sexta-feira, 13 de junho de 2008

Venda de órgãos: NÃO !

Agora, a posição contrária à venda de órgãos para transplantes.
Should we pay donors to increase the supply of organs for transplantation? No Jeremy Chapman, professor 1 Centre for Transplant and Renal Research, Millennium Institute, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia Paymentfor livingkidney donation is illegal in most countries. Arthur Matas (doi: 10.1136/bmj.a157) believes that legalisation is needed to shorten waiting times, but Jeremy Chapman argues that it will reduce the supply of all organs. Transplantation is one of the greatest advances in medical therapy in the second half of the 20th century but is threatened by the global daily carnage brought about by paying for organs.1 The race to the lowest cost donor is on, with the Philippines, Pakistan, or China set to lose the most by winning. Cost of sale Sale of organs is advocated by the rich as a fundamental human freedom, but this right is exclusively exercised by the poor. Solving poverty is unachievable, but if there were no poor people in the Philippines or indentured "workers" in Pakistan sales of their organs would be unlikely to continue. Wealthy people are also placed in jeopardy by legalised organ sales. Every patient able to pay will be faced with the question, "Should I wait for deceased organ donation, seek a family donor, or simply buy one?" The allure of using money leaves the individual ever in doubt, many preferring that a stranger rather than a family member takes risks on their behalf. Some recipients of vendor organs die and do not return home, making it impossible to ascertain the true outcomes of purchased organ transplants. Those that arrive home require care immediately, with many going straight from airport to hospital, since the transplant units aim to discharge patients and get them out of the country before problems arise. The risks of vendor transmitted viral diseases such as hepatitis and HIV are high, and heavy induction over-immunosuppression results in high rates of infection and malignancy. It is hardly surprising that payment is required on arrival and not on departure. Who profits? Evaluation of living kidney donors is complex, and less than half of potential donors are found medically suitable. Evaluation requires sophisticated testing and knowledge of the donor’s medical history and current symptoms, which people trying to sell their organs often hide despite potential consequences for themselves or the recipient. Selling organs does not help people lift themselves from destitution. In the bazaars of India and Pakistan, people sell kidneys to pay off debts, but average family income declines by a third, more live below the poverty line, and 86% report deterioration in their health. The only people who clearly benefit are the intermediaries who take money as the kidney transits from the vendor to the recipient: organ brokers, transplant surgeons, hospitals, government officials, and the wealthy health insurance companies of the West and the Middle East. Wider effects Organ sales distort the vendor country. Sales of kidneys and livers boomed in China between 2004 and 2006. Executions also boomed and were measured with precision since each execution meant one liver transplant. China has recognised the grotesque nature of this trade, which was highlighted by the criminal who murdered a vagrant and forced a surgeon (who later informed the police) to remove the organs for sale. The changes brought about by the Chinese government have yet to fully curtail this business, but the number of executions and liver transplants fell from 3500 in 2006 to around 2000 in 2007. Organ sales also destroy donation. In countries where paid organ transplants occur, such as Iran, there is little or no donation. In the countries where many, most, or all transplant recipients travel overseas for an organ, the domestic transplant programmes are underfunded and failing. Regulated market is a myth Ethical proponents of organ sales advocate a regulated market, managed by government to buy kidneys on behalf of the community. The last vestige of human altruism is at stake. Apart from the devastating consequences of American or European adoption of organ sales on less easily regulated environments in Asia or Africa, the consequences at home destroy the proposition. Which family member will donate if the government will pay someone else $100 000 (£50 000; 63 000) to provide a kidney?8 Which recipient will risk a family member’s health when government will pay? And if a kidney is worth money before death, families or individuals will demand money for consent to retrieval of organs after death. Surely the payment must be higher after death because you can use organs that cannot be retrieved from live people? The consequences of regulated organ purchase will be an implosion in organ donation, reduction in kidney transplantations and destruction of heart, lung, liver, and pancreas transplantation. Purchase of organs is not the answer. Competing interests: None declared.

Venda de órgãos: SIM !

O tema doação de órgãos, principalmente de um dos rins já foi tema várias vezes nesse blogue. (clique aqui).
Abaixo, a posição favorável a venda publicada no British Medical Journal. Should we pay donors to increase the supply of organs for transplantation? Yes Arthur J Matas, professor of surgery 1 Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, Minnesota 55455 Paymentfor livingkidney donation is illegal in most countries. Arthur Matas believes that legalisation is needed to shorten waiting times, but Jeremy Chapman (doi: 10.1136/bmj.a179) argues that it will reduce the supply of all organs Today’s biggest problem in kidney transplantation is the shortage of organs; a regulated system of compensation for living donation may be a solution. For patients with end stage renal disease, a kidney transplant provides significantly longer survival and better quality of life than dialysis. The longer candidates wait on dialysis, the worse the results of transplantation. Thus, early transplantation confers an important advantage. Each year, more patients are placed on the waiting list for a deceased donor transplant than there are available organs. Consequently, each year the waiting list, and the resultant waiting time, get longer. In many parts of the United States, the average wait for a deceased donor transplant is five years; in some parts, it is approaching 10 years. Because of the long wait, the death rate for candidates is increasing: from 6.3% annually in 2001 to 8.1% in 2005. Importantly, those who died were acceptable transplant candidates when listed. Regulated payment Any system of payment to increase the supply of organs must be regulated. In the unregulated systems that currently exist, the buyer contracts with the seller to purchase a kidney (often through a broker). Only the rich can benefit and there is little oversight of the donor evaluation, no long term donor follow-up, and no protection of either the buyer or the seller. However, a regulated system would provide strict control and limit harm. It would include payment made by the government or insurance companies; allocation of kidneys by a predefined algorithm so that every candidate has an opportunity for a transplant; full donor evaluation; informed consent; oversight; long term follow-up; treatment of the donor with dignity and appreciation for providing a lifesaving gift; and illegality of any other commercialisation. The compensation could be a fixed package of life insurance, long term health insurance, and reimbursement for travel expenses and time out of work; it could involve a direct payment or a tax deduction. Because dialysis is much more expensive than a transplant, compensation for donation could be cost neutral to the healthcare system. Such a system would work only in countries where there is appropriate oversight and where long term health care and follow-up for the donor could be guaranteed. Thus, donors would have to reside in these countries. Unmet need The main argument for a regulated system is simple. Compensation for living donors will increase the number of transplants and thus decrease death and suffering on dialysis. Why compensation for living donation? Because even if all potential deceased donors became actual donors, there would still be a substantial shortage of organs. Clearly, every attempt must be made to increase conventional living and deceased donation, but no other alternative (or combination of alternatives) to compensation will provide sufficient numbers of kidneys. The short and long term risks for living donors have been studied extensively, so thorough donor informed consent is possible. There are additional reasons to consider a regulated system. Firstly, unregulated systems that do not protect living donors currently exist in several countries. Many patients, desperate for a transplant, travel to take advantage of these unregulated systems. Development of a regulated system would minimise this "transplant tourism." Secondly, a regulated system respects the autonomy of potential donors, in contrast to our current paternalistic ban on compensation that assumes individuals are incapable of deciding what is in their own interest. Surveys suggest that the public favours compensation and that compensation would increase donation. Numerous arguments have been proposed against a regulated system. On detailed analysis, each fails.We accept living donation; thus, to be successful, arguments must differentiate compensated from conventional living donation, which many fail to do. Other arguments used against regulated payment have no supportive data (but that lack could be resolved by a clinical trial) or are illogical—for example, that unregulated systems have failed elsewhere. Arguments that payment for organs will commodify the body ignore the fact that we already compensate people for sperm, ova, surrogate motherhood, and loss of body parts in court cases, without any loss of humanity or dignity. And arguments that the poor will be exploited ignore the fundamental tenet of Western society—that people be allowed to control their own destiny; being poor does not remove the ability to make rational decisions, and people are free to pursue reasonable options to better their lives. At first glance, compensation for donors might appear repugnant. Yet to me, what is truly repugnant is the sad reality of patients dying and suffering while waiting for a kidney. In an ideal world, there would be no end stage renal disease. But since this is unlikely, I believe we should advocate a change in the law to allow a trial of regulated compensation for living donors to increase the supply of organs and protect the health and dignity of waiting patients. Competing interests: None declared.

Obama ou McCain: palpite do The Lancet

The Lancet analisa as possíveis mudanças no "sistema" de saúde americano, com Obama ou McCain vencendo a eleição em novembro. No entanto, há dois pontos importantes: a questão econômica será mais importante do que o Iraque e, também da saúde. Fato impensável há um ano; o poder legistlativo controla o orçamento e, os democratas já está há 18 meses com maioria nas duas casas.
With John McCain long the last man standing among the Republican candidates, and Hillary Clinton having just stepped aside for Barack Obama, the long drawn out campaign for the US presidential nomination now takes a new path. The electorate can turn its attention to the issues, and not just the personalities, at hand. For many Americans, especially the large number of uninsured and underinsured, the most pressing domestic concern is health care. So where do the presumptive nominees stand on this issue? The first fault line between them is predictable: in traditional Republican style, McCain believes in market-based solutions to health-care reform. He would not dismantle the employer-based insurance system, but would provide tax credits to make it more affordable. McCain claims that he would promote competition among insurance companies by allowing the selling of policies across state lines; whether this step would be enough to create real competition is doubtful. Obama's plan is also predictably Democratic, although it is not as radical as the single-payer plan favoured by the most liberal wing of the party. His plan instead is a compromise of sorts: universal coverage would be achieved through retention of private insurance along with the expansion of existing public programmes, such as Medicaid, the federal insurance scheme for low-income Americans, and SCHIP, the State Children's Health Insurance Program, which is jointly funded by the federal government and the states, and through the creation of a new public plan. Neither candidate mandates coverage for all Americans. Obama would require only children to have health insurance, presumably paid for through the expansion of SCHIP. Perhaps the most innovative Obama proposal is a National Health Insurance Exchange, which would provide a range of insurance choices through a pooling scheme, specifically for those people who are not eligible for existing public programmes and who do not have employer-based insurance coverage. The National Health Insurance Exchange would also benefit small businesses that cannot afford to provide their employees with insurance—the group that has often proved most problematic in debates about mandated coverage. Both candidates therefore aim, commendably, to expand coverage. But just being able to afford insurance does not solve one of the biggest problems that exists in most private plans, that is, the power of insurers to deny coverage, or to charge extraordinary premiums, on the basis of applicants' pre-existing conditions. McCain says he will work with the states to create a plan that would, with the support of the federal government, guarantee coverage to people with pre-existing conditions and limit the cost of their insurance premiums, with financial aid for those who do not meet income minimums. Obama's plan would require insurers in his newly created pool to offer guaranteed coverage, and to charge a fair premium that is not dependent on the applicant's health status. We endorse both candidates' intention to remove the inequity and capriciousness of denial of coverage, though a plan that depends, as does McCain's, on the cooperation and financial support of all of the states, is certainly less likely to succeed than a federal programme. Any programme put forth by either candidate must be funded from the outset. Unfunded mandates pose obstacles in even the most trivial legislation; an issue as important as health coverage cannot be relegated to a state-by-state scramble to find the money to pay for it, or, as is most often the case, robbing one of Peter's state plans to pay for Paul's federal mandate. The issues relevant to health are not, of course, limited to insurance, as important as insurance ranks for Americans. Both candidates pledge to invest in cost-containment and quality-improvement measures. McCain wants legislation that will curb frivolous malpractice claims and protect against excessive damage payments. He wants to promote guidelines-based practice, invest in prevention and chronic-disease management programmes, and use telemedicine in remote areas. Many of Obama's proposals are similar, though he also wants to invest US$50 billion in health information technology, and plans to address the health disparities that exist across the country. That the candidates have many similar goals in the non-insurance arena comes as no surprise, since being against these improvements would be akin to opposing motherhood and apple pie. What is needed now, in the long hot days before the conventions at which the respective party platforms will be adopted, is more nuanced debate on these issues, further specifics, and increased boldness. Let the real campaign begin.

A seqüência do caso dos psiquiatras de Harvard

Interessante verificar o seguimento da questão dos psiquiatras infantis que receberam quantia vultosa da Big Pharma, sem considerar e declarar "conflito de interesse". Aqui, encontra-se a posição do Mass Gen Hosp e, uma crítica ferica do Carlat blog. Aliás, recomendo, o Carlat Psychiatric Report.

quarta-feira, 11 de junho de 2008

Corrigindo o besteirol "Made in UK" ou pelo fim dos "o fim de...."

Desde o famoso texto sobre o "fim da história", passou a ser um modismo decreta o fim de alguma coisa. Agora, a aids. Há dez anos houve a "barriga" história de Gina Kolata no The New York Times, graças ao pouco sério J.Watson, quando eles decretaram o fim do câncer. Eu não tinha lido o original, somente a repercussão no Brasil, com comentários sem qualquer base na realidade. Agora, o desmentido oficial e, a origem do besteirol: The Independent.
Joint Note for the media WHO/UNAIDS11 June 2008 Correction to AIDS story in Independent article 8 June 2008 We wish to clarify misinterpretations concerning WHO and UNAIDS positions on the status of the AIDS epidemic in recent media articles. The story in the Independent on Sunday titled: "Threat of world AIDS pandemic among heterosexuals is over, report admits" contained a few seriously misleading statements that have led to inferences and conclusions that bear no relation to the highly complex realities of the HIV epidemic. First and foremost, the global HIV epidemic is by no means over. At the end of 2007, an estimated 33.2 million people were living with HIV. Some 2.5 million people became newly infected that year, and 2.1 million died of AIDS. AIDS remains the leading cause of death in Africa. Worldwide, HIV is still largely driven by heterosexual transmission. The majority of new infections in Sub-Saharan Africa occur through heterosexual transmission. We have also seen a number of generalized epidemics outside of Africa, such as in Haiti and Papua New Guinea. Heterosexual transmission continues to drive the epidemic among sex workers, their clients, and their clients' partners. In addition, prisoners, injecting drug users, as well as men who have sex with men, may also engage in heterosexual relationships. In sub-Saharan Africa almost 60% of adults living with HIV were women: 48% in the Caribbean. HIV prevention and treatment efforts are showing results. Building on these successes will require improved outreach to populations most at risk with evidence-informed approaches based on local HIV epidemiology - an approach we call "knowing your epidemic." In all settings, a supportive environment is required, free from stigma and discrimination, legal barriers or other obstacles that prevent access to services. AIDS awareness campaigns and school-based efforts are essential to promote sexual and reproductive health, ensuring young people have the knowledge and ability to protect themselves against sexually transmitted diseases, and teenage pregnancy. UNAIDS and WHO remain focused on strengthening monitoring of the epidemic to refine responses further and to recognize changes in transmission patterns should they occur. To recap: AIDS remains the leading infectious disease challenge in global health. To suggest otherwise is irresponsible and misleading. Dr Kevin M. De Cock,Director,Department of HIV/AIDS,WHO, World Health Organization

Situação dos PS...americanos

Para quem adora falar na "vala comum do SUS" ou na "falência da saúde pública", nada melhor do ler o Emergency Department - Pulse Report 2008 onde se apresenta um perfil dos pronto-socorros americanos. O relatório discute muito o tempo de espera e de permanência. Maior do que os observados em pronto-socorros paulistas, com certeza. Aliás, essa foi experiência minha como paciente nas unidades de emergência de Boston há dez anos. Abaixo, uma ação de hospital da Dakota do Sul para reduzir espera no pronto-socorro.
Triage: The hospital condensed the questions that triage nurses ask, made the route patients travel within the department more direct, and started requiring triage nurses to assign patients to their next nurse — rather than waiting for somebody else to do it at the next stop. The Next Step: After triage, patients see a nurse and doctor simultaneously, rather than the old method of nurse first, doctor second. If the nurse isn’t ready, the doctor can go ahead and treat the patient without waiting. For common ailments, there are set protocols folks in the hospital can follow if a doctor is delayed. For instance, patients with likely fractures can get X-rays while they wait. “Universal” Rooms: These are equipped with bedside supplies that allow the hospital to care for 85% of problems patients arrive with at the ER. Other supplies can be rolled to patients on carts. The idea is to keep patients from having to move around and employees from stepping on each others’ toes as they walk around to gather supplies. Paperwork: Registration functions such as getting patients’ addresses and payment information take place at the bedside, after care has been started. Who Goes Where: The hospital did a deep dive into its data to figure out where patients typically end up after going through the ER. Each department is expected to prepare daily to admit the number of patients it tends to get, so that it can pull them out of the ER quickly.

terça-feira, 10 de junho de 2008

Um livro grátis para quem gosta de mudar as coisas

From news to everyday use - The difficult art of implementation. A literature review by Karin Guldbrandsson. Swedish National Institute of Public Health, 2008
Esse livro é de acesso livre sobre a dificil arte de implementar inovações na área da saúde pública. Entre outros exemplos, a demora em administrar suco de cítricos aos marinheiros para evitar o escorbuto. Entre a primeira evidência e a ação foram 200 anos e milhares de vidas...
Não consegui ler todos os textos, mas há dicas muito interessantes, principalmente para quem não tem muita paciência com os elocubradores próprios da saúde pública.

domingo, 8 de junho de 2008

Conflito de interesse: psiquiatras de Harvard

Por falar em conflito de interesse.......
Researchers Fail to Reveal Full Drug Pay By GARDINER HARRIS and BENEDICT CAREY Published: June 8, 2008 A world-renowned Harvard child psychiatrist whose work has helped fuel an explosion in the use of powerful antipsychotic medicines in children earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but for years did not report much of this income to university officials, according to information given Congressional investigators. Senator Charles E. Grassley pushed three experts in child psychiatry at Harvard to expose their income from consulting fees. Dr. Joseph Biederman belatedly reported at least $1.6 million in consulting fees. By failing to report income, the psychiatrist, Dr. Joseph Biederman, and a colleague in the psychiatry department at Harvard Medical School, Dr. Timothy E. Wilens, may have violated federal and university research rules designed to police potential conflicts of interest, according to Senator Charles E. Grassley, Republican of Iowa. Some of their research is financed by government grants. Like Dr. Biederman, Dr. Wilens belatedly reported earning at least $1.6 million from 2000 to 2007, and another Harvard colleague, Dr. Thomas Spencer, reported earning at least $1 million after being pressed by Mr. Grassley’s investigators. But even these amended disclosures may understate the researchers’ outside income because some entries contradict payment information from drug makers, Mr. Grassley found. In one example, Dr. Biederman reported no income from Johnson & Johnson for 2001 in a disclosure report filed with the university. When asked to check again, he said he received $3,500. But Johnson & Johnson told Mr. Grassley that it paid him $58,169 in 2001, Mr. Grassley found. The Harvard group’s consulting arrangements with drug makers were already controversial because of the researchers’ advocacy of unapproved uses of psychiatric medicines in children.