sábado, 2 de agosto de 2008

Lei Seca, Tom Jobim e as motocicletas

Todos os dados federais, estaduais e do município de São Paulo indicam que a mal denominada Lei Seca (ver Lei Seca é papo de otário) é sucesso na redução de mortes no trânsito. Nosso viés economicista também foi acionado e, a economia da medida também foi medida. Simplesmente Excelentente! como diria o humorista Paulo Bonfá.
Na também - simplesmente excelente - exposição da Bossa Nova na Oca do Ibirapuera há um manuscrito de Tom Jobim escrito em Nova Iorque em 1963, onde ele está estarrecido com o "beba, mas não dirija". Sim, em 1963 isso já ocorria nos Estados Unidos.
Por fim, há um novo e triste fato nas ruas que ceifa vidas, mutila e lota os pronto-socorros: o uso sem qualquer regra de motocicletas. Prefeitos são reféns dos motoqueiros. Demagogos não faltam para apoiar os motoqueiros, mas mães e pais ficam órfãos, jovens se arrebentam e os hospitais públicos ficam intransitáveis. Afinal, não há moto que facilite a entrada em centros cirúrgicos.

sexta-feira, 1 de agosto de 2008

Tortura e profissionais de saúde

The Lancet apresenta um relato atualizado sobre a questão médicos e torturas e, proposta de punição. Ou, a participação de médicos no ato da tortura ou no acobertamento de óbitos com atestado médico falso. O relato sobre o Brasil mais atual é o da Anistia Internacional, que apresento em inglês, porque não achei a versão em português. Leia também Hipócrates traído, publicado aqui há mais de um ano.
Há menção no relato brasileiro de membros do Tortura, nunca mais condenados por calúnia de médicos. Não conheço o caso apresentado. Mas, tal como ocorreu em 1964 quando dentro de instituições havia ajustes internos de conta sem qualquer motivação político - maior exemplo, Faculdade de Medicina da USP- houve e, ainda há difamação e calúnia contra médicos que teriam colaborado com os porões da ditadura sem a mínima evidência.
Doctors’ complicity with torture. It is time for sanctions It is an arresting thought. More doctors abet torture than treat the millions of victims. More than 100 countries condone the use of torture. A third to a half of torture survivors report that a doctor oversaw the abuse. Many prisoners never see the doctors who refined the techniques to minimise evidential scars, prolong pain, or cause psychological destruction. Estimates of the numbers of torture victims do not include people whose murders disappear when a doctor writes "natural causes" on a death certificate. The medical profession ought to dissociate itself from torture—a practice that destroys institutions of civil society; that is used against colleagues of conscience, and that has far reaching adverse mental, physical, and social consequences. Instead, medical societies and licensing boards offer lofty condemnation, which is most ardently aimed at offenders abroad rather than accomplices at home. Doctors who abet torture rarely face professional risks. Governments will not punish a doctor for helping them carry out their crimes. Few medical societies or licensing boards have the courage and constancy of vision to investigate or censure colleagues who carry out the law of the land. In principle, medical societies support ethics codes like the World Medical Association’s Declaration of Tokyo, which bars doctors from complying with torture. In practice, they sustain the policy of impunity. The exceptions are instructive. The Nuremberg trial of Nazi doctors for war crimes was the birth of bioethics. That admirable court was convened by victors over defendants from a vanquished nation. But it is the wrong place to look for solutions to the common problem of doctors complying with torture. The problem today is holding doctors accountable for abetting torture and cruel, inhuman, or degrading treatment of their own citizens. Such cases have occurred after a torturing regime loses power. Brazilian medical licensing boards began investigating doctors for collaborating with torture during the last years of military rule. Initially, the government blocked sanctions against doctors; within a decade of civilian government sanctions against doctors took hold. In Greece, Dimitrios Kofas, a doctor stationed at the persecution section of a prison in Athens, was sentenced to prison within a year of the military junta being deposed. The Chilean Medical Society actively investigated complaints against doctors and expelled six doctors for overseeing torture during Pinochet’s rule. Three years after Argentina’s junta fell, Dr Jorge Berges was sentenced to prison for carrying out torture. A South African medical board tabled complaints against police doctors who failed to report or treat the fatal head injury inflicted by police on civil rights leader Steven Biko; two doctors were punished eight years after his death.

quinta-feira, 31 de julho de 2008

Big Pharma caminha para biotecnologia

O fim da química fina como atividade da BigPharma avança. Depois da compra da Genentech pela Roche, agora há outras aquisições previstas no mesmo sentido.Vejam a reportagem abaixo do The New York Times.
Bristol-Myers Offers $4.5 Billion for Rest of ImClone
By STEPHANIE SAUL and ANDREW POLLACK Published: August 1, 2008 Bristol-Myers Squibb said Thursday that it planned an offer of $60 a share, or about $4.5 billion, to acquire the rest of ImClone Systems, the maker of the cancer drug Erbitux.The company said in a regulatory filing that it had delivered the offer by letter to the chairman of ImClone, Carl C. Icahn. Bristol currently owns about 17 percent of ImClone, a biotechnology company. The cash offer represents a premium of about 30 percent over ImClone’s closing share price on Wednesday. But investors apparently believed the sale price of ImClone could go even higher, bidding up the company’s shares by 37 percent, to $63.74, a half-hour before the market close. Shares in Bristol-Myers Squibb were off 1 percent, to $21.28. Global sales of Erbitux in 2007 exceeded $1.4 billion. Bristol’s offer comes little more than a week after another drug giant, Roche, offered to buy the 44 percent of its longtime biotechnology partner, Genentech, that it did not already own for $43.7 billion. And it comes during a period in which big pharmaceutical companies are buying smaller biotechnology players to gain rights to products to replenish their pipelines. Recent deals include Takeda Pharmaceutical’s offer to buy Millennium Pharmaceuticals for $8.8 billion and GlaxoSmithKline’s purchase of Sirtris Pharmaceuticals for $720 million. Companies like Genentech and ImClone sell so-called biologic products, which are made in living cells. Such drugs are particularly attractive because they are not subject to a sudden rush of competition by generic manufacturers. Bristol ’s offer set off speculation on Wall Street that other big drug makers might would seek to acquire biotechnology companies that are already their partners. Share of Onyx Pharmaceuticls, which co-developed a cancer drug with Bayer, were up about 9 percent in midday trading, as were shares of Amylin Pharmaceuticals, which co-developed a diabetes drug with Eli Lilly.

Tio Sam não é bobo, seus bajuladores nacionais são

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

Correção do Check Up de Câncer de Pulmão

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

quarta-feira, 30 de julho de 2008

Fim dos livros médicos?

Vem aí a MedPedia. Uma wikipedia médica, mas com colaboradores com currículo e aceitos por um conselho editorial. Apoio de peso:Harvard, Stanford e Michigan. O proponente é Joseph Martin, ex-diretor da escola de medicina Harvard.
Vamos ver o que ocorrerá, mas esse fato lembra o futuro apresentado em um post (25/07/08) recente no Blog do Alon sobre o fim dos livros.

terça-feira, 29 de julho de 2008

Em breve, mais gente vivendo do que morrendo de aids

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

segunda-feira, 28 de julho de 2008

Chagas é prioridade?

O tema doença de Chagas já foi tratado várias vezes no blogue . Hoje, há notícia de que estamos na linha de descoberta de novos fármacos para a doença. Tudo bem, ninguém é contra o conhecimento. Mas, e deverá constar vários "más", a doença de Chagas é residual em nosso meio. Ela foi eliminada (ver o post citando o artigo do Prof Eduardo Massad) praticamente do cenário brasileiro. Resta entre os mais idosos que foram expostos ao barbeiro e, em acidentes como o do açaí. A epidemiologia brasileira ainda é um brinquedo para epidemiologistas, afirmo com ceticismo, ainda não serve para o planejamento de serviços, muito menos para prioridades na ciência. A única "salvação" é "anexarmos" a Bolívia, onde há uma prevalência enorme de infectados. Talvez, uma troca com o gás loca.
Excelência brasileira (28/7/2008) Por Fábio de Castr o Agência FAPESP – Agência FAPESP – A Organização Mundial da Saúde (OMS) acaba de criar, no Brasil, um novo Centro de Referência Mundial em Química Medicinal para Doença de Chagas , formado por grupos de excelência ligados à Universidade de São Paulo (USP) em São Carlos (SP) e à Universidade Estadual de Campinas (Unicamp). O novo centro atuará diretamente na rede de laboratórios de descoberta de novos fármacos do Programa Especial para Pesquisa e Treinamento em Doenças Tropicais (TDR, na sigla em inglês), da OMS. Depois de uma competitiva seleção internacional, a organização escolheu o grupo brasileiro para formar o centro voltado especificamente para a pesquisa sobre doença de Chagas. (texto completo, clique aqui)

domingo, 27 de julho de 2008

Antibióticos e Longevidade: o primeiro uso da penicilina

No Annals of Internal Medicine há o relato da primeira administração de penicilina a uma mulhere de 33 anos morimbunda por infeçção por estreptococos. Ela morreria de outra causa aos 90 anos.
The first use of penicillin in the United States occurred in 1942 and saved a moribund patient who had [beta]-hemolytic streptococcal sepsis.
The first dose of penicillin given in the United States was administered at Yale–New Haven Hospital on 14 March 1942 to a patient dying of septicemia. As a young Yale house officer, I found myself involved in what few of us then realized was a very profound sequence of events. It was my ninth month of service, and I was an acting assistant resident. On the private floor of the Yale–New Haven Isolation Building, a very ill 33-year-old patient had [beta]-hemolytic streptococcal sepsis. She had run a steady temperature of 103° F to 106° F for 4 weeks Her private physician, Dr. John Bumstead, persuaded Dr. John F. Fulton, another ill patient of his with a severe pulmonary infection, to try to obtain a new drug—penicillin. The drug was not yet available in the United States. Dr. Howard Florey had reported on the use of penicillin in England in 1941, and Dr. Fulton was aware of Florey’s studies. Since their Oxford days together, Fulton and Florey had remained friends. In fact, Dr. Florey’s children were living with the Fultons in New Haven, Connecticut, to escape the German bombs falling on London in 1941. -Dr. Fulton, a National Research Council (NRC) Committee on Aviation Medicine member and Sterling Professor of Physiology, and Dr. Francis G. Blake, Sterling Professor of Medicine and a leading member of the National Academy of Science Chemotherapy Committee, used their considerable influence to complete the tortuous route required to release the small amount of penicillin available in the United States. Dr. Florey and his associate, Dr. Norman Heatley, had come to the United States in an effort to increase penicillin production, because England was so busy with the war with Germany. The first vial was mailed to Dr. Bumstead in New Haven from Merck & Co. in Rahway, New Jersey, and it arrived on Saturday, 14 March 1942. Dr. Bumstead and I took the vial to Dr. Morris Tager, Associate Professor of Bacteriology and Immunology. We discussed what to do with the pungent, brown-red powder. “We decided to dissolve it in saline and pass it through an E.K. Seitz [asbestos] filter pad to sterilize it,” wrote Dr. Tager in 1976. We then returned to the patient, and I injected 5000 U into the intravenous tubing. Rocko Fasanella, a medical student (later a professor of ophthalmology at Yale), gave subsequent doses every 4 hours. By Monday morning, the patient was eating hearty meals, the intravenous treatment was stopped, and she subsequently received 5000 U intravenously every 4 hours. On Monday morning rounds, Dr. Wilder Tileston, a senior consultant, looking at the temperature chart, muttered to those of us close enough to hear, “black magic.” My fellow intern, Dr. Herbert Tabor (later the editor of the Journal of Biological Chemistry for many years), saved all of the patient’s urine because Dr. Heatley had informed us that more penicillin could be purified from it than could be produced by cultivation. Probably up to 95% of each intravenous dose was excreted unchanged. When Dr. Heatley delivered a subsequent vial, some of which had come from the patient’s urine, he carted the gallons of urine back to Rahway. The patient survived and later died of other causes at the age of 90 years. Four hundred million units of penicillin were produced in the first 5 months of 1943. In the next 7 months, 20.5 billion units were produced—an increase of more than 500 times. By August 1945, 650 billion units were distributed each month. The subsurface liquid culture technique produced so well that when the structures of penicillin F and G were later established, it was decided that producing penicillin by culture rather than by any chemical synthetic method would be far less costly. Production costs changed so that the cost of an ampoule of 100 000 units was “scarcely more than the cost of material and labour to put it into an ampoule” If any one person is to be credited with the development of penicillin in the United States, it should be Dr. John F. Fulton. The literature does indeed tell about his significant role. His telephone calls from his own hospital bed demonstrated his persistence, perspicacity, patience (when needed), propriety, and personal influence. He recognized a need and a possible fulfillment of this need, and he effectively pushed for the sequence of events that transpired. Fleming, Florey, and Chain received the Nobel Prize in Medicine in 1945 for their contributions. Fulton deserves credit together with Dr. Francis G. Blake for proving the enormous value of penicillin and effecting the birth of the antibiotic era

Evitar a obesidade infantil é prioridade de saúde pública

Há quem critique a proposta de controle da propaganda de alimentos dirigidos às crianças e jovens no Brasil. Nos Estados Unidos, a televisão é um mistura de anúncios de redes de restaurantes, de carros e de .....antiácidos para a digestão! Ainda não chegamos ao padrão americano, mas se políticas para evitar o aparecimento da obesidade não sejam estabelecidas desde já chegaremos no padrão descrito pelo The New York Times, na edição dominical.
Weight Drives the Young to Adult Pills, Data Says By STEPHANIE SAULPublished: July 26, 2008 A growing number of American children are taking drugs for a wide range of chronic conditions related to childhood obesity, according to prescription data from three large organizations. The numbers, from pharmacy plans Medco Health Solutions, Express Scripts and the marketing data collection company Verispan, indicate that hundreds of thousands of children are taking medication to treat Type 2 diabetes, high blood pressure, high cholesterol and acid reflux — all problems linked to obesity that were practically unheard-of in children two decades ago. The data, disclosed publicly in recent months or provided at the request of The New York Times, shows that concerns that children will be taking adult medications — heightened recently by a controversial recommendation by a national pediatricians group — are already a reality. This month, the American Academy of Pediatrics said that more children, as young as 8, should be given cholesterol-lowering drugs. The recommendation was quickly attacked by some experts as a license to put children on grown-up drugs. While the drugs do help treat the conditions, some doctors fear they are simply a shortcut fix for a problem better addressed by exercise and diet. Even so, some pharmaceutical companies are developing new versions, including flavored ones, of adult medications for children. While some of the percentage increases in the three analyses are significant, doctors empha-size that prescriptions of these drugs to children still represent less than 1 percent of their sales. Express Scripts and Medco developed estimates of how many children might be taking such drugs by extrapolating their data — involving a total of more than four million children — across the broader population. The companies use different assumptions to reach their estimates, but the data suggests that at least several hundred thousand children are on various obesity-related medications. The greatest increase occurred in drugs for Type 2 diabetes, with Medco’s data showing a 151 percent jump from 2001 to 2007. Medco’s data, released in May, showed that use of drugs to treat acid reflux problems in children, often aggravated by obesity, increased 137 percent over seven years. Its analysis also showed an 18 percent increase in drugs to treat high blood pressure and a 12 percent increase in cholesterol-lowering medications during the seven-year period. Express Scripts found a 15 percent increase over three years in drugs to treat cholesterol and other fats in the blood, a category that is primarily statins. “We were amazed at how quickly the rates of drugs used have climbed,” said Dr. Donna R. Halloran, an assistant professor at St. Louis University who worked on the Express Scripts analysis, presented at a meeting of the American Public Health Association in November. Verispan data recorded a 13 percent increase in high blood pressure prescriptions in the under 19 age group from 2005 to 2007. Its numbers show, however, a less than 1 percent increase during the period in cholesterol-lowering drugs in children. Doctors and some financial analysts have said that less pronounced increases in cholesterol drugs compared with some other medications — seen in all three analyses — reflect a wariness by some doctors about using those drugs in children. Some experts have expressed concern that the increases in many of these obesity-related drugs reflect a systemic failure, with doctors and parents turning to them because they find lifestyle changes too difficult to implement or enforce. “I think a lot of people in pediatrics, myself included, are struggling with what is the right management to do for these kids,” said Dr. Russell L. Rothman, an assistant professor at Vanderbilt University, who recently surveyed doctors and found wide variations in how children were being treated. “You see elevated blood pressure, or elevated sugars, or elevated cholesterol and you try exercise and diet and you don’t see any improvement,” Dr. Rothman said. “I worry that some providers and some families are looking for the quick fix, and are going to want to start medication immediately.” Some pediatricians say they have been treating children with statins for several years.