Escândalo no Mississipi: mortalidade infantil aumenta

Incrível, mas há aumento da mortalidade infantil no Mississipi. Além, disso os estados sulistas apresentam valores bem elevados quando comparos aos demais estados. O aumento está ocorrendo entre os negros, que já apresentam taxas bem mais elevadas. The New York Times apresenta reportagem extensa sobre o fato: um escândalo para a maior potência do mundo.

In Turnabout, Infant Deaths Climb in South By ERIK ECKHOLM Published: April 22, 2007 HOLLANDALE, Miss. — For decades, Mississippi and neighboring states with large black populations and expanses of enduring poverty made steady progress in reducing infant death. But, in what health experts call an ominous portent, progress has stalled and in recent years the death rate has risen in Mississippi and several other states. The setbacks have raised questions about the impact of cuts in welfare and Medicaid and of poor access to doctors, and, many doctors say, the growing epidemics of obesity, diabetes and hypertension among potential mothers, some of whom tip the scales here at 300 to 400 pounds. “I don’t think the rise is a fluke, and it’s a disturbing trend, not only in Mississippi but throughout the Southeast,” said Dr. Christina Glick, a neonatologist in Jackson, Miss., and past president of the National Perinatal Association. To the shock of Mississippi officials, who in 2004 had seen the infant mortality rate — defined as deaths by the age of 1 year per thousand live births — fall to 9.7, the rate jumped sharply in 2005, to 11.4. The national average in 2003, the last year for which data have been compiled, was 6.9. Smaller rises also occurred in 2005 in Alabama, North Carolina and Tennessee. Louisiana and South Carolina saw rises in 2004 and have not yet reported on 2005. Whether the rises continue or not, federal officials say, rates have stagnated in the Deep South at levels well above the national average. Most striking, here and throughout the country, is the large racial disparity. In Mississippi, infant deaths among blacks rose to 17 per thousand births in 2005 from 14.2 per thousand in 2004, while those among whites rose to 6.6 per thousand from 6.1. (The national average in 2003 was 5.7 for whites and 14.0 for blacks.)

A hora e vez dos estudos de segurança

A Reuters noticia hoje (20/04/07) que os planos de saúde estão mais sensíveis e receosos em relação aos novos tratamentos, tudo depois do casos Vioxx. Cita também o trabalho fantástico da equipe de epidemiologia da Kaiser Permanent cujas análises argutas já mostraram risco sérios como o da nifedipina e dos Cox-2. A conclusão é óbvia, porque :

(1) os novos tratamentos são eficazes e seguros nos problemas que já se previa na fase de ensaio clínico;

(2) o ensaio clínico por definição limita o tipo de participante, caso contrário, nada concluiria em tempo razoável;

(3) o medicamento ao ser lançado no mundo real passa ser objeto de observação de efeitos em pacientes que foram excluídos do ensaio clínico. Assim, uma série de efeitos não desejáveis que passam a ser notados. O oposto também ocorre, efeitos desejáveis não previstos mudam a indicação do fármaco, como no caso do minoxidil que foi lançado para hipertensão, mas como efeito não esperado, crescia cabelo. Assim, uma solução tópica foi criada com sucesso e, esqueceu-se o anti-hipertensivo;

(4) o ideal é que haja sempre um controle rigoroso de segurança nos primeiros anos, mas como é o momento da indústria recuperar o investimento, tal procedimento é quase sempre relegado.

Health plans back greater scrutiny of new drugs CHICAGO (Reuters) - U.S. health insurers, whose patient records helped uncover heart risks of the withdrawn arthritis drug Vioxx, called on Thursday for a new body to compare the safety and effectiveness of new drugs versus older treatments. America's Health Insurance Plans, a trade group for big health insurers like Kaiser Permanente and WellPoint Inc., also backed greater authority for U.S. regulators to police the safety of drugs once they hit the market. The recall of Merck & Co.'s Vioxx in 2004 helped ignite a growing controversy over whether drugs are adequately monitored for safety after being approved. "We all tend to assume newest is best, which is not always the case," said Roberta Herman, chief medical officer at Harvard Pilgrim Health Care, a hospital system in Boston which recently won the top spot in a national quality ranking of U.S. hospitals. The health insurers group called for a new entity, funded with public and some private resources, that would be independent of the drug industry to conduct real-world studies of drugs. A representative of the Pharmaceutical Research and Manufacturers of America trade group was not available for comment. Kaiser Permanente, a big health maintenance organization in California with about 8.5 million, supplied some of the data used by the FDA finding Vioxx boosted the risk of stroke and heart attack. Several insurers have contracts with the FDA to supply the large swaths of data needed to detect side effects of drugs on the market. On Wednesday, a U.S. Senate panel approved a bill to bolster the FDA's oversight over prescription drugs, which includes a new power to fine companies for not completing studies and a ban on advertising for new drugs for two years. The Bush Administration has called the bill onerous and some Republicans tried to strike language on the advertising ban. Critics say aggressive consumer advertising boosts overuse of new drugs. Jack Hoadley, a professor at Georgetown University's health policy institute said health plans have vested interest in such reforms because they could trim drug costs, but their support adds clout to the idea. "It's the natural rivalry of the payers versus the manufacturers, but I think any time a major industry group comes out with a particular statement like this it does have some effect," Hoadley said

Abaixo o cretinismo!

Já há alguns anos, um grupo do Boston Medical Center vem alertando para o fato de que mulheres grávidas da população local mais pobre apresentam deficiência alimentar de iodo! O último alerta indica que o leite de até 50% dessas mulheres pode estar deficiente em iodo. Tendo acompanhado de perto a batalha contra a deficiência de iodo na América Latina durante anos, nunca pensei que fosse reencontrar esse problema a menos de dois quilômetros do hospital onde trabalho hoje, em Boston.

O texto acima foi escrito por Antônio Bianco, médico, ex-professor da USP, hoje, radicado em Boston, Estados Unidos. O texto completo está em Pesquisa Fapesp que pode ser acessado clicando o título de post. Os países do planeta com deficiência ou excesso de iodo na dieta pode ser acessado clicando no mapa acima. Continua, Bianco:

Infelizmente, a falta de iodo continua sendo a principal causa de retardamento mental em todo o mundo. Esse é um problema muito antigo que está ligado ao surgimento da vida nos oceanos, há cerca de 600 milhões. A origem marítima fez com que o funcionamento da maior parte dos organismos se desenvolvesse baseado em elementos abundantes nos mares, como a água, que constitui mais da metade do organismo humano adulto. Outro elemento marítimo importante é o iodo. Pequenas quantidades desse elemento químico são necessárias para a vida da maioria dos organismos em nosso planeta. Nós, por exemplo, necessitamos da ingestão de cerca de um décimo de miligrama de iodo todos os dias. Ao se aventurarem no ambiente terrestre, os vertebrados bem sucedidos foram aqueles que conseguiram desenvolver mecanismos para se proteger da falta de água e desses outros elementos, inclusive do iodo. Nos animais vertebrados, o iodo é fundamental para a produção dos hormônios da tireóide, uma glândula localizada no pescoço, aderida à traquéia. A deficiência de hormônios da tireóide durante a gravidez e/ou nos primeiros dois a três anos de vida freqüentemente resulta em rebaixamento importante da inteligência (QI), deficiência auditiva e de crescimento, sendo que nos casos graves observa-se retardamento mental, surdez e baixa estatura. Um quadro triste e irreversível, conhecido como cretinismo.

Um novo escândalo: plano especial para jornalistas.

Um novo escândalo divulgado pela Folha de S.Paulo, hoje: jornalistas têm direito a assistência médica na Câmara dos Deputados.

Entende-se parte do problema do financiamento da saúde no Brasil.

(1) poderes judiciários e legislativo criam seus "serviços de saúde' com recurso que não foi destinado a tal;

(2) empresas estatais financiam planos de saúde e repassam o valor ao preço das tarifas;

(3) sindicatos conseguem planos especiais nos dissídios e as empresas repassam ao produto.

Bem, e o povo brasileiro? Fica na dependência do SUS que faz milagres desde vacinação a transplantes de pâncreas. Com isso há superlotação de hospitais universitários e, também dos próprios municipais e estaduais.

A imprensa obviamente prefere fazer reportagens sobre não atendimento em hospital sem recurso para tal. Parte do recurso ficou em Brasília, com o colega jornalista que cobre a Câmara.

Por isso, não é pauta de nenhum órgão da imprensa, questionar os serviços médicos próprios do judiciário e legislativo, nem os planos de saúde das estatais. Legal mesmo é jornalista econômico falar do "rombo orçamentário devido aos desperdícios na área da saúde" na parte da manhã e, depois solicitar atendimento de imediato em hospital público a tarde.

Ministro admite desvio de verbas na Saúde

No Estadão de hoje, o Ministro da Sáude José Gomes Temporão admite aquilo que todos sabem e, poucos têm coragem em explicitar: desvia-se oficialmente recurso da área da saúde. O golpe de prefeitos, governadores e do presidente (na figura do secretário do Planejamento) é de considerar que "alimentação, transporte, etc etc etc" são determinantes do binômio saúde-doença. O casal Garotinho foram os pioneiros e os que melhor executaram essa "cirurgia". Outro aspecto é a não regulamentação da emenda constitucional número 29 de 2000 que aportaria mais R$10 bilhões ao Ministério da Saúde, também obra do secretário do Planejamento.

Declínio do câncer de mama nos Estados Unidos

A incidência de câncer de mama está caindo nos Estados Unidos desde 2003 entre mulheres com mais de 50 anos. Tenho coceira na língua (ou nos dedos) para escrever que trata-se de impacto da redução da hormonioterapia com os resultados do Women´s Health Iniative (julho de 2002). No entanto, sou obrigado a ceder ao argumento de minha mentora, JoAnn Manson, professora titular da Harvard Medical School e pesquisadora do WHI, para quem, esse declínio pode ser devido a um artefato, associado ao resultado do WHI:"houve redução na realização de mamografias porque as mulheres que abandonaram a reposição sentiram-se menos preocupadas ." Argumentação forte, mas obviamente insatisfatória. Aliás, quando não sabemos porque uma doença começa ter incidência aumentada, também não entendemos porque há redução dos casos novos. No Brasil, os padrões epidemiológicos se repetem uns dez anos depois dos observados nos EUA, ou seja ainda é cedo para qualquer alteração nas taxas de incidência no Brasil.O texto está acessível no The New England Journal of Medicine para assinantes e, o resumo pode ser lido clicando o título do post.

Remédios sem médicos e enfermeiros: um dilema africano

Plos Medicine publica um estudo sobre a disponibilidade de medicamentos para aids, malária e tuberculose em países com um número reduzido de médicos e enfermeiros. Os autores fazem paródia com com o movimento Medicine sans frontiers, lançando o Medicines without Doctors, que chamei de Remédios sem médicos e enfermeiros. Ou seja, mesmo com o apoio de fundos beneméritos (Melinda e Bill Gates, p.ex) e a cooperação da Big Pharma (sem ironia), o problema continua, porque há necessidade de uma estrutura mínima. Vou continuar ainda essa semana, discutindo artigo de Laurie Garrett na Foreign Affairs sobre o tema, mas já discuti a situação de Gana (exportação de médicos) e da Nigéria (resistência à vacinação) como exemplos da difícil situação da África.O texto é Ooms G, Van Damme W, Temmerman M (2007) Medicines without Doctors: Why the Global Fund Must Fund Salaries of Health Workers to Expand AIDS Treatment. PLoS Med 4(4): e128 doi:10.1371/journal.pmed.0040128 e, a conclusão segue abaixo. Both the cases of Mozambique and Malawi illustrate the crucial importance of addressing the health workforce crisis. It is easier to remedy the shortage of medicines with external funding than it is to remedy the shortage of health workers with external funding. Medicines can be bought; health workers need to be trained first. This underlines the importance of starting emergency human resources programmes now, before the growing case load—resulting from the fact that most people on ART will stay alive longer, while the number of people in need of ART will grow—undermines either the quality of ART programmes, or the performance of health systems. Without support from the Global Fund, it will be difficult for Mozambique to develop its own emergency human resources programme. Bilateral donors are unable to support human resources programmes that rely on sustained external assistance over decades. The World Bank is unwilling to use foreign assistance for salaries of health workers. The IMF is unwilling to stretch ceilings on wage bills, because commitments from bilateral donors are unreliable. Without flexibility about these ceilings, bilateral donors cannot support salaries of doctors and nurses, even if they want to. It is a vicious circle. The Global Fund is probably the only actor able to break through this vicious circle. It is the only donor mechanism that benefits from an explicit endorsement from the international community to practice a novel approach to sustainability.But donors must give the Global Fund the resources to do so. As one of us argued in a previous article, it is feasible to turn the Global Fund into a world health insurance, funded by rich countries in accordance with their wealth, and creating rights for poor countries to obtain assistance in accordance with their needs. It would allow individual donors to overcome their inability to make commitments beyond the term of their governments, because their contributions would be compulsory. (This is not a heresy. Many bilateral donors consider their contributions to the World Bank as compulsory. This can be achieved for contributions to the Global Fund.) Furthermore, the pooling of resources by many donors would increase continuity: if one donor reduces its contribution, another donor could compensate.And that is exactly what countries like Mozambique need to increase their health workforce: sustained assistance.

Publicidade de medicamentos: será o fim de um suplício?

Não tomei o tempo de ninguém para rebater as críticas das cervejeiras e publicitários da proposta da ANVISA em restringir a propaganda de bebidas alcóolicas. A lorota é a de sempre: "não estamos induzindo o consumo, somente a troca entre marcas". Nossos publicitários são ruinsmesmo, vocês não acham? Bem, o que aconteceu nos Estados Unidos com o fogo cerrado contra a publicidade de cigarros e bebidas alcóolicas? A saída dos publicitários e mídia foi se unir com a Big Pharma e, foi obtida permissão para a publicidade direta de medicamentos. [No Brasil, a propaganda direta continua proibida, apesar de algumas burlas como mensagem subliminares ou então reportagens pagas]. A conseqüência da decisão governamental no início dos anos 90 foi a inundação de publicidade nas revistas, jornais, rádios (insuportável, lembra o nosso Zé Bettio) e, televisão. Todos os três principais jornais da noite têm um seção sobre medicina com reportagens (muito boas, na maioria das vezes, baseadas em artigos originais recém publicados no JAMA ou The New England Journal of Medicine) e, logo após uma enxurrada de publicidade farmacêutica. Obviamente, tudo isso tem um custo e, o consumidor americano sabe muito bem quanto é, visto que paga os remédios mais caros do mundo. Agora, a maioria democrata na Câmara e Senado quer restringir a publicidade, proibindo-a nos dois primeiros anos de lançamento. Prefiro, uma ação radical, mas já é um começo. Abaixo, despacho da Associated Press, de hoje à tarde.

Drug-Safety Bill Would LimitDirect-to-Consumer Advertising Associated PressApril 17, 2007 12:25 p.m. Pharmaceutical companies could be prohibited from advertising new drugs directly to consumers for the first two years they are on the market under a bill moving through Congress this week. The goal, supporters say, is to ensure medicines are safe before allowing industry to promote them to consumers in the hopes they will request prescriptions from doctors. But a reduction in TV and print advertising, which helped transform medications for heartburn and arthritis into blockbusters, would be a serious financial blow to drug makers. According to one study, every $1 spent on pharmaceuticals advertising often adds more than $2 in sales. While the Food and Drug Administration already screens a small portion of ads voluntarily submitted by drug companies, consumer advocates favor much tougher regulation, arguing that the studies companies use to test the safety of new drugs are not always large enough to spot dangerous side effects. "We don't know, and we won't know, how truly safe a drug is until it's been used in millions of people," said Consumer Reports analyst Bill Vaughan. "The real testing of these drugs takes place after a pill hits the market and that's why the advertising needs to be regulated." For its part, the drug industry says pharmaceutical ads are an important tool for patients, giving them information about diseases and treatment options. "Banning this information even for just a couple of years is not in the best interest of patients and physicians who every day make important health-care decisions," said Ken Johnson, Vice President for the Pharmaceutical Research and Manufacturers of America. Drug makers spent nearly $5 billion on direct-to-consumer advertising last year, according to Nielsen Media Research, and a 2004 study found that American TV viewers watch an average of 30 hours of drug ads per year. The freedom companies have enjoyed over the past decade to employ this marketing tool, however, is now in jeopardy. The Senate committee that oversees the Food and Drug Administration meets Wednesday to put the finishing touches on a bill that would give the agency new powers, including a provision that would allow the agency to bar advertisements for two years after a drug is approved -- a restriction the industry says is tantamount to a prohibition on free speech. Sens. Ted Kennedy (D., Mass.) and Michael Enzi (R., Wyo.) began crafting the bill several years ago, following public outcry over FDA's handling of the Merck pain reliever Vioxx, which was pulled from the market in 2004 after showing links to heart attack and stroke. In an effort to show they can better regulate themselves, drug companies including Pfizer Inc. and Bristol-Myers Squibb Co. have voluntarily stopped advertising their prescription drugs for the first 6 and 12 months they are on the market. And the trade group Pharmaceutical Research and Manufacturers of America recently issued voluntary guidelines for members to follow when promoting drugs to patients. The guidelines recommend companies submit all television advertisements to FDA for review before they are broadcast. Under an agreement reached last year, companies are expected to start paying the agency more than $80,000 for each ad reviewed in 2008. The agency said it will use the money to hire 27 new employees. Figures from FDA suggest companies are indeed changing how they promote their medicines. The agency has only cited four companies for consumer-directed ad violations since January 2006. FDA made 17 citations in 2005. Still, lawyers working for the drug industry are attacking proposals that would mandate even tighter restrictions. "In our system of jurisprudence we have a very high threshold that protects the right to free speech, whether it's political or commercial," said Jim Davidson, attorney for the Advertising Coalition, which is funded by advertising firms and drug companies. "What they're saying with this ban is "we don't know where the harm is, but we know there's a statistical likelihood that some adverse event will occur, therefore you can't promote your product.'" Mr. Davidson has urged Senate staffers to eliminate the provision on advertising, arguing that the Supreme Court has already struck down similar attempts to regulate commercial speech. Consumer advocates who support the measure stress that it would merely give FDA the option of barring advertising, and would probably only be used on first-of-a-kind drugs. But that hasn't assuaged drug companies that increasingly invest in consumer-directed marketing. Most of the blockbuster drugs of the last decade have been supported by heavy TV advertising, beginning with AstraZeneca's heart-burn medication Prilosec in 1998 and continuing to the current campaign for Bristol Myers and Sanofi-Aventis' blood thinner Plavix

Prontuário eletrônico para pobres em Nova Iorque

O tema prontuário eletrônic0 existe desde que se iniciou a nova cultura da "tecnologia de informação". Até agora houve grandes avanços, principalmente para contas a receber, a pagar e auditorias. Mas, muito pouca coisa se alterou para melhorar o relacionamento médico-paciente. Quase todas as propostas de "prontuário eletrônico", pioram a relação, porque quebra o eixo "olho no olho" entre médico e paciente, porque obriga a digitar, invés de escrever. Abaixo, mais uma promessa de informação eletrônica. Big Medical Step, Starting With the City’s Poor By RICHARD PÉREZ-PEÑA Published: April 16, 2007 For years, policymakers have said that the next big step in American health care should be electronic records systems that remind doctors and patients about needed care, and make it easier for doctors to share information with one another. New York City officials today are to announce what they hope is a leap in that direction, far beyond what any other part of the country has attempted, by providing free software to doctors who treat hundreds of thousands of people. And defying the usual pattern of wealthy patients benefiting first from technological advances, the city is starting with the poor. “We will cover half of all the high-volume Medicaid providers in the city, those where over 30 percent of their patient encounters are Medicaid or the uninsured,” said Farzad Mostashari, an assistant city health commissioner overseeing the project. Over the next two years, the city’s Department of Health and Mental Hygiene will distribute the software to about 1,500 medical practices, from small neighborhood doctors’ offices to large clinics, including the medical offices at the Rikers Island jail. City officials, and makers of patient records software, said they do not believe any state or large local government has tried such a thing. The department spent months shopping for an electronic records system before awarding a $19.8 million contract to eClinicalWorks, a Massachusetts company that is a sales leader in the field. The medical practices will have to supply the computers. Some already have the equipment. Others that do not might qualify for a state program that awards grants to upgrade medical technology. Many doctors’ offices have computer systems for billing and scheduling, but most do not have software for patient care. The software the city is buying combines all those functions, Dr. Mostashari said. The project is intended to address one of the biggest flaws in modern medicine, that even people who have regular doctors often do not get preventive care. For instance, every year, tens of millions of Americans fail to get recommended flu and pneumonia vaccines, and surveys have shown that many doctors fail to ask patients who smoke whether they want help quitting. “As a doctor, I’m likely to pay attention to the patient’s acute complaint, and not to notice, ‘Oh, my goodness, she hasn’t had a mammogram,’ ” Dr. Mostashari said. “The computer never forgets, and it will remind me.” The system can alert doctors when patients are due for preventive care and then the doctor can advise the patient. With an electronic records system, a doctor or nurse would, ideally, have a computer at hand when seeing a patient, and would record findings with a keyboard, not a pen. (There are even blood pressure cuffs and thermometers that automatically send their readings to computers, but the city will not pay for those.) The Department of Health and Mental Hygiene plans to compile the information in the systems, and tell each practice how it is doing at making sure its patients are receiving routine care. One of the biggest problems with electronic records has been that different software systems cannot communicate with one another — so that, for example, an emergency room doctor might not be able to instantly call up records kept by a patient’s cardiologist. Dr. Mostashari said that no program available commercially is trouble-free on that score, but that creating a network of so many doctors using the same system is a start

O almoço grátis novamente: agora a avaliação de projetos de pesquisa.

Jerry Avorn, professor de farmacoepidemiologia da Harvard Medical School começa seu artigo no The New England Journal of Medicine (Paying for Drug Approvals — Who's Using Whom?) da seguinte forma: "Anos atrás, um diretor de hospital regional explicou me como as reuniões clínicas no seu hospital estavam funcionando bem: " a indústria farmacêutica traz o conferencista, paga seus honorários e o almoço dos médicos que por sua vez garantem audiência". Isso funciona para nós com orçamentos tão apertados" . Avorn utiliza esse exemplo corriqueiro para avaliar outro problema mais sério: o pagamento das indústrias ao FDA para analisar seus processos. De início, parece justo, mas depois há um confusão, que o autor questiona: afinal quem está pagando quem? A questão é polêmica, porque no Brasil não é permitido pelo Conselho Nacional de Saúde, o pagamento às comissões de ética em pesquisa por parte da indústria, para avaliarem uma quantidade grande de projetos originados na própria indústria. Os avaliadores está recebendo, na maioria das vezes salário da própria instituição. Trata-se de um tema que não permite respostas simples.

Outro tema, esse sim com resposta fácil é o almoço grátis oferecido nas reuniões clínicas em hospitais, principalmente os de ensino.. Algumas poucas universidades americanas já abandonaram esse hábito e, aqui ao que consta somente o Hospital Universitário da USP. Esse aspecto e outros do relacionamento indústria farmacêutica-médicos é abordado no site http://www.nofreelunch.org.

O texto de Avorn pode ser acessado clicando o título do post ou em http://www.nejm.org onde há mais dois articulistas analisando a questão.

Years ago, an administrator at a community hospital explained to me how well his institution's grand-rounds program worked. "The drug companies find the speakers, pay their honoraria, and provide free food for the doctors, which helps a lot with attendance," he said. "It works well for us, especially with our budgets so tight." Yet those lunches were actually quite costly for the hospital: attendees at such events predictably go on to prescribe the products promoted there — which is precisely why the drug companies so willingly pay for these programs. This penetration of commerce into the province of science isn't limited to continuing medical education. Since 1992, the United States has relied heavily on the pharmaceutical industry to pay the salaries of Food and Drug Administration (FDA) scientists who review new drug applications. The Prescription Drug User Fee Act (PDUFA) is now up for its periodic 5-year renewal, and Congress seems ready to reauthorize it with the same short-sightedness that afflicted that naive hospital administrator.

Destruir ou não as últimas cepas do vírus da varíola?

Um debate dos mais interessantes está nessa edição do British Medical Journal. Estados Unidos e Rússia têm as duas últimas cepas do vírus da varíola. A questão é destruí-los para evitar acidente ou mantê-los para eventual ataque terrorista. Abaixo início do texto.

Should the US and Russia destroy their stocks of smallpox virus? Edward Hammond, director Sunshine Project, PO Box 41987, Austin, TX 78704, USA hammond@sunshine-project.org Smallpox was eradicated in 1980, but the virus still exists in WHO controlled depositories. Edward Hammond maintains that stocks should be destroyed to prevent the disease re-emerging, but John Agwunobi insists further research is essential for global security The World Health Organization is justly proud of the global effort that led to the eradication of smallpox; but the truth is that the job remains unfinished. Although it is almost 30 years since the last natural transmission of smallpox virus (Variola), laboratories in the United States and Russia retain virus stocks. The destruction of remaining Variola stocks is an overdue step forward for global public health and security that will greatly reduce the possibility that this scourge will kill again, by accident or design. Although deploying modern scientific techniques such as genetic engineering on smallpox virus may be intellectually intriguing, the risks far outweigh the potential benefits. In 1990, the US secretary of health and human services, Louis Sullivan, made a pledge on behalf of the US government. "There is no scientific reason not to destroy the remaining stocks of wild virus," he declared, "So I . . . [Full text of this article]

Aumento do custo da assistência médica na França: um pouco além do envelhecimento

O aumento dos custos da assistência médica na França foram estudados pelos autores no texto que pode ser acessado (clic no título do post) com dados mais específicos e detalhados do impacto do envelhecimento. O custo das novas tecnologias pesa mais do que o aumento da proporção de idosos.

Causes of health expenditure growth: the predominance of changes in medical practices over population ageing. Brigitte Dormont et Hélène Huber Equipe Universitaire de Recherche - Institutions: Coordination, Organisation EURIsCO, Université Paris Dauphine, 2006 “…….The ageing of population is often referred to as a major determinant of the future evolution of health care expenditures. Indeed, at the individual level, health care expenditures is an increasing function of age. As life expectancy keeps improving in developed countries, the likely growing proportion of elderly people should lead mechanically to an accelerated growth of total health care expenditures….” “…..The increase in total health care expenditures in France can be explained by three distinct factors:(i) the purely demographic effect (namely, the increase in the proportion of elderly people, given that health expenditure is an increasing function of age(ii) the changes in morbidity at a given age (iii) the changes in practices, for a given age and morbidity level (e.g. technological progress). The aim of this paper is basically to disentangle, evaluate and interpret the respective effects of these three factors. If the technological progress hypothesis were to explain most of the rise in health care costs, it would reflect a collective choice towards allocating more health care to the elderly, coupled with improved technical feasibility…..”

Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral no Brasil: The Lancet Neurology

Abaixo, encontra-se carta publicada no The Lancet Neurology a respeito da vigilância epidemiológica da doença que mais mata no Brasil, mas ainda é muito pouco estudada: a doença cerebrovascular. Apresentamos as bases do EMMA (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral) que utiliza a metodologia desenvolvida por Ruth Bonita na Organização Mundial da Saúde. O estudo foi financiado inicialmente pelo Conselho Nacional de Pesquisa e depois pela FAPESP. Completará um ano em maio próximo e, permitirá entender vários aspectos da epidemiologia e clínica das diversas formas da doença cerebrovascular. Clicando o título será possível chegar na página do The Lancet Neurology, mas será necessário registro para acessar o artigo. Ou então, solicitar no email desse blogue.

Lancet Neurology 2007; 6:387-388 Improving WHO STEPS Stroke in Brazil Paulo A Lotufo and Isabela M Bensenor Further to your editorial and the article by Truelsen and colleagues, which emphasise the importance of WHO STEPS Stroke methodology for cerebrovascular disease surveillance, we would like to comment on our experience with regard to the use of this surveillance tool. The rationale for studying cerebrovascular epidemiology in a country like Brazil is obvious, but paradoxically, there are few researchers focusing on clinical and epidemiological research about stroke. Death rates from cerebrovascular and coronary heart diseases surpassed those for infectious diseases in the 1960s and stroke mortality rates in Brazil are the highest in Latin America. However, most vascular research in Brazil is focused on coronary heart disease rather than stroke. There is a simple reason for this discrepancy: mortality due to stroke is twice as common among people living in neighbourhoods with low socioeconomic indicators than in those in more affluent ones. In the past 40 years, coronary care units have spread across the country; by contrast, there are no public stroke units. Patients with stroke are treated in emergency wards, and hospitalisation in a critical care unit is not considered a priority. Thrombolysis is common for patients with acute coronary syndromes but is unavailable for people with ischaemic stroke. By contrast with classic surveys located in small towns, our aim is to assess stroke distribution in São Paulo, a large metropolitan area with more than 10 million inhabitants. We chose the neighbourhoods located in the western area of the city, in which a teaching hospital with a 260-bed facility offers the only support for emergencies and is responsible for 80% of the hospitalisations of people living in the area. Here, we launched Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral (EMMA) study, funded by the Brazilian National Research Council. EMMA enrolled its first participant on May 10, 2006, applying the form proposed for step one of STEPS Stroke. In this phase, objectives are to characterise the delay in hospitalisation since the start of symptoms, to determine the frequency of stroke by hour of the day, day of the week, and month of the year, and to calculate the 28 day, 180 day, and 1 year case-fatality rates. For step two—which began in November, 2006—we included the assessment of housing conditions, with a detailed assessment of the place in which each stroke survivor lives. Step three, due to start this year, will offer strong support from primary care physicians in the area, mainly community health agents who are working together in the Family Primary Care Program. In addition to STEPS Stroke, we are implementing other tools to verify motor, speech, and alimentary tract disabilities with specific questionnaires and a clinical consultation with physiotherapists and speech disorder specialists

Entrevista em Pesquisa Médica

No número de Pesquisa Médica (abril-junho de 2006) eu sou o entrevistado discutindo questões sobre doenças crônicas, pesquisa médica e epidemiológica e, detalhando o Estudo Longitudinal de Saúde do Adulto, ELSA.

Além da entrevista há outras matérias como os riscos e benefícios dos stents, como reconhecer as revisões sistemáticas que respondem à sua questão clínica, reprodução assistida, câncer e leishmaniose visceral. O acesso à revista é livre e, basta clicar no título acima ou buscar em http://www.revistapesquisamédica.com.br

A catástrofe chinesa: tabagismo

Na foto acima, vemos o pacote do cigarro chinês exportado para a Austrália com foto e aviso de risco de câncer de boca e garganta e, a mesma marca vendida na própria China. The New England Journal apresenta na edição de 12/4/07, texto com acesso livre (http://www.nejm.org) sobre a catástrofe da epidemia tabágica na China. Nesse ano morrerão 1 milhão de chineses por doenças associadas ao fumo, 2,5 vezes do número que morrerá nos EUA (país com população mais idosa e com exposição temporal mais intensa ao fumo do que a China). Importante a ação de Michael Bloomberg e, da grande ativista anti-tabágica Judith Mackay. Vale a pena ler clicando no título acima.