreira, ao professor da Escola Politécnica, José Carlos de Moraes e a toda equipe de enfermagem do HU.

Mais um exemplo para os especialistas em "decadência da USP" e "falência da saúde pública".

USP desenvolve tratamento barato de cicatrização
Pesquisadores brasileiros desenvolveram um tratamento de custo baixíssimo que pode ajudar milhões de pacientes com dificuldades de cicatrização. Vamos ver na reportagem de Graziela Azevedo. Da escova usada para lavar as mãos é aproveitada a esponja esterilizada. As mangueiras plásticas e a rede de vácuo são as mesmas sobre os leitos de qualquer hospital. Foi com materiais simples que um médico desenvolveu um curativo capaz de mudar a vida dos pacientes. O eletricista Carlos Alberto Oliveira correu o risco de perder a perna depois de um acidente de moto, o corte profundo e infeccionado não cicatrizava. O quadro mudou em sete dias com o uso do novo curativo. “Foi um alívio com certeza, porque eu podia perder minha perna. Graças a esse curativo, eu estou com ela firme e forte para outra”. O médico demonstra como o curativo funciona: feridas provocadas por acidentes, queimaduras ou diabetes são cobertas pelas esponjas e envolvidas com plástico adesivo, um tubo ligado à rede de vácuo faz uma sucção constante. Essa drenagem impede infecções e promove a multiplicação de vasos e a regeneração do tecido. A novidade ajudou o contador João Pinter Neto a se livrar do corte que não fechava depois de uma cirurgia complicada. “Depois de três dias que foi instalado esse sistema, você já percebe a diferença, porque o corte vai se fechando” O curativo a vácuo desenvolvido no hospital da Universidade de São Paulo tem o mesmo resultado do similar importado, usado em hospitais particulares. O que muda, e muito, é o preço, o que faz toda a diferença na hora de tratar quem não pode pagar. De R$ 3 mil a R$ 4 mil por semana, o preço dos curativos cai para cerca de R$ 30. O sistema, aperfeiçoado com ajuda de engenheiros da escola politécnica, foi patenteado e já pode ser usado por qualquer um que precisar. “A idéia é divulgar conhecimento, difundir um tratamento que vai ser mais eficiente, que vai ter um custo mais acessível para todas as pessoas do país inteiro”, declarou o médico Fábio Kamamoto.

Sepse: como a "Agenda Caras" poderá suplantar a "Agenda Científica"

2009-01-30T08:45:00.000-02:00

Quando o jogador de futebol Serginho do São Caetano morreu em campo em 2004, na manhã seguinte o lobby dos vendedores desfibriladores para reverter arritmias cardíacas tomou de assalto a imprensa na tentativa de mostrar que uma vida seria salva com esse equipamento. Leis locais foram promulgadas obrigando a compra do equipamento em próprios municipais.

Agora há uma enorme chance de chegar a Brasília, uma proposta fantástica que seria a do SUS disponibilizar vários medicamentos para sepse. Alguns, poderão ter um futuro como a alfadrotrecogina. Mas, a revisão abaixo transcrita mostra a necessidade de novos estudos. O custo de adotar esse medicamento seria de quase um bilhão de reais por ano a mais para o SUS em edição Boletim Brasileiro de Avaliação em Tecnologia de Saúde: alfadrotrecogina para o tratamento da sepse grave.

Nota importante: a unidade de terapia do Hospital Universitário da USP faz parte de estudo multicêntrico testando a alfadrotrecogina patrocinado pela Ely Lilli.

Human recombinant activated protein C for severe sepsis.
Marti-Carvajal A; Salanti G; Cardona A
Human recombinant activated protein C for severe sepsis.
Martí-Carvajal A, Salanti G, Cardona AF.
Universidad de Carabobo, Departamento de Salud Pública, Centro Colaborador Venezolano de la Red Cochrane Iberoamericana, Valencia, Edo. Carabobo, Venezuela, 2001. amarti@uc.edu.ve
BACKGROUND: Sepsis is a common, expensive and frequently fatal condition. There is an urgent need for developing new therapies to further reduce severe sepsis-induced mortality. One of those approaches is the use of human recombinant activated protein C (APC). OBJECTIVES: We assessed the clinical effectiveness of APC for the treatment of patients with severe sepsis or septic shock. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 2); MEDLINE (1966 to 2005); EMBASE (1980 to 2005) and LILACS (1982 to 2005). We contacted researchers and organizations working in the field. We did not have any language restriction. SELECTION CRITERIA: We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates. DATA COLLECTION AND ANALYSIS: We independently performed study selection, quality assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using I-squared (I(2)). We used a random-effects model. MAIN RESULTS: We included four studies involving 4911 participants (4434 adults and 477 paediatric patients). For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.92, 95% confidence interval (CI) 0.72 to 1.18; P = 0.50, I(2) = 72%). The effectiveness of APC did not seem to be associated with the degree of severity of sepsis (two studies): for an APACHE II score less than 25 the RR was 1.04 (95% CI 0.89 to 1.21; P = 0.70), and in participants with an APACHE II score of 25 or more the RR was 0.90 (95% CI 0.54 to 1.49; P = 0.68). APC use was, however, associated with a higher risk of bleeding (RR 1.48 (95% CI 1.07 to 2.06; P = 0.02, I(2) = 8%). Two studies were stopped early because there was little chance of reaching the efficacy endpoint by completion of the trial. AUTHORS' CONCLUSIONS: This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC seems to be associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.

Um pouco de informação sobre sepse: epidemiologia

2009-01-30T08:32:00.000-02:00

Para ajudar encerrar a onda de bobagem deflagrada com a "superbactéria" , que resultou na "saúde pública em versão Caras" e continuou na "infecção midiática" apresento o resumo da epidemiologia da sepse nos Estados Unidos. Notem o tamanho do problema e, principalmente do ponto de vista de custo-efetividade.

Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Angus DC; Linde-Zwirble WT; Lidicker J; Clermont G; Carcillo J; Pinsky MR Crit Care Med 2001 Jul;29(7):1303-10.
OBJECTIVE: To determine the incidence, cost, and outcome of severe sepsis in the United States. DESIGN: Observational cohort study. SETTING: All nonfederal hospitals (n = 847) in seven U.S. states. PATIENTS: All patients (n = 192,980) meeting criteria for severe sepsis based on the International Classification of Diseases, Ninth Revision, Clinical Modification. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We linked all 1995 state hospital discharge records (n = 6,621,559) from seven large states with population and hospital data from the U.S. Census, the Centers for Disease Control, the Health Care Financing Administration, and the American Hospital Association. We defined severe sepsis as documented infection and acute organ dysfunction using criteria based on the International Classification of Diseases, Ninth Revision, Clinical Modification. We validated these criteria against prospective clinical and physiologic criteria in a subset of five hospitals. We generated national age- and gender-adjusted estimates of incidence, cost, and outcome. We identified 192,980 cases, yielding national estimates of 751,000 cases (3.0 cases per 1,000 population and 2.26 cases per 100 hospital discharges), of whom 383,000 (51.1%) received intensive care and an additional 130,000 (17.3%) were ventilated in an intermediate care unit or cared for in a coronary care unit. Incidence increased >100-fold with age (0.2/1,000 in children to 26.2/1,000 in those >85 yrs old). Mortality was 28.6%, or 215,000 deaths nationally, and also increased with age, from 10% in children to 38.4% in those >85 yrs old. Women had lower age-specific incidence and mortality, but the difference in mortality was explained by differences in underlying disease and the site of infection. The average costs per case were $22,100, with annual total costs of $16.7 billion nationally. Costs were higher in infants, nonsurvivors, intensive care unit patients, surgical patients, and patients with more organ failure. The incidence was projected to increase by 1.5% per annum. CONCLUSIONS: Severe sepsis is a common, expensive, and frequently fatal condition, with as many deaths annually as those from acute myocardial infarction. It is especially common in the elderly and is likely to increase substantially as the U.S. population ages

Mais uma vez, a crise e decadência da Universidade de São Paulo

2009-01-29T23:31:00.000-02:00

Comentei há seis meses em A decadência continua ... que viva a decadência ! que em 1975 era dado como líquido e certo que os Estados Unidos, o futebol brasileiro, o carnaval carioca e a Universidade de São Paulo já tinham tido seu esplendor. Novamente, a USP comprova a sua decadência.

Pesquisa coloca USP como a 87ª melhor universidade do mundo
Leornado Feder.
A USP foi classificada como a 87ª melhor universidade do mundo pela pesquisa "Webometrics Ranking of World Universities", que é feita por um grupo do CSIC (Conselho Superior de Investigações Científicas), ligado ao Ministério da Educação espanhol.
O instituto monta esse ranking a partir da análise das publicações eletrônicas nos sites das universidades, pois, em sua avaliação, eles refletem sua excelência e seu prestígio acadêmico. O objetivo do levantamento é estimular as universidades que não tem o costume de colocar os conhecimentos produzidos na internet a fazer isso.
A pesquisa considera mais de 16 mil instituições de ensino superior pelo mundo e divulga seus resultados duas vezes por ano, em julho e em janeiro. Clique aqui para conferir o ranking.
As 20 primeiras universidades da classificação do CSIC são norte-americanas --a primeira é o Massachusetts Institute of Technology (Instituto de Tecnologia de Massachusetts).
Das universidades brasileiras citadas, a Unicamp (Universidade Estadual de Campinas) obteve o 159º lugar, a UFRGS (Universidade Federal do Rio Grande do Sul), o 285º, e a UFRJ (Universidade Federal do Rio de Janeiro), o 299º.
Critérios
Para calcular a pontuação da universidade, o instituto faz a média ponderada de quatro critérios baseados no conteúdo dos sites das universidades. A quantidade do material é calculada com instrumentos de busca, Google, Yahoo, Live Search e Exalead.
O critério mais valioso é a visibilidade (50%), medida pelo número de links externos exclusivos recebidos pelo site da universidade.
O segundo de maior peso é o tamanho (20%), medido pelo número de páginas do site da universidade, que indica seu grau da internacionalização.
Outro critério é o número de arquivos (15%) contidos no site da universidade que tenham, na avaliação do instituto, relevância acadêmica e estejam salvos em formato Adobe Acrobat (.pdf), Adobe PostScript (.ps), Microsoft Word (.doc) ou Microsoft Powerpoint (.ppt).
Por último, com peso de 15%, também é considerado o número de documentos, artigos e citações de cada área acadêmica.

Infecção midiática

2009-01-29T23:05:00.000-02:00

Hoje, os jornais falam de mais um caso, a de uma nutricionista (qual a importância da profissão???) que se encontra em sepse e teve extremidades amputadas. Com todo o respeito aos doentes e familiares, pergunto: qual a novidade? Na primeira aula que tive sobre o tema (1977) o professor já apresentou os slides de casos semelhantes e, a explicação fisiopatológica. No decorrer da vida profissional observei vários casos de sepse com essa complicação. Mas, repito, porque tanto interesse?

1. falta de notícia no verão, tal como aconteceu com a "epidemia" de febre amarela em 2008;

2. vontade incontida de médicos comentarem caso clínico que desconhecem (e, pior mostrarem ignorância sobre o tema);

3. interesse da Big Pharma, em conseguir que o SUS financie um blockbuster para sepse que até o momento não se comprovou custo-efetivo;.

4.oportunidade de decretar mais uma vez a 'falência da saúde pública", afinal o hospital que a atendeu era estadual;

5. momento de afirmar que mais uma vez houve "erro médico", que a "máfia de branco" etc etc

Aguardo, com ansiedade as novidades no campo médico, como por exemplo: o câncer se espalha à distância ou derrame cerebral pode levar ao coma ou......

SUS, Olinda e Ouro Preto

2009-01-28T11:53:00.000-02:00

O Fórum Social Mundial da Saúde lançou uma palavra de ordem: SUS, Patrimônio da Humanidade! E, considera que com isso melhorará a vida de todos. Cada um age da forma mais apropriada para alcançar seus objetivos. SUS, Olinda e Ouro Preto não combinam. Nesse blogue se publica com insistência todas as ações positivas da assim chamada "saúde pública" (nome que os detratores aplicam ao SUS) e, principalmente contra os propagadores da "falência da saúde pública". Tudo seria bonito e delicioso, se a vida real fosse um happening como esse, principalmente realizado em Belém do Pará.

Mas, a realidade é diferente. Parte considerável dos presentes nesse evento defendem interesses específicos: de corporações ou de portadores de doenças específicas. Poucos entendem o SUS como um dos maiores exercícios de cidadania vividos nesse país. Quase nenhum dos presentes aceita formas avançadas de gestão e de controle efetivo. Confundem o SUS com a administração direta do Estado.

Em tempo: ao contrário do afirmado na reportagem abaixo da Agência Brasil, a mortalidade infantil apresenta taxas declinantes bem antes de 1988 (Constituição) e 1990 (Lei Orgânica).

Ativistas defendem candidatura do SUS a patrimônio imaterial da humanidade
Amanda CieglinskiEnviada Especial
Belém - Os participantes do Fórum Social Mundial da Saúde (FSMS) vão lançar a candidatura do Sistema Único de Saúde (SUS) a patrimônio imaterial da humanidade. A idéia foi apresentada na manhã de hoje (26), durante ato político que contou com a participação do ministro da Saúde, José Gomes Temporão.
Ele afirmou que vai garantir apoio político para a idéia, que classificou como inovadora. Segundo ele, essa é a primeira vez que uma política pública será patrimônio da humanidade. “É uma iniciativa dos movimentos populares e acho importante pela abrangência do SUS e pelo fato de que ele atende indistintamente todas as etinas, todas as nacionalidades que vivem no Brasil”, afirmou Temporão.
O FSMS discute desde ontem a implantação de sistemas universais de sáude em todo o mundo. Temporão ressaltou que o Brasil é um exemplo, já que poucos países adotam o sistema de atendimento universal. Ente eles, Inglaterra, Portugal e Canadá.
“Esse modelo ganha cada vez mais importância em um momento de crise econômica como o atual, porque ela vai causar um aumento do desemprego e as pessoas serão atendidas no sistema público. Eu, que sou militante da causa, apóio que o mundo inteiro seja atendido por sistemas universais”, defendeu o ministro.
Temporão afirmou que o SUS ainda tem suas “fragilidades”. “Um exemplo é o subfinanciamento crônico que impede que esse processo de extensão da cobertura se dê com mais qualidade. Outra questão é a gestão: há o desafio permanente de como usar com mais eficiência o recurso.”
Outra novidade apresentada na manhã de hoje durante o Fórum foi o lançamento da I Conferência Mundial dos Sistemas Universais da Saúde, que será realizada no Brasil. Embora a data ainda não tenha sido definida, a previsão é que ocorra entre 2009 e 2010.
A queda na mortalidade infantil, o programa de combate à Aids e o Saúde na Família foram citados pelo ministro como exemplo do saldo positivo do SUS durante seus 20 anos de existência.

Estamos mal, muito mal

2009-01-27T07:12:00.000-02:00

Quando o Ministro da Saúde é instado a responder sobre o caso clínico de uma modelo e, responde é porque estamos mal. Sim, a sociedade brasileira está sem foco. Não sabe o que é prioridade. As verbas de pesquisa foram cortadas em mais um bilhão de reais. Há em cada hospital público no mínimo 15 pessoas com indicação de internação, mas sem vaga. O dengue vem aí, novamente. Mas, o importante é a modelo capixaba. As celebridades dão o tom do país, até mortas. Chegamos à medicina e saúde pública padrão "Caras".

Caso de modelo capixaba foi "extremo", afirma Temporão
DA AGÊNCIA FOLHA, EM BELÉM
O ministro da Saúde, José Gomes Temporão, classificou ontem de "extremo" o caso da modelo capixaba Mariana Bridi, 20, que morreu na madrugada de sábado em Serra (ES) em decorrência de uma infecção urinária que evoluiu para sepse grave (infecção generalizada)."É um caso extremo. Raro, raríssimo", disse. "Eu não entrei em detalhes da análise do caso. Mas, conversando com alguns colegas, especialistas, [eles] ficaram surpresos com a evolução", afirmou o ministro, depois de participar da terceira edição do Fórum Mundial da Saúde, em Belém (PA).O encontro é um dos eventos ligados ao Fórum Social Mundial, que começa hoje na capital do Pará.Para Temporão, a investigação do caso deve ser feita "no âmbito da Secretaria da Saúde" do Espírito Santo.A doença de Mariana evoluiu a partir de uma infecção urinária causada pela bactéria Pseudomonas aeruginosa.Ela ficou cerca de 20 dias internada no hospital estadual Dório Silva. Sua situação se complicou depois que as bactérias atingiram a corrente sanguínea e ela sofreu necrose nos pés e nas mãos, que foram amputados.Partes dos rins e do estômago da modelo também foram retiradas. Por fim, o quadro evoluiu para uma infecção generalizada.Mariana Bridi ficou em quarto lugar no Miss Mundo Brasil, em 2007.(JOÃO CARLOS MAGALHÃES)

Um sábado de sol no presídio do Barro Branco em 1978/79

2009-01-25T21:35:00.000-02:00

Nos ano de 1978/79, acadêmico de medicina na USP, militante do movimento estudantil, atuava em várias ações do Comitê Brasileiro de Anistia. Uma atividade era visitar os presos políticos no presídio do Barro Branco, zona norte de São Paulo, aos sábados. Lá conheci um preso que foi libertado em 1979 com a Anistia e, continua militando até agora no PT. Em 1966, ele foi falsamente acusado de lançar uma bomba em um aeroporto (nem a então "justiça militar" aceitou a denúncia).

Conversamos um pouco sobre política (nenhuma convergência à época), movimento estudantil (ele não aceitava um congresso da UNE em Salvador, deveria ser em São Paulo) e, chegamos a um único ponto comum: ambos éramos "oriundi". Disse-me ele que o Cônsul da Itália o visitou na prisão logo após sua chegada. O representante consular mostrou que por direito, ele poderia requisitar a cidadania italiana. Esse fato redundaria em um pedido por parte do "governo da Bota" na sua transferência para a Itália. Seria um caso juridicamente confuso, mas que significaria uma reprovação ao governo brasileiro. Ele declinou a proposta porque a sua luta era aqui no Brasil.

Fica o relato, sem o nome, mas que é de fácil identificação para quem é do "meio".

Nosso protagonista poderá ou não confirmar o fato (entendo as conveniências políticas, principalmente as de dentro do PT), mas que aconteceu, aconteceu.

Naquele momento, o Brasile era uma ditadura, que deixou de ser, e a Itália era e continua sendo uma democracia. Apesar de vacilar no golpe da Argentina em 1976, a Itália até hoje persegue os torturadores de ítalo-argentinos da ditadura platina de 1976-83. (fonte: blogue do Nelson Franco Jobim)

O corte na Ciência & Tecnologia passou despercebido

2009-01-25T21:20:00.000-02:00

A Folha de S.Paulo nessa semana foi o único órgão de imprensa a noticiar o corte de mais de um bilhão de reais no orçamento de ciência e tecnologia. Hoje, na própria Folha, um artigo dos presidentes da Sociedade Brasileira para o Progesso da Ciência (Raupp) e da Sociedade Brasileira de Física (Chaves).

Congresso penaliza ciência e tecnologia por Marco Antônio Raupp e Alaor Chaves.
Se o Brasil quer manter as esperanças de se tornar mais inovador e competitivo, é imperativo que se reveja o orçamento para C&T. Ao formular Orçamento da União para o ano de 2009, o Congresso Nacional penalizou com especial severidade a área de ciência e tecnologia (C&T). O orçamento do ministério da área (MCT) sofreu corte de R$ 1,12 bilhão, equivalente a 52% do proposto pelo Executivo. A Capes, órgão do Ministério da Educação que cuida da avaliação e do fomento de nossos cursos de pós-graduação -responsável pela maior parte das bolsas desse nível no país-, sofreu cortes próximos de R$ 1 bilhão, quase metade do previsto.

(assinante da Folha ou do UOL, leia aqui).

No entanto, o mais importante foi o excelente comentário do ombudsman que pegou o gancho do discurso de Barack Obama sobre a importância da ciência para uma sociedade.

Como o ombusdman é pago para avaliar a Folha, sua crítica foi dirigida ao jornal, mas pode ser estendida a todos nós: acadêmicos, sociedades de cientistas, intelectuais e imprensa que se preocupam mais com fofocas do Congresso (e, da política) do que com fatos que interferem no trabalho de todos nós com impacto para toda a sociedade.

Depois do mal feito... (Carlos Eduardo Lins da Silva) De setembro a dezembro, ela realizou diversas sessões. Só depois que a decisão foi tomada o assunto apareceu aqui. Quando a divulgação da ameaça de corte poderia ter alertado entidades e indivíduos para se mobilizarem a fim de impedi-lo, nada ou quase nada se publicou a respeito.É mais um exemplo de como é ineficaz e burocrática a maneira como o jornal cuida dos assuntos do Congresso Nacional. Não faltam espaço e repórteres para ouvir conversa fiada e reproduzir declarações cínicas que só interessam aos que as fazem.O diz-que-diz inconsequente, as pequenas fofocas, os balões de ensaio de deputados e senadores em busca de cargos e poder, para estes há sempre lugar nestas páginas.Mas colocar alguém para acompanhar sistematicamente o trabalho das comissões, na de Orçamento, por exemplo, e verificar se absurdos como esse corte estão sendo perpetrados contra o interesse público, isso o jornal não faz.

(assinante da Folha ou UOL, leia aqui)

2009-01-25T03:38:00.001-02:00

Já comentei o quanto odeio os urubus da imprensa, aqueles que não podem ver um cadáver para

E nos blogues os urubus passeiam a tarde inteira. Entre os girassóis.

2009-01-25T03:38:00.000-02:00

Já comentei o quanto odeio os urubus da imprensa, aqueles que não podem ver um cadáver para voar em cima. Falei também daqueles que entendem de tudo e, falam de transponder, grua, grooving com facilidade imensa. Para quem não lembra são referências ao acidente do avião da Gol, do buraco do metro em Pinheiros, São Paulo e do acidente do avião da TAM, respectivamente.

Agora, um caso triste e complicado, ocasionou a morte de uma modelo no Espírito Santo. Esse episódio ganhou manchetes e, pasmem uma lista de comentários em blogues. Em um blogue havia 53 palpites sobre o tema. Inventaram uma tal de "superbactéria", que talvez seja uma "agente sionista ou imperialista". Depois dessa superbactéria "neoliberal" seguia uma enormidade de desinformação.

Por justiça, havia dois correspondentes sensatos conclamando a não se politizar um fato médico.

Continuando com Caetano Veloso em Tropicália

No pulso esquerdo bang-bang

Em suas veias corre muito pouco sangue

Mas seu coração balança a um samba de tamborim

Emite acordes dissonantes

Feminicídio a toda!

2009-01-23T18:42:00.000-02:00

Hoje, marido matou a mulher em Guarulhos. Há dez dias, o ex-namorado assassinou mulher na Lapa. Há quase dois anos tentei seguir o feminicídio no post Quem Ama, Não Mata, mas não consegui. Com grande chance, os casos de São Paulo têm repercussão, os demais se perdem na imprensa regional. Não há mais tempo para estudos acadêmicos, caso de Segurança Pública e Ministério da Justiça.

Apoio ao Guantanamo Tropical Medicine Institute

2009-01-22T19:37:00.000-02:00

Todo blogueiro é um galo que considera a alvorada, mero produto de seu cantar. Não fujo a regra. Saúdo o Presidente Obama pelo fim da prisão instalada na base militar de Guantanamo, tal como "indiquei" a ele em Demitir Jack Bauer, acabar com a tortura. Agora, aproveito para lembrar a proposta do professor Peter Hotez, da Universidade George Washington, a que foi imediatamente apoiada por esse blogue: a de instalar o Guantanamo Tropical Medicine Institute.

Plano de Saúde dos Servidores: Assino embaixo !

2009-01-15T11:12:00.000-02:00

"Jamais me conformei com o fato de o governo, instituidor e responsável pelo SUS, pagar planos de saúde para seus funcionários. O pior é que os R$ 48 milhões da Câmara significam 1,2% do que o governo federal gasta com planos de seus funcionários e em mais sete estatais. Quando reitor da Unicamp, e no Hospital Pérola Byington (SP), nos anos 80 e 90, oferecemos o serviço SUS aos funcionários. E deu certo. Além deles, milhares de cidadãos desistiram de seus planos de saúde e foram gratuitamente bem atendidos nesses hospitais. O que acontece na Câmara é apenas uma amostra lamentável dessa política de privatização acrítica e da dicotomia da saúde brasileira: saúde pobre para os pobres e no mercado para quem puder pagar ou tenha padrinho. A maior propaganda dos planos de saúde quem faz é o governo, oferecendo um SUS precário e ainda os financiando."JOSÉ ARISTODEMO PINOTTI , deputado federal -DEM-SP (Brasília, DF)

Folha de S.Paulo, 14/01/09

"Seria engraçado se os funcionários das empresas particulares de planos de saúde tivessem cobertura de outras empresas, e não de seus empregadores. Ainda mais se o custo maior recaísse sobre o patrão. Servidores públicos, não importa de que poder, jamais poderiam estar cobertos, com custeio do governo, por outra entidade que não fosse o SUS -Sistema Único de Saúde. No governo petista, então, existem motivos até ideológicos para isso. Mas nunca se viu um jornalista do PT escrever algo a respeito." PAULO SERODIO (São Paulo, SP)

Folha de S.Paulo, 15/01/09.

Crianças do Zimbabwe também morrem estupidamente.

2009-01-13T10:56:00.000-02:00

Zimbabwe cholera deaths near 2,000 - WHO
HARARE (Reuters) - Zimbabwe's cholera epidemic has killed 1,937 people and a total of 38,334 have contracted the normally preventable disease, the World Health Organisation said on Tuesday.
A cholera update dated Jan. 11 showed an increase of 25 deaths and 541 cases compared to an increase of 12 deaths and 300 cases the previous day.
The epidemic is adding to the humanitarian crisis in the country, where President Robert Mugabe and the opposition are deadlocked over a power-sharing deal and the veteran leader is resisting Western calls to step down.n
The waterborne disease, which causes severe diarrhoea and dehydration, has spread to all of Zimbabwe's 10 provinces because of the collapse of health and sanitation systems. The WHO said 89 percent of the country's 62 districts are affected.
Zimbabwe's government has warned that the epidemic could get worse as the rainy season develops.
The rainy season peaks in January or February and ends in late March. Floods, which can affect Zimbabwe's low-lying areas, may increase the spread of the disease.
Cholera has spread to Zimbabwe's neighbours with at least 13 deaths and 1,419 cases in South Africa. Botswana, Mozambique and Zambia have also reported cholera cases.

Agora, José de Souza Martins

2009-01-12T10:44:00.000-02:00

Pouco afeto à ação militante, o professor de sociologia da USP, José de Souza Martins nos brinda com textos complexos toda semana no Estadão (cujo acesso é difícil e, ontem estava com versão eletrônica do caderno Aliás, desatualizada).

Ele comentou a baderna no Ano Novo na Praia Grande e São Vicente, protagonizada por jovens de classe média, sem qualquer motivo aparente. Classificou de niilismo antissocial e, associou a outros fatos como a depredação de escola na zona leste de São Paulo.

Evidentemente, Martins não atende ao interesse da grande platéia da blogosfera.

Quem conseguir o texto na versão eletrônica, por favor, informe o link.

A lição de José de Souza Martins

2009-01-12T09:58:00.000-02:00

Nunca recebi tantas correspondências sobre um tema que não é o motivo desse blogue: a milenar questão do Oriente Médio e seus povos. Não sou imune à situação -sempre ruim - das populações civis em guerras e, em períodos de terror franco, como aquelas onde por razão política irlandeses explodiam pubs ingleses e bascos destruiam lojas espanholas. Para ficar em exemplos fora do eixo Israel-Palestina.

O que me incomoda é que há articulistas de sobra para criticar Israel e, faltam críticos do governo da Líbia quando ela aprisionou médico - pasmem, palestino! - e, enfermeiras búlgaras por motivo falso. Somente esse blogue repercutiu as notícias. Foram oito posts. (clique aqui) Por que ninguém falou da Líbia? Por que a Líbia na "geopolítica dos comentaristas brasileiros" é de "esquerda", antiamericana. Por isso, do "nosso" lado.

Na área da saúde deu-se destaque maior à situação do sistema de saúde americano (que esse blogue, não considera nem que seja "sistema") do que à barbárie perpetrada na África do Sul na política de aids. (clique aqui) Por que não se fala da África do Sul? Porque fica "mal falar da política do Congresso Nacional Africano", que derrotou o apartheid.

Governos se movem pela Realpolitik, mas acadêmicos servem para mostrar o diferente, o pouco percebido, no caso a quantidade grande de manifestações antissemitas em blogues brasileiros.

Não falei nada de José de Souza Martins, motivo do título.

Seguirá no próximo.

A situação das Universidades Federais

2009-01-11T20:29:00.000-02:00

A Folha de S.Paulo publicou reportagem mostrando o novo acordão do Tribunal de Contas da União cujo resultado será somente um: paralisar as pesquisas nas universidades federais. Na página de opinião, o Reitor da Universidade Federal da Bahia, Naomar de Almeida Filho apresenta de forma lúcida, a situação atual das universidades federais e demais organismos que não podem levar adiante sua missão pelas mordaças impostas por órgãos reguladores.

".......No plano administrativo, as universidades federais encontram-se travadas por aparato normativo que compromete tanto a missão acadêmica de formar com qualidade quanto o dever de buscar eficiência e economicidade como instituição pública.Rápidos exemplos triviais. Para atividades de ensino e pesquisa, precisamos de bens de melhor qualidade e serviços mais criativos, pertinentes e competentes, quase nunca baratos.Porém, segundo a lei de licitações, somos obrigados a contratar pelo menor preço.Na UFBA (Universidade Federal da Bahia), seis meses de conta de água bastariam para substituir todo o obsoleto sistema hidráulico dos campi, reduzindo o consumo em até 40%.Não obstante, é proibido mudar rubricas de custeio porque o Orçamento da União é prefixado.Em qualquer caso, inútil economizar, porque todo o montante poupado tem de ser, ao final do exercício, recolhido ao Tesouro Nacional.Diligentemente, órgãos de controle externo nos têm auditado. O TCU (Tribunal de Contas da União), aplicando a lei, tem punido dirigentes universitários por irregularidades supostas em procedimentos que, o mais das vezes, visam a viabilizar a gestão universitária.No plano acadêmico, a universidade se engana, e aparentemente gosta, ao pretender-se autônoma. De fato, longe estamos da mítica autonomia universitária.Submetidos à crescente judicialização da sociedade, concursos docentes, processos seletivos, transferências e matrículas obedecem a leis e regras mais cartoriais que acadêmicas. Projetos pedagógicos seguem, na minúcia, diretrizes curriculares estabelecidas por órgãos externos de regulação, influenciados por interesses corporativos e mercadológicos.Linhas de pesquisa contemplam prioridades definidas por agências de fomento; programas de extensão respondem a demandas ou determinações de organismos governamentais, não-governamentais e empresariais.A autonomia universitária nos é garantida pelo artigo 207 da Constituição Federal. Então, por que não recebemos orçamento global, definido por metas e planos?

(assinante da Folha, clique aqui).

2009-01-11T00:04:00.000-02:00

Vários articulistas sensatos alertam para o "socialismo dos tolos", o antissemitismo. Expressão de August Bebel, embora muito a citam como sendo de Karl Marx. Eu, tracei um paralelo com a frase de Bebel e, um artigo publicado por economistas do BNDES, onde insuflavam um "antipaulistismo", que considerei também com um novo "socialismo dos tolos". (ver O socialismo tolo de economistas do BNDES).

Já discuti aqui que há décadas, ouço falar na decadência do futebol brasileiro, do carnaval carioca e da USP. Bem, continuam liderando qualquer indicador que seja criado para medir futebol, carnaval e universidade brasileira.

Um professor argentino sempre me cumprimenta quando o Brasil ganha com o time B, mais uma Copa América. Um amigo meu, fanático salgueirense, reconhece a competência da Beija-Flor e, não desmerece nem a xinga,como fazem outros torcedores fanáticos.

O anti-semitismo acabou, agora é o antissemitismo.

2009-01-10T23:45:00.000-02:00

Felizmente, o número de educados foi razoável, o suficiente, para permitir que pudessem ser publicados comentários sobre o anti-semitismo, ou melhor o antissemitismo.
Mas, qual o fato discutido? A invasão de Gaza pelo Estado de Israel? A crítica ao ato do Estado de Israel? Não, eu somente alertei que o número de comentários em blogues de jornalistas que se consideram “progressistas”, com conteúdo antissemita era grande na quarta-feira, dia 07 de janeiro. Hoje, 10 de janeiro, abri um blogue famoso e, vi várias barbaridades nos comentários, das quais selecionei a abaixo que segue em negrito, itálico, vermelho e letra menor para que não essa pérola seja confundida com idéia desse blogueiro.

Antonio Lima em 8/janeiro/2009 as 13:17
Talmud Babilônico só o Taalmud, o maior responsável por ISRAEL agir assim, prá se ter uma idéia, diz esse livro das leis júdaico, todo JUDEU É SER HUMANO, todo NÃO JUDEU (GOIN OU GENTÍO) como chamam aos demais povos são animais, nenhum JUDEU pode entrar em casa de GOIN, comer alimentos oferecidos por GOIN, casar-se com alguém GOIN, e em outro capítulo diz esse livro satânico: TODO JUDEU TEM A OBRIGAÇÃO DE MATAR, EXTERMINAR, LIQUIDAR todos os GOINS, ´e baseado nisso os JUDEUS AGIRAM ASSIM NA ALEMANHA DE 1940, E AINDA ESTÃO A AGIR COM OS DEMAIS POVOS, PENSAM ELE QUE SÃO MELHORES QUE OS OUTROS, E SEMPRE SE LEVANTAM CONTRA ALGUÉM, E AGORA SÃO OS PALESTINOS SUAS VITÍMAS, IAM SER OS ALEMÃES E POLONESES, MAS ALGUÉM SE LEVANTOU ANTES.

Que tal? Preciso dar mais exemplos?

Um recado aos jornalistas e blogueiros que permitem e insuflam o anti-semitismo

2009-01-07T21:50:00.000-02:00

Do blogue do professor português Jorge Martins, autor de Portugal e os Judeus sobre pesquisa publicada no AJHG.

A GENÉTICA CONFIRMOU: UM TERÇO DOS PORTUGUESES TEM ASCENDÊNCIA JUDAICA
O American Journal of Human Genetics publicou ontem, dia 4 de Dezembro, véspera do 512º aniversário do Decreto de Expulsão dos Judeus de Portugal (5/12/1496), o estudo “The Genetic Legacy of Religious Diversity and Intolerance: Paternal Lineages of Christians, Jews, and Muslims in the Iberian Peninsula”. As conclusões a que os cientistas chegaram vêm confirmar o que os especialistas em estudos judaicos portugueses têm vindo a sustentar: a população portuguesa tem uma forte componente judaica. Os valores genéticos sefarditas apresentados pelo estudo científico demonstram a incontestável etnicidade judaica na matriz identitária portuguesa. Preservámos a etnicidade judaica (30%) e muçulmana (14%), apesar de quase três séculos de acção criminosa e terrorista da Inquisição.O referido estudo dividiu o país em Norte e Sul, concluindo que 23,6% da população nortenha e 36,3% da população sulista tem ascendência judaica, ou seja, cerca de 30% dos portugueses preservaram as suas raízes sefarditas. Ao contrário de alguma imprensa escreveu (Público, 6/12/2008), não são valores inesperados. E valeria a pena conhecer os valores das Beiras e Trás-os-Montes, particularmente de Belmonte. Seguramente, pela história revelada há um século da existência de um fortíssimo fenómeno criptojudaico nessas regiões, ainda haveria valores mais significativos.

Anti Semitismo toma conta da blogosfera brasileira

2009-01-07T21:25:00.000-02:00

Retorno para um novo ano. O blogue terá temática mais restrita a assuntos internacionais.

Mas, antes disso há necessidade em reconhecer a profusão de comentários publicados em vários blogues nacionais cujo conteúdo se resume a anti-semitismo puro, sem tirar nem por.

Com a palavra, Paulo de Tarso Vanucchi, secretário nacional de direitos humanos.

Psoríase e Doença Coronariana

2009-01-06T10:11:00.001-02:00

Psoriasis and CAD: New call to recognize link January 5, 2009 Lisa Nainggolan
Notre Dame, IN - A new report is reiterating the increased risk of coronary artery disease (CAD) observed in patients with the inflammatory skin disease psoriasis—particularly those with severe forms—and stressing that patients must be informed of this link and have their cardiovascular risk factors regularly assessed [1]. Dr Vincent E Friedewald (University of Notre Dame, IN) and colleagues—an expert panel of cardiologists, dermatologists, and scientists—have penned an editor's consensus on the subject in the December 15, 2008 issue of the American Journal of Cardiology (AJC).
"This is a particularly interesting and unique document in that it bridges current knowledge from two medical disciplines—dermatology and cardiology—that rarely interrelate. Very, very few cardiologists are aware of the relationship between psoriasis and CAD and certainly very few dermatologists are, either," Friedewald told heartwire. "The most important thing of a practical nature," he says, "is that every patient who has psoriasis, and definitely every person who has severe psoriasis, ought to have their cardiovascular risk factors looked at and treated."
Every patient who has psoriasis . . . ought to have their cardiovascular risk factors looked at and treated.
But part of the problem from the patient's perspective, he says, is: "If you have psoriasis, particularly moderate or severe, you already have a terrible disease that you are coping with, and you are not thinking about your blood pressure or cholesterol, but it needs to be assessed, because [these things] are a big killer. These people need to be treated more aggressively than they are being treated today," he stresses. A paradigm shift
Friedewald, who is an assistant editor at the American Journal of Cardiology, explained that the catalyst for this new report was a case-control study performed using the UK's General Practice Research Database, by Dr Joel M Gelfand (University of Pennsylvania, Philadelphia) and colleagues [2], published in the Journal of the American Medical Association two years ago—as reported by heartwire—that showed that patients with psoriasis have a significantly increased risk of MI independent of traditional CV risk factors.
"Not a lot of people have noticed [the Gelfand study], and the important thing—and what really is new and in a state of real evolution—is the role of inflammation in CAD. Psoriasis is one piece of the puzzle and may hold the key to unlocking a lot of the mysteries about coronary disease," Friedewald remarks.
Psoriasis is one piece of the puzzle, and may hold the key to unlocking a lot of the mysteries about coronary disease.
He says it is becoming increasingly evident that inflammation plays a key role in heart disease, citing the fact that many people who have an MI—by today's standards—don't have elevated cholesterol. Add to this the recent JUPITER results, showing a marked effect of lowering high-sensitivity C-reactive protein (hs-CRP) on the incidence of coronary disease, even in those with low LDL cholesterol, and "we start to see a huge paradigm shift going on here," he says.
He believes that there is interplay between the chronic process of atherogenesis that goes on for years and years and the changing, dynamic risk of coronary events related to inflammation, which alters constantly—for example, risk is higher in the colder winter months.
"We have all of these inflammatory conditions—rheumatoid arthritis (there's no question there is a link between this and CAD), psoriasis, and periodontal disease, and we know that during periods of acute infection—particularly respiratory or renal infections—there is an increased risk for a coronary event, but very few doctors are aware of these relationships."
"This AJC editor's consensus focuses on a large new area of evidence strengthening the connection between inflammatory processes and CAD," he adds.A central repository of data is needed
One of the problems with trying to increase awareness of the link between psoriasis, other inflammatory conditions, and CAD is that "the data come from many sources that cardiologists don't normally read," says Friedewald. "And dermatologists don't normally read the cardiology literature, either. So one of the recommendations we made in this paper was that we need a resource center whereby information on inflammation from all of these different sources is in a central repository so people can access it and see what's going on."
We need a resource center whereby information on inflammation from all of these different sources is in a central repository.
As cardiologists, he adds, "we have a responsibility to educate our peers and others, to say, 'Look, these patients with psoriasis and other inflammatory diseases are at increased risk and need to be treated more aggressively.' "
But this is not happening, he says. "The challenge for dermatologists is that they say they don't have time—in the US, dermatologists generally allocate only five minutes each to a patient—but as a bare minimum they should have a brochure in their waiting room to inform patients that if they have psoriasis they may be at increased risk for coronary disease."
"Ideally, psoriasis patients should be referred to a family practitioner or primary-care doctor to have a proper cardiovascular risk evaluation performed, with a minimum assessment of hs-CRP, a lipid panel, and blood-pressure measurements," he says.
Dermatologist Gelfand, a coauthor on this new editor's consensus, agrees. "Based on the evolving science, we recommend that patients with moderate to severe psoriasis be educated about the association of psoriasis and cardiovascular disease and that these patients receive appropriate screening and treatment of modifiable cardiovascular risk factors," he says in an AJC statement.
"This [editors'] consensus statement . . . calls for a new standard of care for patients with moderate to severe psoriasis," he concludes.

Sources
Friedewald VE, Cather JC, Gelfand JM, et al. AJC editors' consensus: psoriasis and coronary artery disease. Am J Cardiol 2008; 102:1631-43.
Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA 2006; 296:1735-1741.

Vamos a la playa !

2008-12-24T15:01:00.000-02:00

Voltarei no ano que vem, se tiver condições físicas em ler e escrever todos os dias. No ano que se encerra foi particularmente difícil manter atualizada a temática desse blogue. Agradeço às três centenas de leitores fiéis, que sempre reclamam da ausência em vários períodos.

Em janeiro, na Rádio USP, se iniciará o programa Saúde Global, onde temas de interesse geral na área da saúde serão apresentados por mim e, depois serão disponibilizados no aqui.

Enquanto isso, "vamos a la playa"...

Brasilíadas: sugestões de leitura

2008-12-22T17:24:00.000-02:00

1. leitura rápida: Estudos Avançados da USP (edição 64, nov/dez de 2008) sobre Epidemias e, de quebra comentários sobre Machado e Rosa.

2. para quem gosta de polêmica: O povo de Luzia, em busca dos primeiros americanos, de Walter Neves e Luiz Piló, editora Globo.

3. para quem quer conhecer Pernambuco: Epidemiologia, políticas e determinantes das doenças crônicas no Brasil, de Eduardo Freese (coordenador), editora da UFPE.
4. para quem se chocou com Bye-bye Brasil de Cacá Dieguez: The Xavánte Transition, de Carlos Coimbra, Nancy Flowers, Francisco Salzano e Ricardo Santos.

Lusíadas: leituras de fim de ano

2008-12-22T17:07:00.000-02:00

1. leitura rápida:Revista de História da Biblioteca Nacional (dezembro de 2008): "Angola é aqui, nossa história africana".

2. para engenheiros e candidados a MBA: Sagres, a revolução estratégica, de Luiz Fernando da Silva Pinto, 11a edição, Editora SENAC.

3. para nutricionistas e gourmets: No tempo das especiariarias, de Fábio Pestana Ramos, Editora Contexto.

4. para quem se prepara para a FUVEST 2010: Por mares nunca dantes navegados, de Fábio Pestana Rmanos, Editora Contexto

5. para apreciadores de romance histórico: Equador, de Miguel Souza Tavares, editora Nova Fronteira, presente do amigo secreto.

6. da série não empresto a nínguém: Goa, história de um encontro, de Catarina Portas e Inês Gonçalves. editora Almedina.

Além da Big Pharma

2008-12-22T16:57:00.000-02:00

Sou da época do professor de biologia que fazia um círculo no quadro-negro com o nome SOL e, afirmava que sem essa essa estrela de quinta grandeza não haveria vida no planeta Terra.

Recentemente, dermatologistas e, hoje oftalmologistas (Folha de S.Paulo) passaram a considerar os raios emitidos pelo Astro-Rei como perigososos aos seres humanos. Obviamente, a Sundown continua agradecendo à possibilidade de aumentar a sobrevida dos humanóides e, agora a RayBan se sente regojizada em poder proteger os incautos Homo sapiens.

Novamente, recomendo que seja traduzido "Skin, a natural history" de Nina G. Jablonski. A revista Science comentou "Jablonski show us that skin, be it thick or thin, is the true mirror of soul".

Começando o centenário da descrição da Doença de Chagas

2008-12-18T15:16:00.000-02:00

Prognostic impact of Chagas disease in the United States

American Heart Journal Volume 157, Issue 1, Pages 22-29 (January 2009
José Milei, MD, PhD , Roberto Andrés Guerri-Guttenberg, MD, Daniel Rodolfo Grana, VMD, Rubén Storino, MD, PhD
A prior publication from our group reported the fact that Chagas disease is underdiagnosed. This review will summarize several aspects of Chagas disease in the United States including modes of transmission, which will demonstrate that clinicians should be more aware of the disease and its consequences.
Trypanosoma cruzi is present in many animal species spread throughout most of the United States. Chagas disease also reaches the North American continent through immigration, making it more frequent than expected. Apart from immigration, non-endemic countries should be aware of transmissions through blood transfusions, organ transplantations, or mother-to-child infections.
In conclusion, it is possible that many chagasic cardiomyopathies are being misdiagnosed as “primary dilated idiopathic cardiomyopathies.” Recognizing that there is an evident threat of Chagas disease present in the United States will allow an increase of clinician's awareness and hence will permit to correctly diagnose and treat this cardiomyopathy. Health authorities should guarantee a generalized screening of T cruzi of blood donors, before organ donations, and of pregnant women who were born or have lived in endemic areas.

Crack se espalha no país

2008-12-14T21:41:00.000-02:00

O Estadão nesse domingo repercutiu pesquisa recente do CEBRID sobre consumo de crack no país. Não encontrei os dados no site do CEBRID, mas isso não importa. Os dados são impressionantes e, muito semelhantes aos observados nos Estados Unidos. Em São Paulo, onde há queda, o consumo se mudou para a área rural e pequenas cidades, embora a cracolândia - bem menor - ainda resista.

O mais importante nesse caso foi a discussão sobre a relação crack e homicídio. Aparentemente, há uma relação relativamente direta entre os dois fenômenos.

Na extensa reportagem há dois momentos que seriam engraçados, se não fossem dramáticos.

O primeiro do responsável pelo programa de saúde mental do Ministério que reclama da falta de leitos, que ele mesmo reduziu. O segundo, de professor universitário cujo discurso leva a concluir que as taxas de homicídio se reduziram em São Paulo por causa do PCC que teria organizado o crime.
Em 20 anos, crack alcançou todo o País
Bruno Paes Manso
Os primeiros relatos sobre o consumo de crack no Brasil surgiram em 1989, entre crianças que viviam nas ruas do centro de São Paulo, um ano antes da primeira apreensão da droga feita pela polícia na cidade. Feito do cozimento da cocaína com bicarbonato de sódio, potente, barato, famoso pela fissura que causa nos viciados, sempre em busca da próxima dose, 20 anos depois do começo da epidemia em São Paulo o crack migrou para os demais Estados e o mercado da droga se consolidou em todo o País.A droga já teve o uso identificado entre consumidores das 27 capitais brasileiras, principalmente jovens e pobres, conforme pesquisas do Centro Brasileiro de Informações sobre Drogas Psicotrópicas (Cebrid). Em São Paulo, Rio, Porto Alegre e Salvador, 39% dos pacientes que procuraram os principais centros de tratamento ambulatorial e hospitalar tinham problemas com crack, duas vezes mais do que os pacientes viciados em cocaína, segundo o Centro de Pesquisa em Álcool e Drogas da Universidade Federal do Rio Grande do Sul.No Rio, onde o Comando Vermelho proibiu que o crack fosse comercializado na década de 1990, a droga chegou com força há cinco anos."É um tsunami e a principal preocupação atual nas comunidades. Favelas como Manguinhos e Jacarezinho têm cracolândias deprimentes", diz Sílvia Ramos, do Centro de Estudos de Segurança e Cidadania da Universidade Cândido Mendes.No Estado de São Paulo, a apreensão de crack pela polícia bateu recorde neste ano, alcançando até setembro 731 quilos, 10% mais do que o total de todo o ano passado. No mesmo período, diminuiu a quantidade de maconha e cocaína apreendida. Para piorar, o problema migrou para municípios paulistas de pequeno e médio porte, alcançando trabalhadores rurais das plantações de cana-de-açúcar.Em São José do Rio Preto, cidade de 450 mil habitantes do interior do Estado, há pelo menos 1.200 viciados em crack sendo acompanhados pelo programa de redução de danos à hepatite e HIV. "Nove mulheres estão grávidas", diz a coordenadora de Saúde Mental de São José do Rio Preto, Denise Doneda. A gravidade do crescimento da comercialização do crack foi um dos principais pontos de discussão do encontro de colegiado dos coordenadores de saúde mental ligados ao Ministério da Saúde, ocorrido em novembro. De Dourados, em Mato Grosso do Sul, veio o relato de que o crack estava sendo consumido entre comunidades indígenas que vivem perto de centros urbanos. "Existe grande dificuldade para lidar com o problema porque a abordagem ao viciado é complicada e não existem leitos hospitalares à disposição para o tratamento", diz Pedro Gabriel Delgado, coordenador Nacional de Saúde Mental do Ministério da Saúde.A disseminação do uso em pequenas cidades brasileiras também foi outro ponto destacado no encontro. Em Estados nordestinos, que demoraram a sentir o drama do crack, a droga já aparece entre as preferidas dos usuários. Em Pernambuco, o crack começou a chamar a atenção entre os anos de 2001 e 2002, principalmente na região metropolitana do Estado. Atualmente, já atinge o agreste e o sertão - área tradicional da maconha.Quixadá, no Ceará, e Picos, no Piauí, são outros municípios que registram problemas com o crack. Em Salvador, viciados que se concentram em cracolândias no centro histórico são chamados de sacizeiros, em referência ao cachimbo usado no consumo. "Em 2004, 25% da droga consumida no Recife era crack. Em 2006, chegou a 50%", diz José Luiz Ratton, coordenador do Núcleo de Pesquisas em Criminalidade, Violência e Políticas Públicas de Segurança da Universidade Federal de Pernambuco.É na Região Sul, no entanto, que atualmente o problema aparece de forma mais dramática. No Paraná, três das cidades mais violentas do Brasil, Foz do Iguaçu, Guaíra e Curitiba, sofrem os efeitos da chegada do crack. Nas quatro principais maternidades de Porto Alegre, nasceram neste ano 117 crianças filhas de mães viciadas. A Secretaria de Saúde do Estado estima que existam atualmente 50 mil viciados na droga. "Duas coisas ajudaram essa disseminação pelo Brasil. Primeiramente, a natureza do produto, forte, barato e bem-aceito entre os mais pobres. Depois, a disseminação das rotas de cocaína para o Sul e o Centro-Oeste", afirma Fernando Francischini, secretário Antidrogas de Curitiba, ex- delegado da Polícia Federal responsável pela prisão do traficante Juan Carlos Ramirez Abadía.

Um alerta: celebridades científicas e médicas irão dominar a cena

2008-12-12T22:17:00.000-02:00

Para quem considera que o jornalismo chegou ao fundo do poço com o livro publicado sobre o "caso Eloá"; e, para quem acha que se passou da conta no "caso Isabela Nardoni"; e, finalmente para aqueles que qualquer notícia sobre o caso "ex-qualquer coisa de Suzana Vieira" foi o limite do suportável, aguardem o pior.

Na área médica e científica, a situação caminha para a consagração de celebridades, sejam pessoas físicas ou jurídicas. Quem leu ministro afirmar que o centro de gravidade da ciência e tecnologia se moveu para hospitais privados sente o despautério. Quem viu presidente, ministros, governador e prefeito paparicando um centro de cardiologia de hospital privado sentiu a barra. Quem vê pesquisador mais interessado em aparecer em coluna social a publicar um artigo científico e, depois reclamar de bancas de julgamento sabe do que se trata. Quem lê blogue de cientista prometendo a cura dos males da humanidade também entende o problema sério com o qual nos deparamos.

Em breve, teremos o Datena criticando a escolha de projetos do Instituto Nacional de Ciência e Tecnologia, a Hebe Camargo indicando o seu candidato preferido para professor titular e, por aí caminharemos.

Ao invés, de estudar para um concurso acadêmico, o candidato será entrevistado no Jô Soares e, utilizará esse fato como ponto alto de seu currículo acadêmico.

Ao CAPES, sugiro que novos critérios sejam estabelecidos como menção em coluna social. A única dúvida: menção em Mônica Bérgamo (Folha) ou Sônia Racy (Estadão) devem ser consideradas ambas como Qualis A? Citação na Vejinha seria Qualis B, porque regional, mas em Veja, seria Qualis A, correto?

Ao CNPq e à FAPESP sugiro que pagamento de assessoria de imprensa (serviços de pessoa jurídica) seja permitido na solicitação de qualquer projeto, afinal não é justo que somente quem tem cônjuge rico possa ter seu esquema de promoção.

Porque o câncer não superará as doenças cardiovasculares no Brasil em 2020

2008-12-11T22:33:00.000-02:00

A imprensa repercutiu essa apresentação o IARC afirmando que as mortes por câncer superarão as por doenças cardiovasculares em 2020. Não há um único estudo sobre o tema, trata-se de mera especulação , a não ser que na China e India, o hábito tabágico se espalha. Mas, o tabagismo também aumenta o número de mortes por doença cardiovascular.

No Brasil, esse quadro não acontecerá porque a prevalência:

1.de hipertensão é muito elevada quando comparada aos países europeus e EUA.

2. do tabagismo nunca foi elevada como na Europa, EUA e Ásia.
3. da obesidade e do diabetes está em elevação e, terá impacto na mortalidade cardiovascular como já se observa no EUA.
O mais grave da afirmativa do IARC é desconhecer que o espectro das doenças cardiovasculares naõ se restringem à sindrome coronariana aguda e à doença cerebrovascular. Essas duas entidades clínicas são manifestações do fenômeno aterosclerótico-hipertensivo que evoluirá para acometer outros órgãos (rins, retina, córtex cerebral) e funções (renal, visual, cognitiva, auditiva).

Cancer set to overtake heart disease as top global killer December 11, 2008 Lisa Nainggolan and Nick Mulcahy
Aarhus, Denmark - Cancer is set to overtake cardiovascular disease to become the leading cause of death worldwide by 2010, according to a new report [1] from the International Agency for Research on Cancer (IARC), a division of the World Health Organization (WHO). President of the American Heart Association (AHA), Dr Tim Gardner, told heartwire he applauds the new report and looks forward to working with cancer organizations to tackle risk factors that increase the likelihood of both cancer and cardiovascular disease.
According to the IARC report—which is a call to action asking governments to help fund cancer-prevention and research initiatives and international tobacco-control policies—the burden of cancer doubled globally between 1975 and 2000 and is set to double again by 2020 and nearly triple by 2030.
The report—which was discussed at an event in Atlanta this week called Conquering Cancer: A Global Effort—says that low- and middle-income countries will experience the impact of higher cancer incidence and death rates more sharply than industrialized countries.
The factors they have identified as predictive of an increase in cancer deaths are the very same factors that are going to result in more cardiovascular deaths, too.
This is also true of heart disease—just last week, as reported by heartwire, researchers predicted that 85% of cardiovascular deaths worldwide would occur in low- and middle-income countries by 2030. However, the authors of this article stressed that there still exists "a window of opportunity" to prevent the epidemic from reaching its full potential and magnitude.
Among the reasons stated by the IARC for the growing cancer burden is the adoption in less well-developed countries of "Western" habits, such as tobacco use and high-calorie, high-fat, and trans-fat diets.
"Obviously, this new cancer report is an important prediction," Gardner told heartwire. "The risk and demographic factors they have identified as predictive of an increase in cancer deaths are the very same factors that are going to result in more cardiovascular deaths, too, so we are on the same track." US deaths from cancer and heart disease currently declining
The news on cancer in developing countries is in contrast with another recent report that shows cancer incidence and death rates for men and women in the US continuing to decline [2].
The number-one and number-three killers in the US currently are coronary heart disease and stroke, respectively, says the AHA [3].
And while the nation has already made progress in reducing death rates from these two conditions, Gardner says that without a concerted effort to reduce some key risk factors, such as obesity and physical inactivity, "the momentum of reducing heart disease and stroke deaths will be lost. We will see our children developing heart disease earlier. This could reverse the progress in cardiovascular death rates that we have seen over the past decade."
We are not jealous about our position in terms of heart disease being the number-one killer.
"We are not jealous about our position in terms of heart disease being the number-one killer; it's a distinction none of us want to have," he added. "The AHA has been working for decades to move out of that 'top spot' of being the number-one killer. But unless we can do better in reducing some of these risk factors in the US, it may be a long time before we can shed the title of number one."Smoking is the easiest target
Cigarette smoking accounts for nearly 440 000 of the more than 2.4 million annual deaths in the US, and there are catastrophic predictions for the number of deaths that will occur due to smoking in developing countries. In India, for example, new research published earlier this year forecasts that by 2010 around one million deaths per year there will be attributable to smoking.
"Tobacco use is an enormous health burden across the globe and makes a significant contribution to deaths from both cancer and cardiovascular disease," Gardner adds.
"We applaud the findings of the IARC report. We're very concerned about smoking rates in the US and newly developed countries, and we are really working very hard on trying to deal with that—the one risk factor that can most easily be targeted."
Sources
Leading US cancer organizations unite against the growing global cancer burden [press release]. December 9, 2008. Available at: http://www.eurekalert.org/pub_releases/2008-12/acs-luc120908.php.
Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008; 58:71-96.
American Heart Association. American Heart Association comment on the International Agency for Research on Cancer, World Cancer Report [press release]. December 11, 2008. Available at: http://americanheart.mediaroom.com/index.php?s=43&item=625.

Prevenção do Câncer de Próstata: melhor do que InCa e SBU

2008-12-10T23:06:00.000-02:00

Abaixo, um artigo do New England Journal of Medicine bem melhor do que as opiniões enviesadas da Sociedade Brasileira de Urologia e "a posição firme e decidida" do Instituto Nacional do Câncer. Aliás, um dos momentos mais infelizes do ano, foi o protagonizado por ambos, Sociedade e Instituto.

Screening for Prostate Cancer among Men 75 Years of Age or Older. Michael Barry.

Prostate-cancer screening with the prostate-specific antigen (PSA) test remains one of the most controversial issues in modern medicine. The U.S. Preventive Services Task Force (USPSTF), an independent group of experts supported by the Agency for Healthcare Research and Quality under a mandate from Congress, recently revised its recommendations regarding prostate-cancer screening. The USPSTF concluded that "the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years," but it now "recommends against screening for prostate cancer in men age 75 years or older."1 In its 2002 statement, the task force did not recommend for or against screening in either age group. The implication of the new recommendation for medical practice is that clinicians should discuss the potential benefits and known harms of screening with men between 50 and 74 years of age, but not necessarily with older men.
Why change the recommendation for men 75 or older, at least given the continuing dearth of evidence from randomized trials that addresses the tradeoff between the benefits and harms of prostate-cancer screening in men of any age? The task force believes that at least a moderate amount of evidence now makes it possible to conclude that the known harms of screening outweigh the possible benefits for this age group.
This statement does not imply that prostate cancer is an unimportant problem among men 75 or older; in fact, as the statement acknowledges, 71% of deaths due to prostate cancer — almost 20,000 annually in the United States — occur after the age of 75. Moreover, it does not mean that no men 75 or older could possibly benefit from screening. After all, there are relatively healthy men in their late 70s and even early 80s harboring high-grade cancers that are likely to kill them; early detection and attempted curative treatment might prevent these men from dying from prostate cancer. So why not continue to offer screening after the age of 74?
First, the effectiveness of attempted curative treatment for prostate cancer among men 75 or older appears to be low or negligible. In the only published randomized trial comparing the effect of radical prostatectomy with a strategy of "watchful waiting" for men with clinically localized prostate cancer, the benefit of radical prostatectomy was statistically significant but small, with an absolute difference of 5.4 percentage points in the rate of death due to prostate cancer at 12 years (which has not widened with continued follow-up). This difference means that about 18 radical prostatectomies would have to be performed to prevent a single death from prostate cancer over a 12-year period.2 However, in subgroup analyses at both 10 and 12 years of follow-up, even this level of effectiveness appeared to be confined to men 65 years of age or younger. Men 75 or older were not enrolled, presumably because they were considered less likely to benefit from surgery.
It is important to note that less than 10% of subjects in this Scandinavian trial had their prostate cancer diagnosed through screening. The long average lag time between a detectable increase in the PSA level — 5 to 10 years — and the development of clinical cancer, as well as the possibility of overdiagnosis associated with PSA screening, suggests that an even smaller benefit may be seen in the U.S. Prostate Cancer Intervention versus Observation Trial (PIVOT), in which about three quarters of participants had their cancer diagnosed through PSA screening. Results from PIVOT are expected in 2010. As in the Scandinavian trial, men 75 or older were not enrolled.
The effect of competing hazards would also attenuate the benefit of screening and attempted curative treatment for men 75 or older. Given the slow growth of most prostate cancers and the resultant long lead times between detectability and clinical disease, men may need to live much longer than 10 years to reap the benefits of PSA screening — and of course, preventing a death from prostate cancer does not bestow immortality. For example, out of 1000 75-year-old male nonsmokers, 19 would be expected to die of prostate cancer over the next 10 years, whereas 430 would be expected to die of other causes.3 Even if a few of the deaths from prostate cancer could be prevented within this time frame, the effect on overall mortality would be small. And fewer older men than younger men would still be alive beyond 10 years to reap any delayed benefits of screening; for example, life expectancy for men surviving to the age of 85 is about 6 years.
Whereas the benefits of screening attenuate with age, the harms increase. PSA levels are strongly age-dependent, so at any given PSA threshold, older men will have substantially higher risks of both requiring a prostate biopsy and being diagnosed with prostate cancer. For example, about 6% of men in their 60s, 21% in their 70s, and 28% in their 80s would be expected to have a PSA level above 4.0 ng per liter,4 a common threshold for considering a prostate biopsy. Regular PSA screening roughly doubles the risk that men will have to face a diagnosis of prostate cancer over the next 10 years, but many of these cancers would never present clinically. Given that the risk of prostate cancer is also age-related, this effect will be greatest among older men. And finally, the risks of both postoperative death and complications of radical prostatectomy are age-related, escalating after the age of 75.5
Given the unfavorable trade-off between the possible benefits and known risks of prostate-cancer screening after the age of 74, I believe the USPSTF recommendation is sound. As with all guidelines, clinical judgment should be used in its application. For example, given the relationship between self-rated health and life expectancy, a clinician might consider having a discussion about PSA screening with (not simply testing) men in their late 70s who rate their own health as "excellent" but discontinue screening discussions at the age of 75 if self-rated health is "good," at the age of 70 if self-rated health is "fair," and at the age of 65 if self-rated health is "poor." These thresholds roughly correspond to a remaining life expectancy of 10 years, a threshold below which other guidelines — for example, those from the American Cancer Society — have recommended against screening. Any threshold, of course, is inevitably somewhat arbitrary.
Considering the ongoing controversies surrounding prostate-cancer screening, evidence from randomized trials about benefit and harms would be welcome indeed. The large, ongoing trials of PSA screening in the United States (the Prostate, Lung, Colorectal, and Ovarian, or PLCO, Cancer Screening Trial), Europe (the European Randomized Study of Screening for Prostate Cancer, or ERSPC), and the United Kingdom (Prostate Testing for Cancer and Treatment, or Protect) will eventually help to resolve some of these controversies — the first two trials should produce results over the next 5 years. However, none of the findings from these trials will bear directly on the question of whether screening is appropriate for men 75 or older, since men in this age group were excluded from all three.
Population-based studies of PSA testing in the United States have shown fairly high levels of screening among men in their late 70s and even in their 80s. The new recommendations from the USPSTF should prompt clinicians and patients to think twice, or even three times, before ordering PSA tests for cases in which screening is especially likely to do more harm than good.

Mais uma vez, as vitaminas não contam

2008-12-09T22:58:00.000-02:00

Uma vez mais, a perspectiva de prevenção do câncer com uso de vitaminas não consegue ser provado em dois ensaios clínicos publicados em JAMA, hoje.
Vitamins E and C in the Prevention of Prostate and Total Cancer in Men: ThePhysicians' Health Study II Randomized Controlled Trial JAMA http://jama.ama-assn.org/cgi/content/abstract/2008.862v1?etoc
Effect of Selenium and Vitamin E on Risk of Prostate Cancer and Other Cancers: The Selenium and Vitamin E Cancer Prevention Trial (SELECT) http://jama.ama-assn.org/cgi/content/abstract/2008.864v1?etoc
Editorials: Randomized Trials of Antioxidant Supplementation for Cancer Prevention:First Bias, Now Chance--Next, Cause http://jama.ama-assn.org/cgi/content/full/2008.863v1?etoc

Esperança em nova vacina para malária

2008-12-08T14:40:00.000-02:00

A Hopeful Beginning for Malaria Vaccines. William E. Collins, Ph.D., and John W. Barnwell, M.P.H., Ph.D.
An effective human malaria vaccine has been sought for over 70 years, with little success.1 A successful malaria vaccine used in conjunction with other control interventions would help reduce and eventually eliminate the considerable global disease burden caused by malaria. Many different antigens have been identified as potential targets for malaria-vaccine development. One of these, the repetitive sequence of four amino acids in the circumsporozoite antigen on the surface of the sporozoite of Plasmodium falciparum, arguably the most important of the human malarias, is the basis for the RTS,S vaccine.2 This vaccine was subjected to extensive studies involving human volunteers, the results of which indicated a potential protective efficacy of about 40% when the vaccine was used in combination with an effective adjuvant therapy.3,4 Subsequently, a number of field studies have indicated that in endemic areas, this vaccine could have a rate of efficacy of about 30% against clinical disease and about 40% against new cases of infection.5,6 This is the first candidate malaria vaccine to show significant protection in laboratory- and field-based clinical studies.
The evaluation of the safety and efficacy of malaria vaccines in infants and children is of utmost importance because most deaths and illness from malaria occur in these age groups, in areas of moderate-to-high transmission. In this issue of the Journal, Abdulla et al.7 describe their safety and immunogenicity trial in which the RTS,S vaccine was used in combination with the AS02D adjuvant (ClinicalTrials.gov number, NCT00289185 [ClinicalTrials.gov] ). The RTS,S/AS02D vaccine had a reasonable safety profile as compared with the control hepatitis B vaccine, and anticircumsporozoite-antibody titers were detectable in more than 98% of the infants receiving the RTS,S/AS02D vaccine. In this trial, RTS,S was given along with other vaccines for children (a vaccine containing diphtheria and tetanus toxoids, whole-cell pertussis vaccine, and conjugated Haemophilus influenzae type b vaccine), according to the Expanded Program on Immunization (EPI) schedule. There was no interference with immune responses to the EPI vaccines. This result suggests that it will be feasible to provide RTS,S together with other routine children's vaccines, making its delivery in endemic areas much easier and less costly. During the 6-month period after immunization, the incidences of malarial infection and clinical disease in the RTS,S group were reduced by 65% and 59%, respectively. There was a correlation between a reduced risk of infection and increased circumsporozoite antibody titers. There was no association, however, between a reduction in the incidence of clinically active malaria and an increased circumsporozoite-antibody titer.
Also in this issue, Bejon et al.8 report on a phase 2b safety and efficacy trial of the RTS,S vaccine combined with the AS01E adjuvant, in children 5 to 17 months of age (NCT00380393 [ClinicalTrials.gov] ). The RTS,S/AS01E vaccine was associated with fewer severe adverse events than the control rabies vaccine. Overall, there was an unadjusted rate of efficacy of 60% against all episodes of P. falciparum clinical malaria, with anticircumsporozoite-antibody titers detectable in more than 99% of the recipients of the RTS,S/AS01E vaccine. However, as in the trial by Abdulla et al., there was no evidence that protection against clinical disease was correlated with anticircumsporozoite titers in children vaccinated with RTS,S/AS01E. The AS01E adjuvant used by Bejon et al. was developed to enhance the immune response to the circumsporozoite target antigen and, it was hoped, provide greater efficacy than the AS02D adjuvant used by Abdulla et al. and in earlier clinical studies of RTS,S.
A comparison of the two articles reveals that the mean circumsporozoite antibody titers among the children receiving the RTS,S/AS01E vaccine were approximately 10 times that among those receiving the RTS,S/AS02D vaccine. However, although the overall mean antibody titers were lower with the AS02D adjuvant, both in the trial by Abdulla et al. and in a previous trial involving infants in Mozambique,9 the protection against infection and clinical disease was similar to that in the trial of AS01E by Bejon et al. In the studies by Abdulla and Bejon and their colleagues, the efficacy against clinical disease did not differ whether AS01E or AS02D was used as an adjuvant, but the efficacy with either is greater than the 30% rate reported in a previous trial.6 Whether the higher antibody titers associated with the use of AS01E might translate into a longer duration of protective efficacy for the RTS,S vaccine remains to be demonstrated.
The correlation of reduced incidence of infection with higher antibody levels is encouraging and intuitive, given the biologic basis of infection. Correlations between antibody levels and protection against disease are more difficult to reconcile in the context of the biologic features of malaria and the target of this vaccine. In humans, there are two main developmental stages of the malaria life cycle: the exoerythrocytic stage in the liver, involving the sporozoite and hypnozoite, and the erythrocytic stage in the blood, involving the merozoite. Immunity acquired against one form of the malaria parasite does not operate against other forms. Sporozoites — the target of RTS,S — are injected into humans through mosquito bites, infect hepatocytes, and initiate the development of other liver-stage parasites. One sporozoite produces thousands of merozoites that parasitize erythrocytes to initiate the blood stage of infection, which in turn produces the clinical disease of malaria. Thus, if immune responses generated by "leaky" pre-erythrocytic vaccines such as RTS,S fail to block just a single sporozoite from invading or developing in the hepatocyte, then a blood-stage infection will follow, and typical paroxysmal fevers and, perhaps, severe malarial disease will manifest.
Although the results of Abdulla et al. and Bejon et al. are promising, the baseline incidence of malaria was low in each study area. Evaluations of vaccine-efficacy studies can be complicated by the introduction of insecticide-treated bed nets and artemisinin-based combination drug treatments through ongoing control programs across sub-Saharan Africa.10 Recent reports indicate that, in some areas in which malaria is endemic, such as in the Gambia in West Africa and Kenya and Tanzania in East Africa, there have been dramatic reductions in the malarial disease burden.11,12
However, as the RTS,S vaccine heads into phase 3 trials in 2009, large areas across Africa still have moderate-to-intense malaria transmission. Malaria transmission of yet higher intensity, with greater and more continuous assault by mosquito-injected sporozoites, could affect the efficacy of this vaccine.6 This is the first malaria vaccine to reach this stage of development, and it will be essential to learn how it performs in areas of more intense transmission. Only then will we have a clear idea of what effect it will have on the well-being of children in Africa and elsewhere and its role in malaria control. It is, indeed, a hopeful beginning.
No potential conflict of interest relevant to this article was reported.
Source Information
From the Malaria Branch, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta. The opinions expressed in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. This article (10.1056/NEJMe0808983) was published at www.nejm.org on December 8, 2008. It will appear in the December 11 issue of the Journal.
References
Druilhe P, Barnwell JW. Pre-erythrocytic stage malaria vaccines: time for a change in path. Curr Opin Microbiol 2007;10:371-378. [Medline]
Gordon DM, McGovern TW, Krzych U, et al. Safety, immunogenicity, and efficacy of a recombinantly produced Plasmodium falciparum circumsporozoite protein-hepatitis B surface antigen subunit vaccine. J Infect Dis 1995;171:1576-1585. [ISI][Medline]
Stoute JA, Slaoui M, Heppner DG, et al. A preliminary evaluation of a recombinant circumsporozoite protein vaccine against Plasmodium falciparum malaria. N Engl J Med 1997;336:86-91. [Free Full Text]
Kester KE, McKinney DA, Tornieporth N, et al. Efficacy of recombinant circumsporozoite protein vaccine regimens against experimental Plasmodium falciparum malaria. J Infect Dis 2001;183:640-647. [CrossRef][ISI][Medline]
Bojang KA, Milligan PJ, Pinder M, et al. Efficacy of RTS,S/AS02 malaria vaccine against Plasmodium falciparum infection in semi-immune adult men in The Gambia: a randomised trial. Lancet 2001;358:1927-1934. [CrossRef][Medline]
Alonso PL, Sacarlal J, Aponte JJ, et al. Efficacy of the RTS,S/AS02A vaccine against Plasmodium falciparum infection and disease in young African children: randomised controlled trial. Lancet 2004;364:1411-1420. [CrossRef][Medline]
Abdulla S, Oberholzer R, Juma O, et al. Safety and immunogenicity of RTS,S/AS02D malaria vaccine in infants. N Engl J Med 2008;359:2533-2544. [CrossRef]
Bejon P, Lusingu J, Olotu A, et al. Efficacy of RTS,S/AS01E vaccine against malaria in children 5 to 17 months of age. N Engl J Med 2008;359:2521-2532. [CrossRef]
Aponte JJ, Aide P, Renom M, et al. Safety of the RTS,S/AS02D candidate malaria vaccine in infants living in a highly endemic area of Mozambique: a double blind randomised controlled phase I/IIb trial. Lancet 2007;370:1543-1551. [CrossRef][Medline]
Snow RW, Guerra CA, Mutheu JJ, Hay SI. International funding for malaria control in relation to populations at risk of stable Plasmodium falciparum transmission. PLoS Med 2008;5:e142-e142. [Medline]
Ceesay SJ, Casals-Pascual C, Erskine J, et al. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. Lancet 2008;372:1545-1554. [Medline]
O'Meara WP, Bejon P, Mwangi TW, et al. Effect of a fall in malaria transmission on morbidity and mortality in Kilifi, Kenya. Lancet 2008;372:1555-1562. [Medline]

PLOS: doenças negligenciadas nos Estados Unidos

2008-12-07T14:08:00.000-02:00

Neglected Infections of Poverty in the United States of America
Peter J. Hotez. Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University and Sabin Vaccine Institute, Washington, D.C., United States of America
Abstract
In the United States, there is a largely hidden burden of diseases caused by a group of chronic and debilitating parasitic, bacterial, and congenital infections known as the neglected infections of poverty. Like their neglected tropical disease counterparts in developing countries, the neglected infections of poverty in the US disproportionately affect impoverished and under-represented minority populations. 1The major neglected infections include the helminth infections, toxocariasis, strongyloidiasis, ascariasis, and cysticercosis; the intestinal protozoan infection trichomoniasis; some zoonotic bacterial infections, including leptospirosis; the vector-borne infections Chagas disease, leishmaniasis, trench fever, and dengue fever; and the congenital infections cytomegalovirus (CMV), toxoplasmosis, and syphilis. These diseases occur predominantly in people of color living in the Mississippi Delta and elsewhere in the American South, in disadvantaged urban areas, and in the US–Mexico borderlands, as well as in certain immigrant populations and disadvantaged white populations living in Appalachia. Preliminary disease burden estimates of the neglected infections of poverty indicate that tens of thousands, or in some cases, hundreds of thousands of poor Americans harbor these chronic infections, which represent some of the greatest health disparities in the United States. Specific policy recommendations include active surveillance (including newborn screening) to ascertain accurate population-based estimates of disease burden; epidemiological studies to determine the extent of autochthonous transmission of Chagas disease and other infections; mass or targeted treatments; vector control; and research and development for new control tools including improved diagnostics and accelerated development of a vaccine to prevent congenital CMV infection and congenital toxoplasmosis.

Brasileiro vence concurso do The Lancet

2008-12-05T09:20:00.000-02:00

O médico Enrique Falceto de Barros, recém formado na Universidade Federal do Rio Grande do Sul venceu com mais cinco concorrentes o prêmio Young Voices In Research for Health do The Lancet e do Global Forum for Health Reseaarch. Para ler a monografia de Enrique, clique aqui.

Winners of the 2008 essay competition, Young Voices in Research for Health
The Lancet, together with the Geneva-based Global Forum for Health Research, is pleased to announce the winners of the 2008 essay competition, Young Voices in Research for Health. The theme of this year’s contest was research for climate change and health. Essayists were asked to devise research questions on the topic as it applies to vulnerable populations around the world.
Almost 300 entries were submitted, from 66 countries. A shortlist of 42 was chosen by a team of judges from the Global Forum and The Lancet. Six winners were selected from the shortlist.
The six winners, whose essays are posted here, are Enrique Falceto de Barros (Brazil), Philippa Bird (UK), Lester Sam Geroy (Philippines), Rhona Mijumbi (Uganda), Marame Ndour (Senegal), and Charles Salmen (USA).

Boanerges de Souza Massa: história finalizada

2008-12-04T21:49:00.001-02:00

Boanerges formou-se em medicina na USP em 19

Boanerges de Souza Massa: história finalizada

2008-12-04T21:49:00.000-02:00

Boanerges formou-se em medicina na USP em 1965 (ano a confirmar). Durante muito tempo foi uma figura mítica na Faculdade, pouco se falava dele, a maioria das vezes como se fosse ou um louco irresponsável ou um agente policial disfarçado. (assim ouvi mais de uma vez nos anos 70) Nunca foi alçado à condição de "herói da resistência". Alguns lembravam dele por uma cirurgia realizada em ambiente clandestino em um militante da Ação Libertadora Nacional (ALN) que fora baleado. Eduardo Manzano e Heloisa L. Manzano, médicos que moram em Porto Nacional e, se formaram com ele, afirmam que o viram no início dos anos 70 e, mantinham a descrição de Boanerges em seu livro "Memórias de um casal de médicos nas barrancas do Tocantins" como a de um sujeito estranho. (expressão a confirmar, transcrita pela memória do blogueiro)

Nessa semana, duas publicações, uma transcrita no Correio Braziliense de um livro que não foi publicado de autoria do próprio Exército nos anos 80 e, a outra o livro Sem Vestígios de Taís Morais trazem informação nova. Boanerges de Souza Massa era militante do Movimento de Libertação Popular (MOLIPO), uma dissidência da ALN esteve em Cuba, montou um foco guerrilheiro no oeste baiano e, foi preso em Goiás em 1971.Após sessão de tortura foi conduzido à Bahia para reconhecer o local e, na volta foi executado em um sítio em Formosa, Goiás.

O secretário dos direitos humanos, Paulo de Tarso Vannuchi, ex-militante da ALN, ex-aluno da FMUSP poderia conduzir o reconhecimento póstumo de Boanerges, como mais um daqueles da Casa de Arnaldo que tombaram nos anos de chumbo.

P.S recomendo o livro Sem Vestígios onde descreve as "memórias" de Carioca, um agente da repressão política. Há momentos horríveis como a descrição da morte de David Capistrano. Porém, a autora poderia ter revisado melhor algumas passagens onde derrapa em gongorismos e redundâncias. Mas, o pior foi a nota de rodapé, que inimigos de José Dirceu utilizaram fora de contexto, com a interpretação de que o ex-presidente do PT e ex-chefe da Casa Civil teria sido agente duplo (uma mera suposição do Carioca, sem base fática).

BMJ: uma vez mais a emigração de profissionais de saúde da África.

2008-12-04T17:23:00.000-02:00

Globalisation spurs migration of healthcare workers from poor nations; John Zarocostas
Globalisation has made it easier for rich nations to "pull in" skilled migrants such as healthcare workers from poor nations, says a report from the International Organization for Migration, which promotes humane and orderly migration. Such migrants include a large number from sub-Saharan Africa, the region with the greatest shortage of healthcare personnel, and the trend is unlikely to abate, the report says.
"Their [rich countries’] ability to offer higher pay, better working conditions and greater opportunities in safer environments will continue to pull foreign health workers until supply exceeds demand," says the report.
It says that the search for employment is at the heart of most migration and concludes that pressures "are set to increase."
There are "more than 200 million international migrants in the world today, two and a half times the number in 1965," it says, and most countries are now simultaneously countries of origin, transit, and destination.
Nearly a quarter of foreign trained doctors in countries of the Organisation for Economic Co-operation and Development were trained in sub-Saharan Africa, and the report suggests a series of possible policy options to limit the negative effects of emigration on the countries of origin.
Countries of destination should continue to develop guidelines for recruiting skilled professionals from poor nations, the report recommends, but it emphasises that self imposed restraints on recruitment by public sector employers "have not been effective in limiting the migration." It says that "exhorting private-sector employers to recruit ethically" is also likely to prove equally ineffective.
"These [guidelines] can serve as a benchmark against which civil society organisations and the nationals and governments of destination and origin countries can evaluate the practice of destination countries."
Anita Davies, a public health specialist at the International Organization for Migration, said that the World Health Organization has taken the lead by preparing a global code of recruitment of health workers, in consultation with other relevant agencies and stakeholders.
A draft has been sent out for comment and will be presented to WHO’s governing board for consideration in January. If agreed, it will be sent to the annual World Health Assembly for adoption.
The report says that policy innovations can help to mitigate some of the risks to poorer nations of diminished service access and availability. These schemes include flexible, multi-use, multi-annual work permits that may allow poor nations of origin to manage flows more effectively and thus avoid critical shortfalls in the provision of health care. Such schemes may include fixed term contracts to train or work for a period in a rich nation and may also include commitments to upgrade their own healthcare system with the support of a destination country.
The report estimates that Lesotho and Namibia have lost more than 30% of their physicians to emigration and that this percentage rises to more than 50% in Malawi, Tanzania, and Zambia and to 75% in Mozambique. Every year 1000 doctors emigrate from South Africa, says the report, and an estimated 30% to 50% of all South African medical school graduates emigrate to the United Kingdom or the United States annually. Doctors from South Africa make up just under 10% of all foreign trained doctors in Australia and 7% in the UK, it says
However, it points out that South Africa is also the destination for skilled health workers from other parts of Africa, including Botswana, the Democratic Republic of Congo, Ghana, Nigeria, and Zimbabwe.
South Africa has the highest ratio of doctors to population on the continent, at 56.3 per 100 000 people, whereas in the Democratic Republic of Congo the figure is only 6.2 per 100 000.
The report says that South Africa has tried to deal with staff shortages in the public health sector by hiring Iranian and Cuban health personnel to work in rural areas.
Meanwhile, a joint working paper by the OECD and WHO on international health mobility in Canada concludes that foreign trained doctors accounted for more than 22% of Canada’s total in 2005-6.
Among rich OECD nations, New Zealand had the highest proportion of foreign trained doctors, with 36%, it says.
The joint study also found that in 2005 about 15% of newly registered doctors in Canada were trained in countries from the WHO list of countries with critical shortages of health personnel. The corresponding figure for the UK was 46% and that for the US was 39%.
But the report also shows that in 2006 about 8000 Canadian trained doctors were practising in the US. It says that differences in income and availability of positions were often among the reasons cited for emigrating

Circuncisão e prevenção da aids: vale a pena ler texto do NEJM

2008-12-03T23:01:00.000-02:00

Circumcision — A Surgical Strategy for HIV Prevention in Africa.
Ingrid T. Katz, M.D., M.H.S., and Alexi A. Wright, M.D.
In a radical departure from earlier strategies, public health officials are now arguing that circumcision of men should be a key weapon in the fight against infection with the human immunodeficiency virus (HIV) in Africa. Recent studies have shown that circumcision reduces infection rates by 50 to 60% among heterosexual African men. Experts estimate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. But skeptics argue that efforts to "scale-up" circumcision programs on the continent that has the fewest physicians per capita may draw funds away from other necessary public health programs, ultimately threatening already tenuous health care systems.
How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa. Early evidence of circumcision's protective effect dates back to the late 1980s. Researchers working in Africa and Asia noticed that HIV-prevalence rates differed dramatically among neighboring regions and were often lowest in areas where circumcision was practiced. More than 40 observational studies followed, but most researchers remained skeptical about the results. Then, in 2002, Bertran Auvert, professor of public health at the University of Versailles, launched one of the first randomized, controlled trials of circumcision in Orange Farm, South Africa, a community with a low rate of circumcision and a high prevalence of HIV infection. After the 12-month interim analysis, the data and safety monitoring board decided to stop the trial. The data were clear: circumcision reduced the rate of HIV infection among heterosexual men by 60%.
Since then, two other randomized, controlled clinical trials in Kenya and Uganda have confirmed the results from South Africa. Both were stopped early because of overwhelmingly positive results. The research teams thought it was unethical to require men in the control group to wait 24 months before undergoing circumcision. A few men had already obtained off-protocol circumcisions, but since the study results were released, the demand has skyrocketed. "We have three operating rooms running every day," said Ronald Gray, lead author on the Ugandan study and professor at the Johns Hopkins Bloomberg School of Public Health. "We have done about 1000 surgeries in 3 months — after completing all of the surgeries for trial participants."
Researchers have also found that circumcision provides increased protection against the human papillomavirus, herpes simplex virus, syphilis, and chancroid. But the most compelling evidence is still for HIV prevention, argues Roger Shapiro, a researcher at Harvard School of Public Health who is helping to implement a pilot program to offer infant circumcision in Botswana: "Circumcision isn't a new scientific breakthrough, but it works. It is the only proven medical intervention that can complement condom use and improve protection. If we had this level of data for a vaccine or a microbicide, you can bet there would be a massive push for immediate scale-up."
Key distinctions between penile surgery and less-invasive methods of HIV prevention, however, may hinder momentum. For one thing, some African officials remain wary of circumcision because of concerns about cost and safety. Currently, physicians are performing most circumcisions, but many countries are hoping to decrease costs by training a cadre of lower-level health care workers (such as medical or clinical officers and nurses) to fill the provider gap that many countries face. Adequate training is essential, however, since complication rates ranged from 1.7 to 3.6% among HIV-negative men in the trials (as compared with rates of 0.2 to 2.0% associated with infant circumcision in the United States). Most complications were minor — pain or bleeding — but higher complication rates have been reported outside trial settings. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction. Inadequate sterilization procedures and surgical instruments were probably important factors in the higher rates, but Daniel Halperin, senior research scientist at Harvard School of Public Health, argues that high complication rates primarily reflect a problem with training, not with the procedure itself: "Circumcision can be performed safely, with relatively few complications, anywhere in the world, if clinicians are trained properly."
Policymakers are also struggling with complex cultural barriers in societies where circumcision is not part of mainstream practice. In countries such as South Africa, for example, most men are not circumcised, but certain subpopulations, including the Xhosa ethnic group, practice circumcision of boys as a rite of passage into manhood. Many South Africans frown on the practice, and after several young Xhosa boys died from circumcision-related complications, then-President Thabo Mbeki signed a bill banning (with some religious and medical exceptions) circumcision in boys under 16 years of age. Some fear that the deaths associated with traditional circumcision have prevented expansion of the program in South Africa, but others argue that offering clean, safe medical circumcision to these communities could be lifesaving.
Many public health researchers fear that there are deeper reasons for some African governments' skepticism. Some speculate that Africa's colonialist history has left these leaders with lingering suspicions about possible oppression, which have long taken the form of "deep denial regarding HIV treatment and prevention in certain regions of Africa," according to Francois Venter, clinical director of HIV management and reproductive health at the University of the Witwatersrand in South Africa. Others reference the dark history of surgical interventions deployed in the name of public health, citing the Indian sterilization camps of the 1970s. All agree that implementation of circumcision on a national level will require in-country champions and strong political will to succeed. "Currently all of the funding is coming from Western nations," says Venter, "and this makes people suspicious."
To counterbalance perceptions of Western intrusion, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs. "Countries are going to have to scale-up according to their own goals," said Catherine Hankins, chief scientific adviser to the Joint United Nations Program on HIV/AIDS (UNAIDS). "We are not setting any international agendas." UNAIDS, the World Health Organization (WHO), and their partners have set up a Web site (www.malecircumcision.org) to allow interested countries to trade information directly.
Most people involved in scaling up adult male circumcision recognize that the surgery is a costly endeavor and a socially complex intervention that may compromise other public health priorities. Venter argues, "In South Africa, we have many other competing health issues, including maternal and child health and tuberculosis, which still need much more support." Nevertheless, he remains a proponent of circumcision as a means for getting young men into the health care system to help protect them against HIV and educate them about safe sex practices.
Major international funders, including the Bill and Melinda Gates Foundation and PEPFAR, agree that ramped-up circumcision efforts must be funded as add-on services to guarantee that they will not detract from other programs. Although PEPFAR has granted $26 million for circumcision programs in 13 African countries — Botswana, Kenya, Rwanda, Zambia, South Africa, Lesotho, Malawi, Mozambique, Tanzania, Uganda, Namibia, Ethiopia, and Swaziland — implementation has been highly variable.
In order to optimize HIV-prevention measures, officials from WHO and UNAIDS are advising that countries offer a minimum package of services in addition to circumcision, including HIV testing, screening for sexually transmitted infections, promotion of condom use, and counseling on safer sex. Such a comprehensive approach is meant to address concerns that circumcised men may adopt riskier behavior because they feel protected after undergoing the procedure. Despite these concerns, Gray and others have shown that there are no differences between the sexual behaviors of circumcised men and those of uncircumcised men — reassuring news, since many researchers and policymakers see circumcision programs as an opportunity to engage young men and women in HIV prevention. Robert Bailey, lead author on the Kenya study and professor of epidemiology at University of Illinois at Chicago, has noticed more participation of sexual partners in voluntary HIV counseling and testing since circumcision programs started.
Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women. In a small substudy, Ugandan researchers circumcised HIV-positive men and then followed their HIV-negative female partners to see whether their risk of infection was reduced. Data presented earlier this year did not demonstrate a benefit — a failure the researchers attributed to a sample size too small to allow differences to reach statistical significance. Indirect evidence from modeling, however, suggests that women will ultimately benefit from circumcision programs that reduce the HIV prevalence among men.
Although circumcision has increasing support from researchers, donors, and politicians, its status as a non–behavior-based intervention may ultimately be its biggest obstacle. Neil Martinson, deputy director of the Perinatal HIV Research Institute at the University of the Witwatersrand in South Africa, summarizes this concern: "People are used to policies that target behaviors, but circumcision is a surgical intervention — it's cold, hard steel — and that doesn't always go down well." Ultimately, as programs move forward, the scale-up of circumcision will require strong political backing, adequate funding, and leaders to champion the cause to ensure that it is a safe, low-cost option available throughout Africa.

Demitir Jack Bauer, acabar com a tortura

2008-12-02T09:41:00.000-02:00

Futuro Presidente dos EUA, Barack Obama: demissão sumária de Jack Bauer.

Secretário dos Direitos Humanos, Paulo de Tarso Vanucchi: menos bravatas em auditórios com ar condicionado e caça aos Jack Bauers tupiniquins.

Who is Jack Bauer? Dr Homer Drae Venters MD (publicado no The Lancet)
A patient of mine, Kofi, once asked me, “Who is Jack Bauer?” I felt a little queasy because the patient, question, and answer all shared a common element, torture. I first met Kofi when I was a resident, only 1 year into my training in assessing survivors of torture who were seeking asylum at the Bronx Human Rights Clinic, New York, USA. The application of these people can be strengthened by medical examination of the physical and mental sequelae of torture. Before fleeing his country, Kofi endured several brutal detentions, as part of government persecution of his ethnic group. During his assessment at the Bronx Human Rights Clinic, Kofi described in detail the beatings, stabbings, and various humiliations that his government had perpetrated on him. Kofi then underwent a laborious 3-h physical examination, cataloguing every scar and musculoskeletal and neurological finding. The final part of this examination was to assess Kofi's psyche for the inevitable consequences of his experiences. Several months later, Kofi's asylum application was granted; we have continued to see each other for his primary-care needs. So what of Jack Bauer?
Kofi has taken a deep interest in the politics of his adopted country, and has watched every US presidential debate so far. During one debate, a scenario was put to all the candidates, that can be summed up as the torture dilemma: terrorists have struck on US soil; the authorities have detained suspects, and have reason to think that some may possess knowledge of another imminent attack. The presidential candidates were asked whether to torture or not to torture. Only one candidate, Senator John McCain of Arizona, unequivocally responded in the negative; the others advocated various forms of so-called enhanced interrogation: a phrase which gives torture a more palatable label, and perpetuates the false impression that torture enhances interrogation. The most popular and memorable response came from Representative Tom Tancredo of Colorado, who responded: “I'm looking for Jack Bauer at that time, let me tell you”. Jack Bauer is the immensely popular character from the Fox TV show 24, who regularly relies on his own version of enhanced interrogation. Jack Bauer makes torture popular.
Somewhere in the fog of war, terror, and politics, we have become accustomed to the idea of torture. Recent polling shows that American acceptance of torture is increasing, from 36% in 2006 to 44% in 2008.Additionally, more than half of Americans support torture in some situations, and an equal number support the practice of so-called rendition to other countries for the purpose of torture.During prime-time television, this approval of torture is generated and reflected by Jack Bauer, roughing up prisoners in a weekly struggle to protect the country. As I chatted with Kofi about how we arrived at this acceptance of torture in the USA, he said, “You have no idea what you would do to your neighbour if you thought he would harm your family.” Kofi went on to explain that acceptance of torture can arise from a heightened level of fear, that overcomes good judgment and gives way to inhumanity. For him, tribal fears and animosities paved the way for his persecution. For Americans, Kofi observed, a toxic fear of terror has allowed torture to emerge as an accepted practice.
A central argument against torture is exemplified by Senator John McCain's belief that torture is inherently un-American. Senator McCain believes that to torture is to debase our national identity. George Washington, as a general in the American War for Independence, observed British troops executing surrendered American prisoners, and banned any retaliation in kind, stating: “Treat them with humanity, and let them have no reason to complain of our copying the brutal example of the British Army in their treatment of our unfortunate brethren”.4 In torturing, even out of fear for our survival, we lose our virtue and identity as a nation. Virtually every US president since George Washington has endorsed his rebuttal of torture as un-American, as has President-elect Senator Barack Obama. If we cannot torture because of who we are, the damning question then becomes: who have we become if we accept torture? The use of torture undoubtedly has consequences for the external identity of a nation as well. Referring to revelations of torture by US forces in Iraq, historian Alfred McCoy writes that it has “subtly subverted American rhetoric about democracy and has damaged the nation's moral leadership in the Middle East”.5 The use of torture by US forces was not new;6 but the photographs from Abu Ghraib in Iraq forced people to ask if systematic use of torture was consistent with the ideals of democracy and freedom.
A second critique of torture is that it simply does not work. Torture apologists often appeal to a desire to get tough, and the reported need to increase the amount of information extracted from so-called high-value detainees. Without widespread understanding of the ineffectiveness of torture, the debate often devolves into duel by anecdotes. But analysis of interrogations has shown torture to be ineffective. One of the most successful US interrogators during World War 2, Marine Corps Major Sherwood Moran, eschewed torture as counterproductive. During interrogations of Japanese prisoners, Moran observed that brutality “played right into the hands of those who were determined not to give away anything of military importance”. By contrast, Moran's success was based on the approach to “forget, as it were, the ‘enemy’ stuff, and the ‘prisoner’ stuff. I tell them to forget it, telling them I am talking as a human being to a human being”.7
After World War 2, the US Military Intelligence Field manual was updated to state that the USA “prohibits the use of coercive techniques because they produce low quality intelligence. The use of force is a poor technique as it yields unreliable results, may damage subsequent collection efforts, and can induce the source to say whatever he thinks the interrogator wants to hear”. A 2006 report by the National Defense Intelligence College reviewed all available evidence on interrogation techniques and concluded “…studies of the role of assault in promoting attitude change and in eliciting [false] confessions revealed that it was ineffective. Belief changes and compliance were more likely when physical abuse was minimal or absent…although pain is commonly assumed to facilitate compliance, there is no available scientific or systematic research to suggest that coercion can, will, or has provided accurate useful information from otherwise uncooperative sources”. In his book, Torture and the Ticking Bomb, Robert Brecher further deconstructs the usefulness of torture, particularly in the type of scenario presented in the debate watched by Kofi. Brecher concludes that in matters of extreme urgency or importance, a nation would be ill-served to turn to the least reliable method of interrogation.
These two arguments against torture, though compelling, still fall flat when I think of Kofi. Each of these criticisms addresses a larger context: our national identity and our national security. However, the most abhorrent aspect of torture is what Kofi and other survivors of torture often reveal to their physicians. That one human being picked up a knife and cut into another. Or suspended them from the ceiling while they were beaten. Or raped them. Or burned them. Long after his scars healed and he adjusted to the aches in his joints, Kofi has continued to struggle with mental anguish from being tortured. We are tempted by the glamour and raw charisma that we project onto Jack Bauer, the illusion of protection, and the lure of vigilante justice. But the raw truth of torture is that whatever the original motive, the torturer and the tortured are transformed into a perpetrator and a victim of violence. The torturer visits inhumanity on his victim, but also on himself and the surrounding community. Athar Yawar notes the relation between the use of torture and the inexorable decay of social fabric, as cruelty and inhumanity becomes pervasive and normative.

In an analysis of state tyranny, Riadh Abed similarly observes that the dehumanisation of the individual torturer and the acceptance of his acts “leads to the erosion of accepted social norms of behavior and the normalization of violence”.
As physicians, we have a responsibility to oppose torture. We treat many patients who describe torture, and many more who have experienced it, but cannot bring themselves to disclose it. If Kofi is correct that irrational, overwhelming fear can lead to inhumanity, we should stoke the fires of reason. Three areas for intervention exist for us as physicians. First, we can educate ourselves (as students, residents, and attending physicians) about torture as a public-health issue, its prevalence in our patient populations, and how it affects our ability to deliver care. In recognising torture as a form of violence affecting many of our patients, we can develop standards of screening, medical education, and patient information that facilitate good medicine. When physicians become more knowledgeable about the effects and prevalence of torture, we can begin to detect and, when necessary, treat the adverse effects of torture among our patients. Second, we should strengthen ties with human-rights organisations, lending the credibility and resources of our profession to this endeavour. Just as physicians eventually became integral to campaigns against child abuse and intimate-partner violence, we should now join the international effort against torture. In their landmark report, Medicine Betrayed, the British Medical Association stated that physicians who are aware of torture “have a positive obligation to make those activities known”.

Finally, we should proceed in the least partisan manner possible. The political nature of torture is inescapable. But we will need to cast this discussion in terms of violence, public health, and our ability to deliver medical care to our patients. By bearing witness to the brutality visited on Kofi and others, we may be able to care for our patients better, while helping to eliminate public acceptance of torture.

Sensacionalismo e ciência: mamografias e circuncisão

2008-12-01T14:30:00.000-02:00

Shah Ebrahim é editor do International Journal of Epidemiology e, um arguto observador da cena mundial. Abaixo, um texto instigante exigindo mais ação e menos sensacionalismo ou de como o culto às celebridades nos desvia de questões da maior importância, como a prevenção da aids.

Media hype: good or bad for patients and the health care system?Shah Ebrahim
E-mail: shah.ebrahim@lshtm.ac.uk
Kylie Minogue develops breast cancer and the associated publicity might well be expected to increase young women's demand for breast screening. Kelaher and colleagues1 demonstrate the expected increase in breast imaging (about 20%) in the months following publicity. Interestingly, the biopsy rate did not change in younger women and declined in older women. The odds of surgical procedures following biopsy also fell markedly. These findings led the investigators to propose that the media furore affected doctors as well as patients, leading to a retraction of usual evidence-based practice in the months after the publicity. Is this a good or a bad thing? Celebrity disease is something that can be used to good public effect—notably Ronald Regan's Alzheimer's disease diagnosis contributed to moving dementia syndromes from Cinderella status to high National Institutes of Health funding opportunities in the United States.
But what about preventing breast cancer given rising incidence rates (http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/). Kylie Minogue was young but was at risk due to nulliparity—a powerful risk factor, first recognized in the 1920s by Janet Lane-Clayton.2 The Million Women study has demonstrated the importance of number of children and breast feeding, among other risk factors,3 prompting Valerie Beral, its director, to urge greater research on prolactin, a hormone that increases in late pregnancy and regulates lactation, at a recent UK National Cancer Research Institute conference.
While there are plenty of ‘orphan’ or neglected diseases craving publicity, AIDS is not one of them. The theme of this issue is human immunodeficiency virus—do we still need upper case to denote its importance? Usually associations of social inequalities and disease are negative—it is the poor that suffer. In an analysis of the Tanzanian HIV/AIDS indicator survey, higher standard of living was associated with increased odds of HIV infection, whereas there was no evidence of association with education.4 Higher occupational status was associated with HIV in women but unemployed men were at greater risk than working men. These findings indicate that simplistic notions of HIV risk among rich and poor need to be more nuanced in appreciating what is clearly a complex social matrix of risk.
Perhaps the greatest success in the last year has been the randomized trial evidence, building on a decade of observational epidemiology, demonstrating the reduction in risk of infection due to male circumcision. Many doubted the original observational evidence, so it is particularly gratifying to see how large robust clinical trials have been implemented and pooled to provide strong, compelling evidence of benefit in terms of relative risk reductions as big as a halving of risk.5 On a recent visit to South Africa, in a particularly high prevalence location, I asked about how this new evidence was going to change policies, practices and research directions locally. ‘Not at all’ was the reply.
The prospect of persuading young men to have circumcisions is not everyone's favourite challenge, but it does seem important that preventive surgical initiatives are evaluated and that private sector circumcisions are safely performed, for example. Londish and Murray's6 paper in this issue follows in the steps of previous attempts to model the effects of male circumcision using a wider range of covariates than in previous models. They conclude that targeting of interventions to younger men with risky sexual behaviours is the most effective strategy. In an accompanying commentary, Gray and colleagues7 question whether models will persuade reluctant health service providers and funders to invest in services. They note that several obvious conclusions derive from commonsense: the impact of circumcision is clearly going to be greatest in high HIV incidence but low circumcision prevalence places; circumcising men who are HIV positive is unlikely to be helpful and may increase transmission of infection to sexual partners; opting for infant circumcision, rather than adolescent and adult surgery, will delay any impact by 20 or more years.
HIV modelling also gets some criticism in Elizabeth Pisani's remarkably entertaining and insightful book, The Wisdom of Whores,8 reviewed in this issue by John Cleland from the London School of Hygiene and Tropical Medicine9. Pisani was a student of demography at the School and went on to build a successful career in HIV modelling having been a journalist formerly. The story she tells is of misdirection of research effort and resources as individuals and institutions attempt to get their share of the action. I took this with me for holiday reading and was not disappointed. I recommend you read Cleland's review, get a copy of the book and read it too—whether you are in the HIV field or not.

Morte por falhas dispara no SUS ou Falhas disparam na imprensa?

2008-11-16T09:25:00.000-02:00

Novamente, repito: não sou crítico da mídia. Mas, depois do 'aumento da aids em mais letrados', agora o Estadão publica que "Morte por falhas dispara no SUS". Eles comparam um período, janeiro a agosto de 1998 com o mesmo intervalo de meses em 2008. Apresentam que houve aumento da proporção de óbitos decorrentes de atos médico-hospitalares de 1 para cada 478 mortes em 1998 para 1 para 147 em 2008. Muito estranho. Primeiro, de onde vieram os dados de 2008? Desconheço tamanha velocidade de apuração. Segundo, a origem da informação é a declaração de óbito e, obviamente com o decorrer do tempo, a qualidade melhora. No caso específico, a subnotificação diminui. Terceiro, a declaração de óbito está longe de ser instrumento adequado a verificar erros na atenção médica.

Ou seja, não dá concluir nada, exceto que erros são mais comunicados agora do que antes, mas talvez em número menor.

A queda dos homicídios em São Paulo

2008-11-14T10:19:00.000-02:00

Na revista Espaço Aberto da USP há uma reportagem que sintetiza pesquisa da Secretaria Municipal de Planejamento de São Paulo sobre a queda das taxas de homicídio na cidade publicada no livro Olhar São Paulo - Violêncai e Criminalidade. A tendência é semelhante à ocorrida no restante do estado. O dado importante e, relativamente previsível é que a distribuição espacial continua ainda sendo diferenciada na cidade.

A reportagem completa pode ser lida clicando aqui.O livro Olhar São Paulo – Violência e Criminalidade, já está disponível para a população no site da Sempla . As estatísticas da Secretaria de Estado da Segurança Pública podem ser conferidas aqui.

Aids em mais escolarizados

2008-11-13T03:53:00.000-02:00

Esse blogue não faz parte dos "midia watchers". Porém, quando informações totalmente defeituosas são mantidas na imprensa, não há como ficar calado.

O Estadão, ontem e, a Folha, hoje insistem em repercutir notícia de que "aumenta o número de casos de aids entre mais escolarizados".

A leitura do relatado mostra a incapacidade de se trabalhar com conceitos mínimos em epidemiologia. Primeiro equívoco: a informação compara 1997 com 2007, justamente o período onde houve mais aumento de pessoas com escolaridade superior. Segundo equívoco: aumento proporcional não significa risco maior!!!! Simplesmente, pode ter havido queda muito expressiva entre aqueles com escolaridade inferior à universitária.

Bem, não somente a imprensa precisa ser criticada. Informações como essa precisam primeiro ser publicadas em órgãos com revisão por pares e, somente depois serem divulgadas ao grande público.

Entrevista ao ELSA Brasil

2008-11-12T14:19:00.000-02:00

Entrevista na sala de imprensa do site do Estudo Longitudinal de Saúde do Adulto, o ELSA. (http://www.elsa.org.br)
Dr. Paulo Andrade Lotufo leciona na Faculdade de Medicina da Universidade de São Paulo e é superintendente do Hospital Universitário da instituição. No ELSA Brasil, Lotufo é pesquisador principal e coordenador do Centro de Investigação SP.
Em entrevista ao site ELSA, o médico, autor de vários estudos epidemiológicos sobre doenças cardiovasculares, debate o andamento deste tipo de pesquisa no Brasil, além de falar sobre as crenças e tratamentos relacionados à atual conjuntura de aumento de doenças crônicas não transmissíveis no país.
ELSA Brasil: No Brasil, houve uma transição das principais causas de morte, de doenças infecciosas para as enfermidades crônicas não transmissíveis, em destaque as cardiovasculares. Como o senhor encara as condições do Sistema Único de Saúde para atender a população brasileira dentro desse novo contexto?

Paulo Lotufo: A transição epidemiológica em etapas é descrita somente com finalidades didáticas. De fato, o perfil das doenças se modifica no tempo de forma desigual tanto espacial como socialmente. Por exemplo, a mortalidade por doenças infecciosas é suplantada pela cardiovascular no Brasil nos anos 60, mas no Rio de Janeiro e São Paulo isso aconteceu vinte anos antes, em 1940. Mas, mesmo nessas cidades, a transição foi desigual de acordo com os segmentos sociais. Se essa dinâmica da incidência de doenças não é de assimilação fácil por cientistas, para os planejadores de saúde ela é muito mais difícil. De certa forma, o SUS está uma geração em descompasso com a realidade. Exemplifico: somente agora a hipertensão e diabetes foram alvo de uma política efetiva de controle com o co-pagamento de medicamentos nas farmácias. Aliás, um sucesso que o próprio governo federal não divulga e capitaliza a seu favor. Porém, essa proposta de assistência farmacêutica já era defendida pelos pesquisadores da época há mais de 20 anos, sem qualquer eco no Ministério e secretarias da saúde, cujos dirigentes raciocinavam como se o país estivesse nos anos 50. Agora, temos uma pletora imensa de idosos em pronto-socorros com insuficiência cardíaca, doença pulmonar obstrutiva e fraturas de fêmur, por um lado, e redução expressiva das taxas de fecundidade e natalidade, por outro lado. Mas, ainda há iniciativas em criar institutos da criança ou assemelhados pelo país afora.
E.B.: Estudos epidemiológicos sobre a efetividade de programas e serviços de saúde direcionados à prevenção e ao tratamento de doenças cardiovasculares têm sido desenvolvidos no Brasil?

P.L.: Sim, há cada vez mais estudos. A iniciativa do Ministério da Saúde, em conjunto com as Fundações de Amparo a Pesquisa do PPSUS, foi excelente. Aqui em São Paulo, na equipe que desenvolve o ELSA no Hospital Universitário, realizamos dois projetos. Um dos projetos identificou as internações evitáveis, por isso chamado de EVITA, e criou tecnologias de ação na atenção primária a programas de prevenção cardiovascular. Em breve, estaremos oferecendo um curso de especialização em doenças crônicas não-transmissíveis dirigidas inicialmente a médicos para que atuem na promoção de saúde, prevenção primária e secundária, aplicando os conhecimentos desse projeto. O outro projeto, com apoio do CNPq e FAPESP, é o Estudo de Morbidade e Mortalidade do Acidente Vascular Cerebral (EMMA) que estuda incidência, sobrevida e incapacidade com base hospitalar na fase 1, a mortalidade na fase 2 e a prevalência na fase 3. As informações dessa pesquisa orientarão a execução de ações de prevenção, tratamento e reabilitação.
E.B.: Existem muitas crenças errôneas em relação às doenças cardiovasculares, entre elas as de que tais males atingem apenas idosos e homens. Como evitar que tais idéias continuem se propagando, inclusive entre os profissionais da área médica?

P.L.: Sim, havia um estereótipo de que o “cardíaco” era um paulista ou carioca investidor da Bolsa de Valores, que habitava a ponte-aérea Rio-SP. Coube à atual geração de epidemiologistas demolir essa bobagem. O risco de morte por acidente vascular cerebral de um habitante da periferia de São Paulo ainda é o dobro do morador de regiões afluentes. Apesar da incidência e prevalência maior entre homens e idosos, as taxas de mortalidade na faixa dos 45-64 anos no Brasil ainda são das maiores quando comparadas à de outros países, principalmente entre as mulheres.
E.B.: Ainda que as doenças cardiovasculares sejam a principal causa de morte entre as mulheres, a preocupação com a saúde cardíaca feminina é recente. O que o reconhecimento desse dado implica no atendimento médico da mulher?
P.L.: A mulher é vítima da ginecologia, sempre gosto de brincar com o meu colega, Edmundo Baracat, professor de ginecologia aqui na USP. Incrível, mas mesmo setores feministas sempre viram a assim chamada “saúde da mulher” como algo relacionado à genitália e às mamas. Há uma obsessão em relação ao câncer, mas a chance de morte por doença cardiovascular é cinco vezes maior do que morrer por neoplasia de mama. O ELSA será um momento para testar a minha hipótese de que a sobrecarga de trabalho da mulher brasileira traz conseqüências terríveis refletidas na obesidade, tabagismo, hipertensão e diabetes.
E.B.: Em que estágio se encontra o campo de pesquisas epidemiológicas em doenças cardiovasculares no Brasil?
P.L.: Repetimos aqui uma seqüência que outros países já trilharam. Primeiro, os estudos de mortalidade pela simplicidade e baixo custo; depois, os inquéritos populacionais, caros e com muitos dados, mas com potencial baixo em comprovar hipóteses; agora, estamos com o ELSA avançando nos estudos observacionais. O próximo salto para 2012 será um ensaio clínico de grande envergadura. Aqui, em São Paulo, além das “mulheres ELSA, EMMA, EVITA”, temos também o projeto Avaliação do Grau de Aterosclerose em Adultos e Adolescentes, o AGATAA, que tem como objetivo avaliar populações específicas para verificar o grau de aterosclerose. O primeiro estudo está sendo realizado em pacientes HIV positivo em uso ou não de terapia antiretroviral. Um grande equívoco é insistir em estudos de prevalência, quando coortes ou ensaios clínicos trazem muito mais respostas às nossas indagações.
E.B.: E o que representa o ELSA neste cenário?
P.L.: Não sou modesto. O ELSA é um sucesso porque conseguiu colocar as doenças cardiovasculares e o diabetes na agenda da pesquisa epidemiológica brasileira. Ele é incrivelmente complexo, com muitas variáveis em estudo e, muitos desfechos a serem conferidos no tempo. Afirmei na inauguração do ELSA em São Paulo que se trata de projeto que visa a próxima geração, não a próxima eleição.

Reputação em Chamas

2008-11-11T11:36:00.000-02:00

Cada vez me horroriza mais a sede de justiça daquele setor que o jornalista Jânio de Freitas denominou "classe média raivosa". Quem não pode gastar na Daslu deve ter ficado satisfeito com a prisão da sua proprietária da forma como foi feita. Quem não gostou de Celso Pitta deve ter se sentido vingado com sua prisão de pijamas. Um setor da blogosfera saudou a prisão de Daniel Dantas mais do que a conquista do pentacampeonato, agora viu-se os desmandos da PF, que atingiram o próprio autor dos desmandos iniciais. Agora, o sério problema das licitações em hospitais expõe personalidades médicas do mais alto quilate, queimando reputações contruídas com zelo por décadas.

Angola e o Brasil

2008-11-11T08:35:00.000-02:00

Na semana anterior estive em Luanda, Angola, a convite da Clínica Multiperfil para apresentar junto com a professora Isabela Benseñor palestras sobre doenças cardiovasculares, em particular hipertensão arterial. Participaram também colegas da Medicina USP, David Uip, Dario Birolini e Marcos Boulos. O tempo foi curto lá, mas o suficiente para consolidar a idéia que será impossível ao Brasil desconhecer Angola. Empresas da construção civil já sabem disso, a Globo e Record dominam a televisão. Agora, caberá ao setor de educação e saúde colaborar na reconstrução do país. Vejam só: o governo angolano aprovou 150 bolsas de graduação em Cuba. Ora, a USP, UNIFESP, UNICAMP e UNESP podem fornecer vagas mais do que suficientes, somente em São Paulo, para suprir demandas e, também formar a elite científica daquele país.

Júpiter abala a Terra

2008-11-11T08:24:00.000-02:00

Na reunião anual da American Heart Association que se realiza em Nova Orleans foi apresentado o JUPITER. Ensaio clínico que mostrou que uso de estatina reduz a incidência de infartos do miocárdio, acidente vascular cerebral, internação por angina instável e morte cardiovascular em indivíduos com colesterol normal, mas com valores elevados da proteína C reativa. Há muito a discutir. Importante que o professor Francisco Fonseca da UNIFESP participou do estudo e, quando ele voltar dos Estados Unidos será entrevistado pelo blogue. Aguardem. O texto completo pode ser acessado no site do The New England Journal of Medicine. O autor do texto é Paulo Ridker com quem trabalhei em Boston e, a segunda autora Eleanor Danielson é a mais fantástica organizadora de pesquisas que conheci. Interessante que administradores não recebiam autoria, agora, merecidamente Ellie está na lista.

Momento de lucidez vindo de Boston: "menas" concorrência em áreas vitais

2008-11-03T10:35:00.000-02:00

Reproduzo, post do Running a Hospital, do diretor do Brigham and Women´s Hospital, afiliado à Harvard Medical School. Ele critica a competividade excessiva entre hospitais, principalmente no transplante de órgãos sólidos. O quadro apresentado em Boston, nada difere do existente em São Paulo, onde há excesso de equipes e, resultados que ficam aquém do da qualificação médica existente. Isso porque os resultados dependem de um número grande de fatores que necessitam ser rigidamente padronizados.

The downside of competition
A funny moment the other day.The CEOs of the larger Harvard hospitals founds ourselves in several meetings over the course of consecutive days, working together on areas of common concern -- clinical research, supporting greater diversity on our staff and faculty, and stimulating enhancements between engineering and medical care. These were great sessions, with a clear commonality of interest and purpose, characterized by healthy give-and-take in friendly and helpful discussions, and good progress. After the last of these sessions, one of my colleagues turned to the rest and said, "Okay, enough collaboration for today. Let's go back to competing."He was joking, of course, and we had a good laugh; but, as I have noted before, this is in fact the nature of the relationship. It has its advantages and disadvantages.I think the major disadvantage is that the competition in the clinical arena is so intense that we end up duplicating services that could be consolidated or otherwise rationalized. (In saying this, by the way, I also mean to reference the duplication that also occurs when we include the non-Harvard hospitals in Boston.) I have talked about this before, focusing on the area of solid organ transplants. If there are fewer than say, 400, adult liver, kidney, and pancreas transplants in all of Eastern Massachusetts per year, does it make sense to spread them out among six or seven hospitals located within 15 miles of one another?Each hospital has to make major investments in staff and equipment to carry out a proper transplant program, and the current organization makes economies of scale impossible. It also means that each program is unlikely to be highly profitable -- or perhaps profitable at all -- because it lacks sufficient volume to spread the fixed costs across a large enough patient base.And yet we persist in this fashion, responsive to the demands and wishes of our physicians and because we have a mindset that we cannot be a "real" hospital unless we offer this service to the public.As I have said in recent forums and elsewhere, we need to be protected from ourselves in this regard, either by the insurance companies or the state government. Thus far, though, they have been too timid to act. The public ends up paying the price for this inefficiency.

Bendita crise econômica: a Big Pharma fora da jogatina

2008-11-02T17:50:00.000-02:00

Não sou crítico de mídia. Mas, faltou uma análise mais econômica para explicar o que existe de errado com os remédios. Respondo, nada há de errados com os remédios. O que está errado é a Big Pharma. Mas, quem na Big Pharma? Pesquisa & Desenvolvimento? não! Departamento Médico? não! Departamento de Marketing? não! CEOs? em parte. A resposta é banal e um lugar comum: o capitalismo "selvagem". As indústrias farmacêuticas foram transformadas junto com o setor de informática em um dos mais lucrativos setores para o capital especulativo em bolsas de valores. Utilizando informações fajutas divulgadas em órgãos de imprensa confiáveis, o ganho com ações foi fantástico. De quebra, arrrebente com o FDA e, crie a expectativa da vida eterna. Pronto, a fórmula para o lucro está definida com ganhos astronômicos na Bolsas de Valores.

A principal diretriz foi de que todo medicamento novo, patenteado, é bom para todo mundo, sempre, sem qualquer limitação de uso. Com isso, remédios muito úteis foram "queimados". Exemplo: inibidores da Cox-2, excelentes para uso por poucos dias. Mas, forçaram a barra para uso crônico.

Agora, espera-se que quem entende de remédios comande a estratégia de lançamentos de medicamentos na Big Pharma. Porém, a realidade é que CEOs que ganharam bônus incríveis com a valorização das ações continuam morando bem nos subúrbios americanos ou nas vilas européias. Mas, pesquisadores e médicos corretos que trabalham na Big Pharma ao redor do mundo, correm o risco de desemprego.

o caso Acomplia: estava escrito nas estrelas

2008-11-02T17:43:00.000-02:00

Na úlltima semana estive com vários pesquisadores que chegaram a trabalhar com o rimonabant (Acomplia). Vários deles trabalham na indústria farmacêutica. A dúvida, não era sobre a retirada do Acomplia do mercado, mas sim porque foi comercializado.Atitudes vindas de cima para baixo na Big Pharma, sem ouvir os departamentos médicos e científicos terminam dessa forma.
Leia mais, notícias de ontem nesse blogue sobre o Acomplia.

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

2008-09-30T16:17:00.000-03:00

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

2008-09-26T14:00:00.000-03:00

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

2008-09-25T20:05:00.000-03:00

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.

2008-09-24T11:34:00.000-03:00

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

2008-09-24T07:43:00.001-03:00

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

2008-09-24T07:38:00.000-03:00

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

2008-09-23T08:07:00.000-03:00

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 Group 1
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

2008-09-23T07:41:00.000-03:00

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

2008-09-22T08:06:00.000-03:00

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

2008-09-18T21:41:00.002-03:00

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 article 1 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 article 1 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 Program 2, 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 criteria 2: 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 level 2, 10-12; second, high cholesterol intake relates independently to CHD risk over and above its role in increasing serum cholesterol levels 2; third, feeding cholesterol (eg, from egg yolks) is and has been since 1908 13 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

2008-09-18T14:04:00.000-03:00

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

2008-09-18T11:47:00.000-03:00

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

2008-09-18T02:57:00.000-03:00

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

2008-09-17T19:13:00.000-03:00

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

2008-09-17T18:46:00.001-03:00

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

2008-09-15T20:51:00.000-03:00

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

2008-09-15T15:47:00.000-03:00

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?

2008-09-12T17:03:00.000-03:00

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

2008-09-12T16:18:00.001-03:00

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

2008-09-12T15:41:00.000-03:00

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

2008-09-12T15:39:00.001-03:00

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

2008-09-11T16:56:00.000-03:00

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

2008-09-10T20:41:00.000-03:00

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?

2008-09-09T05:52:00.000-03:00

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 !

2008-09-07T13:23:00.000-03:00

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

2008-09-02T20:09:00.000-03:00

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.

2008-09-02T07:26:00.000-03:00

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

2008-09-02T07:15:00.000-03:00

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).