Uma nova perspectiva para a prevenção cardiovascular

No The Lancet, o cálculo da estratégia da polipílula para prevenção primária e secundária da doença cardiovascular. A proposta é administrar aspirina+estatina+hidroclorotiazida+enalapril a indivíduos com risco elevado de doença cardiovascular. Para aqueles que já sofreram infarto do miocárdio se acrescentaria o atenolol. O estudo apresentado é um simulação para países de baixa e e média renda, mas poderá ser também um bom exercício para uma política ampla de prevenção cardiovascular. Infelizmente, o texto no The Lancet é somente para assinantes. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs Stephen S Lim, Thomas A Gaziano, Emmanuela Gakidou, K Srinath Reddy, Farshad Farzadfar, Rafael Lozano, Anthony Rodgers In 2005, a global goal of reducing chronic disease death rates by an additional 2% per year was established. Scaling up coverage of evidence-based interventions to prevent cardiovascular disease in high-risk individuals in low-income and middle-income countries could play a major part in reaching this goal. We aimed to estimate the number of deaths that could be averted and the fi nancial cost of scaling up, above current coverage levels, a multidrug regimen for prevention of cardiovascular disease (a statin, aspirin, and two blood-pressure-lowering medicines) in 23 such countries. Identifi cation of individuals was limited to those already accessing health services, and treatment eligibility was based on the presence of existing cardiovascular disease or absolute risk of cardiovascular disease by use of easily measurable risk factors. Over a 10-year period, scaling up this multidrug regimen could avert 17·9 million deaths from cardiovascular disease (95% uncertainty interval 7·4 million–25·7 million). 56% of deaths averted would be in those younger than 70 years, with more deaths averted in women than in men owing to larger absolute numbers of women at older ages. The 10-year financial cost would be US$47 billion ($33 billion–$61 billion) or an average yearly cost per head of $1·08 ($0·75–1·40), ranging from $0·43 to $0·90 across low-income countries and from $0·54 to $2·93 across middle-income countries. This package could effectively meet three-quarters of the proposed global goal with a moderate increase in health expenditure.

Quase tudo sobre tuberculose no Brasil

A Revista de Saúde Pública lançou edição especial sobre a tuberculose no Brasil. Com acesso livre (clique aqui) há quase tudo que “você-gostaria-de-saber-sobre-tuberculose-no-Brasil-mas-tem-vergonha-em-perguntar”. Abaixo, a apresentação dessa edição com o panorama histórico. A tuberculose (TB) afeta a humanidade há pelo menos cerca de 8.000 anos. Até a metade do século XIX o caráter infecto-contagioso da tuberculose não era reconhecido; a doença era atribuída a diversas causas como a hereditariedade, aos miasmas e a outros determinantes ambientais e sociais. Em 1882, Robert Koch identificou a Micobacteria tuberculosis, definindo assim a TB como uma doença infecciosa. Isto permitiu que a florescente pesquisa biomédica iniciasse a busca por vacinas e tratamentos medicamentosos. A vacina BCG foi, em 1921, usada pela primeira vez em humanos. Anos mais tarde, em 1944, a estreptomicina foi utilizada com sucesso no tratamento da TB, sendo o primeiro de uma série de medicamentos utilizados na terapêutica anti-TB. Essas descobertas trouxeram renovadas possibilidades para prevenção e tratamento da TB. Porém, não se deve esquecer que a mortalidade por esta doença na Europa no século XIX era mais alta do que é hoje na África. Entretanto, naquele continente, a mortalidade começou a declinar de maneira vertiginosa já no final do século XIX, portanto muitas décadas antes da existência dos modernos recursos preventivos e terapêuticos, possivelmente, em razão das mudanças ocorridas nas condições de vida da sua população. Na atualidade, nos países mais desenvolvidos a tuberculose continua sendo um problema quase restrito aos imigrantes dos países pobres e outras populações marginalizadas (desabrigados, alcoólatras, prisioneiros, e outros).

Big Pharma ameaçada pelos genéricos

The Wall Street Journal apresenta hoje uma reportagem bem objetiva, acompanhada de quadro mostrando que todos os grandes produtos da Big Pharma em cinco anos poderão ser vendidos como genéricos. Entende-se a nova linha de "pesquisa-marketing" de remédios combinados, p.ex. hipertensão e dislipidemia, como um jeito de aumentar o período de patente.

Big Pharma Faces Grim Prognosis Industry Fails to FindNew Drugs to ReplaceWonders Like Lipitor By BARBARA MARTINEZ and JACOB GOLDSTEIN

December 6, 2007; Over the next few years, the pharmaceutical business will hit a wall. Some of the top-selling drugs in industry history will become history as patent protections expire, allowing generics to rush in at much-lower prices. Generic competition is expected to wipe $67 billion from top companies' annual U.S. sales between 2007 and 2012 as more than three dozen drugs lose patent protection. That is roughly half of the companies' combined 2007 U.S. sales. At the same time, the industry's science engine has stalled. The century-old approach of finding chemicals to treat diseases is producing fewer and fewer drugs. Especially lacking are new blockbusters to replace old ones like Lipitor, Plavix and Zyprexa. The coming sales decline may signal the end of a once-revered way of doing business. "I think the industry is doomed if we don't change," says Sidney Taurel, chairman of Eli Lilly & Co. Just yesterday, Bristol-Myers Squibb Co. announced plans to cut 10% of its work force, or about 4,300 jobs, and close or sell about half of its 27 manufacturing plants by 2010. Between 2011 and 2012, annual industry revenue will decline, estimates Datamonitor, a research and consulting firm. That would be the first decline in at least four decades. Patent expirations are a big problem. Drugs are granted 20 years of patent protection, although companies often fail to get a product to market before half of that period has elapsed. Once it hits the market, however, the patent-protected drug is highly profitable: Typical gross margins are 90% to 95%. When patents expire, generic makers offer the products at a price much closer to the cost of production. Pfizer Inc. will be particularly hard-hit when the patent expires as early as 2010 on Lipitor, the cholesterol-lowering blockbuster that ranks as the most successful drug ever. Pharmacists and managed-care companies will aggressively fill prescriptions with generics, reducing annual Lipitor sales to a fraction of last year's $13 billion.

Como é difícil aceitar que a poção mágica não é mágica

Somente nosso pensamento é mágico. A natureza segue seu rumo, com lógicas próprias que deixo para Edward Wilson, Stephen Jay Gould, Richard Dawkins e outros discutirem. Destaco hoje, pesquisa publicada em JAMA que avalia informações oriundas de estudos observacionais: vitamina E e doença cardiovascular, beta-caroteno e câncer e estrógeno e doença de Alzheimer. Todas essas associações não se comprovaram em ensaios clínicos, porém a maioria dos artigos abordando o tema, ainda consideram que vitamina E, beta-caroteno e estrógeno têm utilidade na prevenção da doença cardiovascular, do câncer e da demência, respectivamente. Persistence of Contradicted Claims in the Literature Athina Tatsioni, MD; Nikolaos G. Bonitsis, MD; John P. A. Ioannidis, MD JAMA. 2007;298(21):2517-2526. Context Some research findings based on observational epidemiology are contradicted by randomized trials, but may nevertheless still be supported in some scientific circles. Objectives To evaluate the change over time in the content of citations for 2 highly cited epidemiological studies that proposed major cardiovascular benefits associated with vitamin E in 1993; and to understand how these benefits continued being defended in the literature, despite strong contradicting evidence from large randomized clinical trials (RCTs). To examine the generalizability of these findings, we also examined the extent of persistence of supporting citations for the highly cited and contradicted protective effects of beta-carotene on cancer and of estrogen on Alzheimer disease. Data Sources For vitamin E, we sampled articles published in 1997, 2001, and 2005 (before, early, and late after publication of refuting evidence) that referenced the highly cited epidemiological studies and separately sampled articles published in 2005 and referencing the major contradicting RCT (HOPE trial). We also sampled articles published in 2006 that referenced highly cited articles proposing benefits associated with beta-carotene for cancer (published in 1981 and contradicted long ago by RCTs in 1994-1996) and estrogen for Alzheimer disease (published in 1996 and contradicted recently by RCTs in 2004). Data Extraction The stance of the citing articles was rated as favorable, equivocal, and unfavorable to the intervention. We also recorded the range of counterarguments raised to defend effectiveness against contradicting evidence. Results For the 2 vitamin E epidemiological studies, even in 2005, 50% of citing articles remained favorable. A favorable stance was independently less likely in more recent articles, specifically in articles that also cited the HOPE trial (odds ratio for 2001, 0.05 [95% confidence interval, 0.01-0.19; P < .001] and the odds ratio for 2005, 0.06 [95% confidence interval, 0.02-0.24; P < .001], as compared with 1997), and in general/internal medicine vs specialty journals. Among articles citing the HOPE trial in 2005, 41.4% were unfavorable. In 2006, 62.5% of articles referencing the highly cited article that had proposed beta-carotene and 61.7% of those referencing the highly cited article on estrogen effectiveness were still favorable; 100% and 96%, respectively, of the citations appeared in specialty journals; and citations were significantly less favorable (P = .001 and P = .009, respectively) when the major contradicting trials were also mentioned. Counterarguments defending vitamin E or estrogen included diverse selection and information biases and genuine differences across studies in participants, interventions, cointerventions, and outcomes. Favorable citations to beta-carotene, long after evidence contradicted its effectiveness, did not consider the contradicting evidence. Conclusion Claims from highly cited observational studies persist and continue to be supported in the medical literature despite strong contradictory evidence from randomized trials.

Avandia: agora osteoporose

Quando uma empresa força demais a indicação de um medicamento, ocorre uma reação inversa, que muitas vezes é desproporcional ao potencial dano do medicamento. Um exemplo é o relatado abaixo pela Associated Press e, repetido em todos os jornais do planeta. Apesar, da empresa reconhecer a possibilidade de aumento de fraturas, o objeto de discussão - osteoporose - não é objeto de preocupação em termos clínicos. Primeiro, os dados foram obtidos em animais. Segundo, o risco cardíaco é mais importante do que o aumento de risco de osteoporose. Por último, notem que o pesquisador que identificou o mecanismo em ratos de forma súbita já indica ações médicas a longo prazo.

Popular Diabetes Drug May Increase Osteoporosis Associated PressDecember 2, 2007 1:29 p.m. WASHINGTON -- The popular diabetes drug marketed as Avandia may increase bone thinning, a discovery that could help explain why diabetics can have an increased risk of fractures. New research raises the possibility that long-term treatment with rosiglitazone, as Avandia is also called, could lead to osteoporosis. The diabetes drug is used to improved response to insulin. While bones seem solid, they constantly are being broken down and rebuilt by the body. Researchers found that in mice, the drug increased the activity of the cells that degrade bones, according to a report in this week's online issue of Nature Medicine. Avandia recently was labeled with warnings about the risk of heart failure in some patients. GlaxoSmithKline, which markets the drug, already has acknowledged that a study found a higher risk of fractures among women who take the drug. But this report is the first to attempt to explain the link between the drug and fractures. The finding "has led to a better understanding of the challenges associated with long-term treatment of patients with Type II diabetes," said Ronald M. Evans of the Salk Institute for Biological Studies in La Jolla, Calif., lead author of the report. "It also provides a basis for the development of a "next generation" of drug that can specifically dial out this side effect and a new insight into a previously unrecognized aspect of bone physiology that has important medical consequences," he said in an interview via e-mail. Nearly 21 million people in the United States have diabetes. Rosiglitazone is widely used in people with Type II, or adult onset diabetes, the most common form of the disease. Evans said the discovery was fortuitous. Researchers were looking at different aspects of the diabetic mice and did not realize they would be able to change the bone-removing activity. The assumption had been that more brittle bones in diabetics were the result of a reduced bone-building activity, not increased bone removal. "Considering the widespread use of these drugs and the known action in people it is surprising that such a key observation had been missed," he said. "The long-term use of rosiglitazone should be cautious in patients with higher risk of fractures such as older women," he added. Using it in combination with anti-osteoporosis drugs could be beneficial, he said. The research was funded by the Howard Hughes Medical Institute and the National Institutes of Health.

Vacinação para gripe e redução das desigualdades: pesquisa da USP no IJE

Professores da USP publicam no International Journal of Epidemiology pesquisa mostrando o impacto da vacinação para gripe na cidade de São Paulo. Mais um dado que vai contra os famosos detratores do SUS, aqueles da "falência da saúde pública", "má utilização de recursos" etc etc

Effectiveness of influenza vaccination and its impact on health inequalities de José Leopoldo F. Antunes, Eliseu A. Waldman, Carme Borrell and Terezinha M. Paiva. O artigo completo pode ser solicitado a leopoldo@usp.br , o resumo é apresentado abaixo.

Background Since 1998, annual publicly funded campaigns for mass vaccination against influenza of the population aged 65 years or older have been performed in the city of São Paulo, Brazil. The effectiveness of the intervention was not assessed for its contribution to the reduction of influenza-attributable mortality. This study sought to compare the age-specific mortality (65 years or older) before and after the onset of yearly vaccination, and to assess the impact of the intervention on health inequalities in relation to inner-city areas. Methods Official information on deaths and population allowed assessment of overall pneumonia and influenza mortality. Monitoring of outbreaks and the estimation of mortality attributable to influenza peaks used Serfling and ARIMA models. Rates were compared between 1998 and 2002, when vaccination coverage ranked higher than 60% among individuals aged 65 years or older, and 1993–97 (prior to vaccination). Results Overall mortality due to pneumonia and influenza fell by 26.3% after vaccination. An even higher reduction was observed for mortality specifically attributable to influenza epidemics; the number of peaks of influenza mortality also decreased. Deprived areas of the city had a higher decrease of mortality by pneumonia and influenza during the vaccination period. Conclusions Influenza vaccination contributed to reduce influenza-attributable mortality in this age group, and was associated with the reduction of inequalities in the burden of the disease among social groups. The concurrent promotion of health and social justice is feasible when there is political will and commitment to implement public health interventions with prompt and effective universal access.

Os precursores da epidemiologia moderna

Abaixo, os comentários de MichaelMarmot publicados no The Lancet sobre o livro mostrado ao lado.

When I joined Epidemiology at the London School of Hygiene and Tropical Medicine, in 1976, I was told: this School is run by upper-class Englishmen and lower-class Scotsmen—my informant was a Scotsman. He went on: it reflected the old Colonial Medical Service; the Englishmen went to the tropics to run the empire, and the Scots to escape their lousy weather. In the USA, I had been told, it was surprising how many of the older generation of epidemiologists had a father who was a preacher, or were of Jewish background. It reflected their social concern. Of course, the London School has Hygiene as well as Tropical Medicine in its title and there were motivations, other than noblesse oblige or the weather, that brought people into epidemiology. One of the attractions of The Development of Modern Epidemiology is the insight it gives into these motivations. It brings together contributions from many who have been centrally involved in the International Epidemiology Association (IEA) during the 50 years of its existence. So many of the key figures came to epidemiology because they wanted to improve health in society. John Pemberton, the co-founder of the IEA, was a member of the Socialist Medical Association that was started in 1930. Many of their members believed that poverty was an important cause of ill-health and that some solutions to health problems required political action. In the same vein, Mervyn Susser was aroused to hope and commitment to a socially useful occupation. He, and Zena Stein, saw the practice of socially oriented medicine as an important form of activism. As always, such commitment does not arise, prosper, or otherwise in a vacuum. The pioneers of this approach in South Africa, among them Sydney Kark, as well as Susser and Stein, had to leave because they fell foul of the political regime promoting apartheid. Jerry Morris, in the UK, stated it clearly: “Society largely determines health; ill-health is not a personal misfortune due often to personal inadequacy but a social misfortune due, more commonly, to social mismanagement and social failure.” The commitment to improving health for the whole of society runs through many of the contributions in this volume. Ian Prior's great grandfather was a missionary in Fiji whose public-health contribution was to convince his parishioners to give up cannibalism. Henry Blackburn, the master of the ECG in epidemiology, was influenced by experiences in Cuba, in 1949, that taught him of the limitations of medicine to deal with mass disease due mainly to poverty and ignorance. Lester Breslow, slightly coy, says that friendly advice was that “with my ideology, I consider public health”. Public Health is grateful that he heeded this advice. I am in awe of these pioneers. Today, rightly, we expect our students to do Master's degrees and PhDs, to get accredited, pass exams. That is as it should be. But it does not stop me worshipping at the shrine of these founders of our discipline who had none of these qualifications. It may be social concern that motivated these pioneers of epidemiology, but they brought methodological rigour to their enquiries and they had to make it up as they went along. Richard Doll, in a characteristically pithy piece, does not suggest that he chose to go into “epidemiology” as such. Rather, he used his mathematical bent to help a distinguished clinician, Avery Jones, to investigate variations in the occurrence of peptic ulcer. A short course in medical statistics with Bradford Hill (what, no PhD!) and he was put to work to figure out why lung cancer was on the rise. He reports that there were a few early case-control studies of cancer that had come in for methodological criticism. Doll and Hill, therefore, designed their case-control study of lung cancer and smoking to be better. They published in 1950, concluding, with no messy understatement or qualification: “that cigarette smoking is an important cause of cancer of the lung”. The pioneers developed their investigations with rigour and, in part because of shortage of funds, with precision. Archie Cochrane is justly famous for effectiveness and efficiency and has been immortalised in the Cochrane collaboration. He also did so much to develop observational epidemiology. Nearly 30 years ago I made a pilgrimage to south Wales to see Archie at work, then in his 80s. He drove me in his little car out into the Rhondda where he was still following a cohort of miners. We called on a miner's cottage and a woman took a death certificate off the mantelpiece with the words that her husband had died 3 years previously and she kept the certificate because she knew that Professor Cochrane would call. We then drove back to Cardiff. “That's it”, I asked, “just the death certificate, no questionnaire to the widow?” “What would you want to ask?”, said Archie, “I got all the information I needed.” Archie Cochrane's personal contribution sums up another theme running through the volume: the different uses of epidemiology, to borrow Jerry Morris' 1957 phrase. Breslow and Detels are clear: epidemiology is the basic science of public health. Richard Heller and Kerr White are equally clear: epidemiology can be used to improve clinical practice and the evaluation and, hence, operation of health services. When we discover that some non-infectious diseases are infectious in origin it makes clear that there should not be two epidemiologies—infectious and non-infectious. There is surprisingly little whingeing in this volume. There is the occasional allusion to sneering reactions from the medical establishment to the pursuit of epidemiology. These pioneers cannot have had it easy, yet they focus on getting the job done rather than dwelling on their critics. Richard Doll says simply: “epidemiology has contributed more than any other branch of science to our knowledge of the causes of cancer”. There is some allusion to the political nature of a concern with the health of populations. Adapting this to contemporary debates, a critic, exercising his prejudices, might read the accounts by John Pemberton and others of their social concerns and see not a group motivated by the highest ideals but a bunch of do-gooders who are out to provide ammunition to the nanny state to control people's lives. Rodolfo Saracci puts this another way. In a thoughtful chapter he suggests that, in the period 1945–75, the rise in epidemiology reflected the impulse of postwar reconstruction and a sense of social solidarity. Accepting health as the right of everybody meant that epidemiology with its focus on whole populations had a ready political acceptance and results had some chance of influencing policy. At the start of the millennium, says Saracci, a neoliberal climate will pay more attention to economics than to a political desire to improve the lot of all sectors of society. Saracci's implications are plain: we need high-quality epidemiological research and we need the political commitment to implement findings to improve population health. In: Walter W Holland, Jørn Olsen and Charles du V Florey, Editors, The Development of Modern Epidemiology: Personal Reports From Those Who Were There, Oxford University Press (2007) ISBN 0-19856-954-8 Pp 472. US$110·00

Os riscos da tomografia computadorizada

No The New England Journal of Medicine, o artigo Computed Tomography — An Increasing Source of Radiation Exposure de David J. Brenner e Eric J. Hall cujas conclusões apresento abaixo.

Conclusions The widespread use of CT represents probably the single most important advance in diagnostic radiology. However, as compared with plain-film radiography, CT involves much higher doses of radiation, resulting in a marked increase in radiation exposure in the population. The increase in CT use and in the CT-derived radiation dose in the population is occurring just as our understanding of the carcinogenic potential of low doses of x-ray radiation has improved substantially, particularly for children. This improved confidence in our understanding of the lifetime cancer risks from low doses of ionizing radiation has come about largely because of the length of follow-up of the atomic-bomb survivors — now more than 50 years — and because of the consistency of the risk estimates with those from other large-scale epidemiologic studies. These considerations suggest that the estimated risks associated with CT are not hypothetical — that is, they are not based on models or major extrapolations in dose. Rather, they are based directly on measured excess radiation-related cancer rates among adults and children who in the past were exposed to the same range of organ doses as those delivered during CT studies. In light of these considerations, and despite the fact that most diagnostic CT scans are associated with very favorable ratios of benefit to risk, there is a strong case to be made that too many CT studies are being performed in the United States. There is a considerable literature questioning the use of CT, or the use of multiple CT scans, in a variety of contexts, including management of blunt trauma, seizures, and chronic headaches, and particularly questioning its use as a primary diagnostic tool for acute appendicitis in children. But beyond these clinical issues, a problem arises when CT scans are requested in the practice of defensive medicine, or when a CT scan, justified in itself, is repeated as the patient passes through the medical system, often simply because of a lack of communication. Tellingly, a straw poll of pediatric radiologists suggested that perhaps one third of CT studies could be replaced by alternative approaches or not performed at all. Part of the issue is that physicians often view CT studies in the same light as other radiologic procedures, even though radiation doses are typically much higher with CT than with other radiologic procedures. In a recent survey of radiologists and emergency-room physicians, about 75% of the entire group significantly underestimated the radiation dose from a CT scan, and 53% of radiologists and 91% of emergency-room physicians did not believe that CT scans increased the lifetime risk of cancer. In the light of these findings, the pamphlet "Radiation Risks and Pediatric Computed Tomography (CT): A Guide for Health Care Providers," which was recently circulated among the medical community by the National Cancer Institute and the Society for Pediatric Radiology, is most welcome. There are three ways to reduce the overall radiation dose from CT in the population. The first is to reduce the CT-related dose in individual patients. The automatic exposure-control option on the latest generation of scanners is helping to address this concern. The second is to replace CT use, when practical, with other options, such as ultrasonography and magnetic resonance imaging (MRI). We have already mentioned the issue of CT versus ultrasonography for the diagnosis of appendicitis. Although the cost of MRI is decreasing, making it more competitive with CT, there are not many common imaging scenarios in which MRI can simply replace CT, although this substitution has been suggested for the imaging of liver disease. The third and most effective way to reduce the population dose from CT is simply to decrease the number of CT studies that are prescribed. From an individual standpoint, when a CT scan is justified by medical need, the associated risk is small relative to the diagnostic information obtained. However, if it is true that about one third of all CT scans are not justified by medical need, and it appears to be likely, perhaps 20 million adults and, crucially, more than 1 million children per year in the United States are being irradiated unnecessarily

Maurício Lima Barreto, Editor do JECH

O professor Maurício Lima Barreto foi indicado pelo BMJ Group- após seleção disputada - editor do Journal of Epidemiology and Community Health. Um dos melhores periódicos de saúde coletiva do planeta. Parabéns a Maurício, a Estela - incansável companheira, às duas meninas, à imensa família Barreto (vai ter buchada!), ao Instituto de Saúde Coletiva (ISC), à Universidade Federal da Bahia (dirigida agora por Naomar Almeida, também fundador do ISC como Maurício e, seu primeiro diretor) e todos que colaboram nessa conquista, que como sempre decorre da competência e tenacidade de um indivíduo, cujo memorial na base lattes pode ser acessado livremente. (clique aqui)

foto: Agência Fapesp

IDH: o problema é a estatística alheia

Acabei de ler a notícia no UOL: O Brasil entrou pela primeira vez para o grupo de países de "alto desenvolvimento humano" no ranking elaborado pelo Programa das Nações Unidas para o Desenvolvimento (PNUD), divulgado nesta terça-feira em Brasília. De acordo com o relatório da ONU, o Brasil atingiu o Índice de Desenvolvimento Humano (IDH) de 0,800, em uma escala de 0 a 1. Países com índice inferior a 0,800 são considerados de "médio desenvolvimento humano", categoria na qual o Brasil figurava desde 1990, quando o PNUD começou a divulgar o ranking.

Não li as repercussões, mas imagino que todos os espectros da blogosfera irão vociferar, exceto o site "voz do brasil". Eu já corri um pouco opaís e esse planeta e, para mim a septuagésima posição é ainda reflexo de problemas estatísticos (falseamentos) que são sistemáticos em outros países. Aqui temos uma tradição das melhores, graças à tradição entre outras instituições, o IBGE.

Ditaduras não deveriam ser incluídas, porque seus dados não são confiáveis. O mesmo vale para países semi-democráticos, como os do Leste Europeu e, os membros da OPEP. O Brasil encontra-se em posição muito mais favorável em termos de desenvolvimento humano do que vários do que nos antecede nessa lista.

Aos pessimistas de plantão, o blog está oferecendo bolsas de estudo (na moeda local) com passagem somente de ida para Albânia, Belarus, Cuba, Líbia, Quatar, Panamá e Romênia. Todos países melhor classificados do que o Brasil.

Os bastidores de um ótimo artigo científico: a segurança das estatinas e o mercado americano OTC

Quinta-feira à noite é publicado no The Lancet uma revisão excelente mostrando que as estatinas são muito seguras, mas como pouco destaque para a efetividade desse grupo de medicamento. Confesso que não entendi o desbalanço dessa revisão, mas fui convencido que o medicamento deve ser amplamente comercializado no Brasil. Tanto que no domingo, eu recomendei nesse blogue que as estatinas façam parte do rol do programa Farmácia Popular. Além disso, já há genéricos da lovastatina, pravastatina e lovastatina no mercado brasileiro. Segunda-feira, à noite, compreendi a preocupação com a segurança das estatinas expressa no referido artigo. Publicou-se a notícia que a Glaxo Smith Kline (britânica como The Lancet) comprou os direitos da lovastatina nos Estados Unidos para venda livre de receita. O FDA não aprovou o uso sem receita (OTC, over the counter) por causa dos riscos do uso indevido do medicamento, principalmente lesões musculares e hepáticas. A recusa ocorreu em duas oportunidades, mas no Reino Unido há permissão para venda sem receita. Ou seja, há uma possibilidade maior de aprovação para venda OTC.

Como se pode deduzir, as decisões editorias do The Lancet são bem independentes e, desligadas de qualquer interesse empresarial.

Glaxo Gets Rights to Sell ProposedOver-the-Counter Cholesterol Drug By JEANNE WHALENNovember 26, 2007 3:28 p.m.GlaxoSmithKline PLC acquired the rights to sell a cholesterol-lowering drug without a prescription in the U.S. but could face a tough time winning Food and Drug Administration approval to actually sell the product. Glaxo said Monday that it has bought the marketing rights to the drug Mevacor from Merck & Co. for an undisclosed sum. Despite two past attempts, Merck has so far been unable to get the FDA to approve Mevacor for sale without a prescription. Selling a cholesterol-lowering drug without a prescription could potentially be big business for Glaxo. The drugs, known as statins, are available only by prescription in the U.S. today and are among the industry's top sellers. The drugs racked up U.S. sales of $21.6 billion last year, according to IMS Health, a healthcare research firm. An FDA advisory panel is scheduled to meet Dec. 13 to consider Merck's most recent application to sell Mevacor without a prescription. A Merck spokesman said the company plans to present new data addressing earlier concerns that consumers wouldn't take the drug correctly. Merck will handle that FDA meeting, but Glaxo will take over marketing of the drug should the FDA grant approval, the Merck spokesman said. Merck will receive royalty payments on any sales, he said. The company's decision to sell the rights does not reflect any concern that OTC Mevacor won't be approved. "We're optimistic," he said.The FDA's rejection of Mevacor goes back to 2000, when it rejected an application by Merck to sell a weaker version of the drug without a prescription. In 2005, the FDA again rejected an application for over-the-counter Mevacor, this time filed by Merck and former partner Johnson & Johnson, after advisers to the FDA expressed concern that consumers would use the drug incorrectly. In 2004, the U.K. approved for sale a non-prescription version of the statin Zocor, which is sold by a joint venture between Merck and Johnson & Johnson—and is similar to Mevacor. When they started selling the drug, the companies estimated that the market for an OTC statin was about £600 million ($1.25 billion) in the U.K. alone. Merck began selling prescription Mevacor in 1987. The U.S. patent for the drug expired in 2001

Homicídios: Nova Iorque, Rio de Janeiro e São Paulo

Bem, continuando o texto publicado na Folha de S.Paulo, por Alba Zaluar, que afirma que a experiência do criminólogos americanos indica que o homicídio é o indicador de violência menos influenciável pelo policiamento. Ela traz de volta a questão do crack tanto nos EUA como no Brasil como sendo o determinante maior da epidemia de homicídio, uma hipótese muito plausível. Abaixo, o texto

E no Brasil, como estamos? Mal. É verdade que a epidemia de crack também se abateu sobre as cidades do Sudeste, a região mais rica do país, em diferentes momentos e ritmos. No Rio de Janeiro, em 1998 morreram assassinadas 2.406 pessoas, das quais 94% eram homens. Destes, 29% eram brancos, 13% negros e 42% pardos. Em 2005, nos últimos dados disponíveis no Ministério da Saúde, foram 2.044 homicídios, dos quais 95% de homens, 30% brancos, 17% negros e 52% pardos. Uma suada diminuição de 15%. Na taxa de homicídio entre homens de 15 a 39 anos, a queda naquela cidade foi de 20%. No mesmo período, essa taxa de homicídio em São Paulo diminuiu 55%. Em Belo Horizonte, ao contrário, a taxa subiu 230%. Em parte porque as epidemias da cocaína e do crack não foram simultâneas; em parte pelas diferentes estratégias adotadas pelas polícias em cada estado. De todo modo, a queda registrada ainda é muito pouca diante dos extraordinários números de assassinatos nas três cidades mais ricas do país.

Um momento! se, em Nova Iorque a queda foi de 81% de 1990 até 18/11/2007, não é justo afirmar que a queda do Rio de Janeiro de 15% é "suada" entre 1998 e 2005. Simplesmente, não dá para comparar. O mesmo vale para o que ocorre em São Paulo. A queda de 55% em sete anos é muito expressiva, talvez superior ao observado em Nova Iorque.

Outro comentário: a autora reconhece que diferenças entre as três cidades brasileiras (SamPa, Rio, BH) deve-se também a "diferentes estratégias adotadas pelas polícias em cada estado", ou seja o policiamento conta.

Uma picuinha, pela primeira vez na grande imprensa há informação do aumento dos homicídios em BH, que já mostrei superaram as taxas do Rio de Janeiro em 2005. A aliança tucano-petista mineira ignora o problema.

Finalmente, encerrando meus comentários. Os cientistas sociais precisam acreditar que polícia pode e deve ser forma de administração da democracia e, não um "aparato repressivo da burguesia" como gostam de repetir frases dos surrados (e, mal traduzidos) textos do final do século XIX.

Homicídios em Nova Iorque: queda de 400% ?

De, Alba Zaluar - uma das acadêmicas mais produtivas e competentes na área de violência (leiam o texto "8 pontos para debate", por exemplo) - a prova que o erro pode estar presente até em textos de abalizados intelectuais. Detesto corrigir , mas essa afirmativa foi muito forte, nem o marqueteiro Rudy Guiliani endosssaria. Abaixo, trecho do artigo na Folha de S. Paulo.

Que guerra é essa? O HOMICÍDIO É O CRIME menos suprimível pela polícia, concluem criminólogos e policiais na cidade de Nova York. Ali se comemora a contínua queda do número de homicídios desde o início dos anos 90, após a severa alta provocada pela epidemia de crack nos anos 1980. Em 1990, a cidade registrava o número mais alto de assassinatos em um ano -2.245-, quando predominava a violência entre estranhos. Em 2007, até 18 de novembro, foram mortas 428 pessoas, ou seja, a queda foi de mais de 400%. E agora se pergunta: o que fazer para manter a façanha?

A queda não foi 400%, mas 81%. ((2245-428)/2245)) Uma conta, simples, mas que começou com o ataque à logica que se consagrou na imprensa brasileira : a tal expressão "cinco vezes menos recursos no orçamento", quando o correto é "um quinto do orçamento anterior".

Estatinas no programa "Farmácia Popular já!"

The Lancet apresenta um revisão excelente sobre as estatinas.(infelizmente, somente para assinantes) Medicamentos para redução do colesterol, cuja ação na redução de eventos cardiovasculares suplanta aquele obtido na diminuição dos lípides séricos. A primeira geração das estatinas - lovastatina, simvastatina e pravastatina - já estão disponíveis na formulação de medicamentos genéricos. O primeiro estudo que mostrou utilidade dessa classe de medicamentos foi em 1995, o 4S ( The Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin SurvivalStudy (4S). Lancet 1994; 344: 1383–9.) destinado a quem já tinha doença coronariana. Posteriormente, outros estudos foram mostrando que as estatinas vieram para ficar no arsenal terapêutico da aterosclerose. Aqui, no Brasil as estatinas de primeira geração poderiam ser incorporadas de imediato no programa Farmácia Popular com preços reduzidíssimos.

Programa antitabágico: aumentar o imposto (IPI) do cigarro

Após avanços na última década, o programa antitabágico perdeu o foco, ou melhor, deixou de ser interessante para efeitos midiáticos. Melhor, discutir descriminação da maconha ou o aborto ou mesmo a obesidade infantil. Apesar de reduções importantes na prevalência, a magnitude do problema é maior do que das três situações acima somadas. Veja divulgou estudo pouco conhecido feito entre outros por Vera Costa e Silva, uma das responsáveis pelo sucesso do plano brasileiro no início dos anos 90. Abaixo, trecho da reportagem.

O programa brasileiro de combate ao cigarro colecionou uma série de avanços ao longo das últimas duas décadas. O país foi o primeiro no mundo a proibir, nas embalagens, o uso de palavras que poderiam levar o consumidor a uma falsa idéia de segurança. Eram termos como "light" e "baixos teores". Também se destacou por fazer constar nos maços fotografias pavorosas sobre os males do fumo à saúde. Foram os primeiros passos de uma campanha que teve no banimento da propaganda do tabaco seu ponto forte. Nos primeiros sete anos conseguiu reduzir o consumo per capita de cigarros em 33,6%. Com medidas e resultados assim, o programa, criado em 1987, deu ao país uma posição de liderança na luta contra o tabagismo. Mas as notícias agora já não são tão animadoras. Ao completar duas décadas, acaba de sair do forno a primeira grande avaliação sobre sua eficácia. Um estudo do Banco Mundial, ao qual VEJA teve acesso com exclusividade, concluiu que o programa empacou. Desde 1994 ele não produz nenhum impacto significativo. O consumo per capita naquele ano era de 1.220 unidades e hoje se encontra em 1 200 . Pior, nada indica que será reduzido. A estagnação é preocupante. O tabaco é responsável por 200 000 mortes por ano no Brasil. Para vencer essa guerra, serão necessárias armas mais poderosas. A estratégia sugerida pelo estudo é mirar diretamente o bolso dos fumantes. Nos anos 90, o maço de cigarros populares custava, em média, 2,45 reais. Hoje está em torno de 2,27 reais. Os pesquisadores perceberam que a queda do preço se deu em razão da redução do peso do imposto sobre produtos industrializados (IPI) no preço do cigarro. Nos anos 90, ele representava 41% do preço final do maço. Atualmente, equivale a 20%. (assinante de Veja, clique aqui)