Uma homenagem a Leonardo Lotufo

Leonardo Lotufo, meu tio-avô foi dirigente várias vezes do então Palestra Itália e, depois do Palmeiras. Dirigiu o Conselho do clube quando houve a mudança de nome. Ao contrário do que ocorre hoje, pessoas com posse - ele era proprietário da NeoBrasil, empresa de luminosos - junto com outro palestrino compraram o passe de Jair Rosa Pinto para o time do Palmeiras, agora reconhecido como Campeão Mundial. Como meu tio disse uma vez, a Copa Rio foi a redenção brasileira, não somente paulista ou palmeirense depois do fracasso da Copa do Mundo de 1950

Turistas, não o filme, mas a realidade dos transplantes no Paquistão, India e Filipinas

Estarrecedora essa mensagem da Reuters mostrando o aumento do turismo de transplante. O relato é da Organização Mundial da Saúde. No Paquistão há local onde há uma proporção considerável de habitantes somente com um rim. O preço é 2500 dólares, mas pouco fica com o doador.

Já tinha ouvido muito a respeito, mas essa informação é das mais documentadas.

Interessante o nosso mundo atual: O Paquistão gasta dinheiro formando médicos (e, dos bons), a Filipinas gasta outro tanto com enfermeiras. Ambos profissionais não ficam em seu país e, vão para os Estados Unidos, Canadá e Europa. Em troca, pacientes americanos e europeus recebem rins de paquistaneses e filipinos. Bem, os cubanos não têm nada a ver com a história.

Transplant tourism" on rise due to donor shortages Fri Mar 30, 2007 1:50pm ET By Laura MacInnis GENEVA (Reuters) - "Transplant tourism" is on the rise because organ donations are not keeping up with growing demand, especially for kidneys, the World Health Organization (WHO) said on Friday. The United Nations agency said it was concerned about a rise in cases where people in countries such as Pakistan, Egypt and the Philippines were persuaded to sell their body parts to outsiders, mostly through a broker. The practice has increased over the past decade, said Luc Noel of the WHO's health technology and pharmaceuticals unit. We believe 5 to 10 percent of all kidneys transplanted were in 2005 transplanted in this setting," he told a news conference in Geneva, home to the WHO's headquarters. Transplantation is increasingly regarded as the best solution to end-stage organ failure, according to the WHO. Jeremy Chapman, a physician at Westmead Hospital in Sydney, Australia, said medical advances in transplantation surgery have resulted in surging demand from those needing new kidneys, livers, hearts, corneas and bone marrow. Long waiting lists for organs from cadavers have caused frustrated patients to look overseas for new sources, he said. The wealthy, in search of their own survival, will sometimes seek organs from the poor," Chapman said after experts convened by the WHO recommended stricter organ donation and transplantation rules to confront the practice. Farhat Moazam of the Sindh Institute of Urology and Transplantation in Karachi, Pakistan, said increasing numbers were traveling to her country to buy kidneys. "There are villages that are in the poorer parts of Pakistan where as many as 40 to 50 percent of the population of the village we know only has one kidney," Moazam told the briefing. She said donors are often promised as much as 150,000 rupees ($2,500) for an organ but may only get a fraction of that after brokers' fees and associated medical costs are paid. It is possible for healthy individuals to donate organs and tissues which they can live without, such as a kidney, part of the liver, blood or bone marrow. Living donations regularly take place in developed countries, most often between relatives. Noel said many of those who sell their organs and tissues do not receive adequate follow-up medical care, increasing their health risks.

Enfermeiros estrangeiros nos EUA: bom para quem recebe, mal para quem envia.

The American Journal of Public Health publica artigo original onde verifica a tendência e qualidade do enfermeiro vindo de outro país. Em uma década, aumentaram de 8,8% para 15,2%. Na maioria com formação muito boa e adequada.

Sempre tive dúvidas porque as escolas de enfermagem, quando existem e, não meros departamentos da escola médicas, são relativamente fracas. Descobri há dez anos que eles não precisam gastar com a formação de enfermeiros, compram fora. Essa tendência está aumentando e, nós precisamos ter o cuidado para não sermos também um celeiro de enfermeiros para os EUA. E, depois importarmos enfermeiros cubanos semi-escravos.

Trends in Skills and Country of Origin Among Foreign-Trained Nurses in the United States, 1990 and 2000 Daniel Polsky , Sara J. Ross , Barbara L. Brush Julie Sochalski Objectives. We describe long-term trends in the characteristics of foreign-trained new entrants to the registered nurse (RN) workforce in the United States. Methods. Using the 1990 and 2000 US Census 5% Public Use Microdata Sample files, we compared trends in characteristics of US- and foreign-trained new entrants to the RN labor force (n=40827) and identified trends in the country of origin of the foreign-trained new entrants. Results. Foreign-trained RNs grew as a percentage of new entrants to the RN workforce, from 8.8% in 1990 to 15.2% in 2000. Compared with US-trained RNs, foreign-trained RNs were 3 times as likely to work in nursing homes and were more likely to have earned a bachelor’s degree. In 2000, 21% of foreign-trained RNs originated from low-income countries, a doubling of the rate since 1990. Conclusions. Foreign-trained RNs now account for a substantial and growing proportion of the US RN workforce. Our findings suggest foreign-trained RNs entering the United States are not of lower quality than US-trained RNs. However, growth in the proportion of RNs from low-income countries may have negative consequences in those countries

The Lancet: compra a briga com Blair por causa do Iraque.

Richard Horton, editor do The Lancet, não aguentou os ataques aos artigos publicados sobre a guerra do Iraque vindos do governo britânico. Whitehall não gostou do número: 650 mil civis mortos no Iraque. Ontem, no The Guardian, ele respondeu em texto reproduzido na íntegra. Fez uma associação com o fim dos 200 anos da abolição da escravatura e tráfico pelos ingleses. Our collective failure has been to take our political leaders at their word. This week the BBC reported that the government's own scientists advised ministers that the Johns Hopkins study on Iraq civilian mortality was accurate and reliable, following a freedom of information request by the reporter Owen Bennett-Jones. This paper was published in the Lancet last October. It estimated that 650,000 Iraqi civilians had died since the American and British led invasion in March 2003. Immediately after publication, the prime minister's official spokesman said that the Lancet's study "was not one we believe to be anywhere near accurate". The foreign secretary, Margaret Beckett, said that the Lancet figures were "extrapolated" and a "leap". President Bush said: "I don't consider it a credible report". Scientists at the UK's Department for International Development thought differently. They concluded that the study's methods were "tried and tested". Indeed, the Johns Hopkins approach would likely lead to an "underestimation of mortality". The Ministry of Defence's chief scientific adviser said the research was "robust", close to "best practice", and "balanced". He recommended "caution in publicly criticising the study". When these recommendations went to the prime minister's advisers, they were horrified. One person briefing Tony Blair wrote: "Are we really sure that the report is likely to be right? That is certainly what the brief implies?" A Foreign and Commonwealth Office official was forced to conclude that the government "should not be rubbishing the Lancet". The prime minister's adviser finally gave in. He wrote: "The survey methodology used here cannot be rubbished, it is a tried and tested way of measuring mortality in conflict zones". How would the government respond? Would it welcome the Johns Hopkins study as an important contribution to understanding the military threat to Iraqi civilians? Would it ask for urgent independent verification? Would it invite the Iraqi government to upgrade civilian security? Of course, our government did none of these things. Tony Blair was advised to say: "The overriding message is that there are no accurate or reliable figures of deaths in Iraq". His official spokesman went further and rejected the Johns Hopkins report entirely. It was a shameful and cowardly dissembling by a Labour - yes, by a Labour - prime minister. Indeed, it was even contrary to the US's own Iraq Study Group report, which concluded last year that "there is significant underreporting of the violence in Iraq". This Labour government, which includes Gordon Brown as much as it does Tony Blair, is party to a war crime of monstrous proportions. Yet our political consensus prevents any judicial or civil society response. Britain is paralysed by its own indifference. At a time when we are celebrating our enlightened abolition of slavery 200 years ago, we are continuing to commit one of the worst international abuses of human rights of the past half-century. It is inexplicable how we allowed this to happen. It is inexplicable why we are not demanding this government's mass resignation. Two hundred years from now, the Iraq war will be mourned as the moment when Britain violated its delicate democratic constitution and joined the ranks of nations that use extreme pre-emptive killing as a tactic of foreign policy. Some anniversary that will be. · Richard Horton is a doctor and the editor of the Lancet

Ministra Matilde: uma proposta

Prezada Ministra, acho que você já recebeu muitas pedradas pelo que disse, não disse e, que acharam que dissera. Agora, passada a tempestade, recomendo em prol da redução das desigualdades de cor, raça e etnia que solicite três audiências:

(1) ao ministro Paulo Bernardo (Planejamento), solicitando que pare de implicar com a área da saúde e retire os entraves á regulamentação da emenda constitucional número 29 e, repor o valor devido à Saúde com o novo cálculo do PIB;

(2) ao ministro Tarso Genro (Justiça), explicando que a repressão à violência interessa muito mais ao pobres e negros do que ao ricos e brancos, como muitos no governo federal adoram falar;

(3) ao seu chefe, sua Excelência, o Presidente da República para que entre para a história reduzindo a diferença de mortalidade entre negros, pardos e pretos. Para tanto, basta ordenar aos seus dois colegas de cima que parem com essas estultícies em relação à saúde e à segurança pública.

Veja, então o exemplo americano que a senhora tanto gosta. Afinal, a senhora adota o "one drop rule", (que eu particularmente abomino, mas respeito sua opinião). Esse foi o mote de um post editado nesse blogue na semana passada: JAMA publica estudo mostrando a evolução da mortalidade entre brancos e negros. Há uma redução na diferença de mortalidade entre os homens devido a redução da mortalidade por aids, traumas em geral e homicídios entre o negros. Entre as mulheres por causa das doenças cardiovasculares entre as negras.

Coragem para contestar os stents e sua indústria.

Na sessão da American College of Cardiology, que se encerra hoje, houve a apresentação de vários estudos novos, um deles chamado COURAGE. Esse estudo avaliou 2287 pacientes com angina do peito para comparar se angioplastia com stent não farmacológicos é superior ao tratamento convencional com medicamentos. Houve uma leve vantagem para o tratamento clínico, ou seja não há porque indicar angioplastia nessa situação. O texto completo está em http://www.nejm.org Abaixo segue um reportagem muito esclarecedora do The New York Times com a repercussão do estudo. Um pouco antes, a Boston Scientific que produz o Taxus - stent farmacológico - aproveitou-se da situação para lançar a idéia que o problema do estudo foi que somente 3% dos participantes teriam usado o seu produto.

By BARNABY J. FEDER Published: March 28, 2007 NEW ORLEANS, March 27 — Is today the first in a new era for angioplasty and stenting, the artery-clearing technology that enchanted doctors while giving birth to a multibillion-dollar industry? Many heart specialists at the annual scientific meeting here of the American College of Cardiology said it ought to be, based on a report Monday that found little additional value in giving stents to most heart patients as long as they received the right medicines. “We were amazed at how well people did with medical therapy,” said Dr. William Weintraub, chief of cardiology at the Christiana Care Health System in Newark, Del., who is leading the analysis of the economic and quality of life data from the trial. The trial focused on patients with severe constrictions in their arteries that were causing angina chest pains or other symptoms but were not immediately life-threatening. Device makers and some doctors, however, doubted that the trial would have broad impact. They noted several reasons to question the results, starting with the fact that only 3 percent of the stented patients in the trial received the latest drug-coated models. Those models were just reaching the market when enrollment in the study ended in 2004. Whether the trial results lead to a change in the use of stents depends on how the doctors and patients react. In any event, the research comes as sales have already been dropping because of safety concerns. Estimates from doctors and analysts of the number of stent patients whose conditions resembled those in the trial ranged from 20 percent to as much as 80 percent. Marshall Gordon, who follows device makers for Credit Suisse Securities in New York, said that in conversations with cardiologists, 30 percent to 40 percent of them said they would recommend less angioplasty. But, he cautioned, it was too soon to know how the practice would unfold. Dr. Salim Yusuf, a Canadian cardiologist who has argued that stents are overused, questioned how much impact the study would have. “We’re going to have a hell of a time putting the genie back in the bottle,” Dr. Yusuf said to the researchers gathered Tuesday. “It’s a $15 billion to $20 billion industry. You have huge vested interests that are going to push you back.” Dr. Yusuf was referring not just to device makers but also to interventional cardiologists, the specialists who do angioplasty and stenting. The technology was born 30 years ago when Dr. Andreas Gruentzig first used a catheter threaded into a coronary artery to inflate a tiny balloon inside a developing blockage. The arrival of a minimally invasive alternative to bypass surgery for restoring blood flow to ailing hearts led to a rush of investment in device companies. Small fortunes were made in the mid-1990s when stents were invented in response to angioplasty’s biggest shortcoming — the tendency of arteries to quickly reclose. Those fortunes became giant ones when drug-coated stents were introduced in the United States in 2003, sending the number of patients returning for repeat procedures below 10 percent. The Taxus stent from Boston Scientific, which arrived in 2004, achieved more sales in its first year than any health care product in history. By last year, more than 60 percent of the patients getting stents had more complex blockages than those the drug-coated stents had been tested on in clinical trials, according to federal regulatory officials. Then reports began emerging that deadly clots could form in the drug-coated stents long after implantation. Sales began dropping on uncertainty about the stents’ safety even though the data showed that the problem affected only a handful of patients out of every thousand. The available data, which some doctors say is inadequate, suggests that the clotting is not frequent enough to make the new stents less safe than the older bare-metal devices they have largely supplanted. A decline in sales last year reflected some switching to the cheaper bare-metal stents, but by the end of the year, the total number of procedures was falling for the first time. Now the question is whether the new trial data will accelerate the decline and make it harder for the companies to reverse with new products that might be safer. Medical therapy — which to cardiologists means a combination of modern drugs, exercise, healthy diets and almost anything else that does not break the patient’s skin — was so successful at relieving angina that Dr. Weintraub and others said angioplasty should be used as a fallback, after the drug treatments failed in patients like those in the trial. In common practice, many such patients get angioplasty and stents because they are sent to interventional cardiologists for angiograms — X-rays of the blood vessels sustaining the heart muscle. The angiogram requires inserting a thin catheter to deliver a dye to the arteries being pictured. Because the same system is used to deploy the tiny angioplasty balloons that create channels through blockages and then to implant stents to prop the vessel open, interventional cardiologists often do such procedures immediately after a major blockage is identified. “It’s very difficult to turn your back on the angiogram and not fix what’s there,” Dr. William Boden, a lead investigator in the trial, said. Yet that is exactly what the trial results suggest that doctors could safely do in patients like those studied. Two-thirds ended up not needing angioplasty and stents. The one-third whose symptoms worsened to the point that they underwent stenting or bypass surgery did not suffer higher rates of death, heart attacks or hospitalization if stenting was delayed to try aggressive medical therapy first, the trial found. In the trial, patients who received angioplasty and stents got quicker and more complete relief initially. By the end of five years, 74 percent of that group and 72 percent of the patients assigned to the medical therapy group had no symptoms of the chest pains — in essence, statistically speaking, an identical outcome. Dr. Weintraub said on Monday that the trial data suggested that the cost of gaining an additional year of improved quality of life from stenting came out to $217,000 a patient, because so many patients gained nothing. That data, however, covered such a broad range of individual outcomes that he cautioned against relying too much on it. More notably, he said, the data suggested that 1 percent of stenting patients gained an additional year of improved quality of life for less than $50,000, a commonly used standard for whether medical resources were being used wisely. But all of the researchers stressed that angioplasty with stenting was still the preferred therapy for many less-stable patients. Some doctors said they were worried that patients reading about Courage, as the new study is called, might get the wrong impression. “If someone comes in with a heart attack, you could lose vital time having to convince a patient or family member it’s appropriate,” Dr. Ralph Brindis, a cardiologist in San Francisco, said

O boicote à vacina contra a pólio na Nigéria.

Na Plos Medicine desse mês há um relato muito interessante sobre o boicote à vacinação contra a poliomielite em cinco estados da região norte da Nigéria. O tema é interessante para verificar que não bastam recursos financeiros, mas sim uma rede mínima - social, política, cultural - para permitir políticas de saúde pública.

O texto completo está em http://medicine.plos.org. Abaixo, um resumo.

Community Prevent Further Boycotts? The vaccine boycott in Nigeria was influenced by a complex interplay of factors. These factors included lack of trust in modern medicine, political and religious motives, a history of perceived betrayal by the federal government, the medical establishment, and big business, and a conceivably genuine—albeit misplaced and ineffective—attempt by the local leadership to protect its people. A recent editorial in The Lancet argued that “few data exist on the best way to stop the spread of false information” . One lesson from the Kano boycott is that research is needed to investigate why people have concerns and fears about vaccination, and what steps should be taken to avoid boycotts in the future. Other lessons are discussed below. Governments should be sensitive to local politics, especially as they affect health-care delivery Immunization campaign programs should be a participatory event involving state and local governments, community leaders, and parents. There are three types of community leaders in northern Nigeria—traditional rulers, political leaders, and religious leaders. Traditional rulers acquire their status through succession and their authority is rooted in traditions and customs [40–42]. Political leaders acquire their status through the political process and religious leaders do so on a religious basis. Among the three, the traditional ruler is best placed to represent the interests of children. Community leaders may contribute to the success or failure of health research and delivery . Public awareness campaigns about vaccination are crucial. These should stress the value of immunization and involve the media. Reaching the community requires radio, television, and folk media (such as local music, theatre, and festivals). Immunization messages can be packaged into songs by local musicians and can be communicated through drama in the language that local people understand. Research ethics committees should be established in each local government. These committees would examine and approve or reject health research in its sphere of influence. Members of these community-based ethics committees should include volunteers who are ready to undergo basic ethics training relevant to their duties. The committees should be under the supervision of, and funded by, the local government's councils, and the committees should work with local medical associations. They should choose their own chairperson and determine their own agenda in line with the national ethics code. Barriers to the formation of local ethics committees include inadequate capacity, funding, and communication.

A decisão do STJ: vitória ou derrota do consumidor de planos de saúde?

A decisão do Supremo Tribunal de Justiça que cabe somente ao médico e, não ao plano de saúde decidir medidas diagnósticas e terapêuticas é um entendimento que poderá ser tornar jurisprudência. Assim interpretam a decisão, as entidades de defesa do consumidor. A Agência Nacional de Saúde Suplementar minimizou o caso, considerando com um problema restrito aos planos antigos.

Minha opinião é que a participação dos planos de saúde e seguros-saúde deve ser novamente discutida dentro da lógica do Sistema Único de Saúde, onde o nome já diz tudo, representam um setor "suplementar". Continuo defensor ardoroso que esses planos deveriam atuar somente nos setores de atenção básica e secundária (consultas, cirurgias simples, gravidez e parto) e, o tratamento do câncer, transplantes e terapia intensiva ficaria em hospitais públicos ou então em hospitais particulares, para que a "minoria branca de Claudio Lembo" possa se tratar. Qual a vantagem da minha proposta? Haveria aumento real e, não fictício da cobertura à assistência médica porque esses planos poderiam oferecer propostas acessíveis ao orçamento familiar e, principalmente das empresas que manteriam como benefício trabalhista. Com isso haveria um desafogo do pronto-socorros e hospitais públicos que poderiam se dedicar aos procedimentos que exigem maior implementação tecnológica. A pergunta do título vem da possibilidade de que premido cada vez mais pelo alto custo, as seguradoras deixem o mercado de saúde.

Casa Branca 2008: cobertura universal à assistência médica

A disputa presidencial americana no próximo ano terá como tema, assistência médica, mais especificamente a ampliação da cobertura restrita atual para o atendimento universal. Essa questão candente foi discutida com os candidatos potenciais à Casa Branca, mas somente os democratas compareceram. Todos concordam que é um imperativo do momento atual americano, mas poucos explicitam que haverá aumento de impostos. Essa questão é tão importante, que governos estaduais estão se adiantando à legislação federal. Hillary Clinton é que mais pode falar, afinal foi destroçada há doze anos quando no governo de seu marido tentou abordar o tema. Abaixo, trecho da reportagem do The New York Times.

LAS VEGAS, March 24 — Seven Democratic candidates for president promised Saturday to guarantee health insurance for all, but they disagreed over how to pay for it and how fast it could be achieved. Senator Barack Obama of Illinois said Saturday that he would develop a plan that would provide health care insurance for all by January 2013. Senator Hillary Rodham Clinton of New York assailed the health insurance industry and said she would prohibit insurers from denying coverage or charging much higher premiums to people with medical problems. John Edwards, the former senator from North Carolina, offered the most detailed plan for universal coverage, saying he would raise taxes to help pay the cost, which he estimated at $90 billion to $120 billion a year. Senator Barack Obama of Illinois appeared less conversant with the details of health policy and sometimes found himself on the defensive, trying to explain why he had yet to offer a detailed plan to cover all Americans. “The most important challenge is to build a political consensus around the need to solve this problem,” Mr. Obama said. Gov. Bill Richardson of New Mexico offered a potpourri of ideas to achieve universal coverage, including tax credits to help people buy insurance and an option to let people ages 55 to 64 buy coverage through Medicare. To help pay for his proposals, Mr. Richardson said, he would “get out of Iraq” and redirect money from the military to health care. The candidates spoke at a forum on health care at the University of Nevada, Las Vegas, sponsored by the Service Employees International Union and the Center for American Progress Action Fund, a liberal advocacy group. Sponsors of the forum said they had also invited Republican candidates, but none attended. Health care is emerging as a top issue in the 2008 presidential race, as businesses join consumers in demanding action to curb costs and cover the uninsured. Nevada has gained new prominence in the political calendar. It will provide an early test of voter sentiment in a Sunbelt state with a large Hispanic population, and the results here could help create momentum for a Democratic candidate going into New Hampshire. Nevada Democrats are scheduled to hold presidential caucuses on Jan. 19 next year, five days after the Iowa caucuses and three days before the first-in-the-nation primary in New Hampshire. Mrs. Clinton said she hoped to make health care “the No. 1 voting issue in the 2008 election.” Her remarks were reminiscent of a speech she gave to the service employees union in May 1993, when she attacked “price gouging, cost shifting and unconscionable profiteering” in health care and the insurance industry. On Saturday, she said that the failure of her proposal for universal coverage in 1994 made her more determined to achieve the goal now. “It also makes me understand what we are up against,” Mrs. Clinton said. “We have to modernize and reform the way we deliver health care. But we have to change the way we finance it. That’s going to mean taking money away from people who make out really well right now.” Mrs. Clinton complained that “insurance companies make money by spending a lot of money, and employing a lot of people, to avoid insuring you, and then if you’re insured, they try to avoid paying for the health care you receive.” To deal with such problems, Mrs. Clinton said, “we could require that every insurance company had to insure everybody, with no exclusion for pre-existing conditions.”