Outubro com tudo: blogue em recesso (ou o Red and Green October)

Amigos: como todos sabem, um blogue não fecha, está sempre aberto. Nesse mês de outubro permanecerá em estado de latência, quase sem sinal de vida.

Motivo: o excesso de compromissos acadêmicos e administrativos assumidos que se acumularam quase todos nesse mês.

Nos anos 70, outubro era mês complicado na Faculdade de Medicina: eleições sempre disputadas no CAOC, Mac-Med e Show Medicina.

Agora, décadas depois, a vida continua apertada nesse mês.

Sem contar, claro que o Boston Red Sox estará defendendo seu título e, o Palmeiras caminha para o pentacampeonato. Ambos, o vermelhão e o verdão me obrigarão a plantões televisivos intensos.

Transfat: o novo alvo

Walter Willett esteve essa semana em São Paulo e Porto Alegre. Ele é um dos assim chamados "figurões" da ciência mais acessíveis e de fácil trato. Publiquei em 2004, um trabalho em conjunto com ele. Agora, ele (na esquerda da foto) começa a campanha pra banir os alimentos com gordura trans.

Nutrition Chair Willett Joins Mayor Menino in Reminding Bostonians of Start of Trans Fat Ban Walter Willett, chair of the HSPH Department of Nutrition, joined Mayor Thomas Menino at a press conference on Friday, September 12, to remind residents that Boston’s ban on artificial trans fat would begin officially the next day. The press conference was held at local Mission Hill bistro The Savant Project, which stopped using trans fat three months ago. According to a press release from the Boston Public Health Commission, Boston is the first city in Massachusetts to implement a ban on trans fats. Brookline has passed a similar ban, but it will not go into effect until later this year. Approximately 5,600 restaurants and other food service establishments in the city must start eliminating partially hydrogenated oil from food or beverages. Businesses that violate the ban will receive a citation and fine ranging from $100 to $1,000. Trans fatty acids, or trans fats, raise the level of bad (LDL) cholesterol in the body and lower the good (HDL) cholesterol. Consuming trans fat can increase one’s risk of developing heart disease and stroke. It can also put people at higher risk of developing Type 2 diabetes. Willett has been a leading voice in encouraging the removal of trans fats from foods. His research has helped contribute to the public's understanding of the health detriments of consuming the substance and to federal regulations requiring it be listed on food labels. The Public Health Commission board approved the trans fat ban in March and is implementing it in two phases. As of September 13, food service establishments may no longer use oils, shortenings, and margarines containing partially hydrogenated vegetable oil for frying, sautéing, grilling, or as a spread. Six months later, the ban will apply to baked goods, mixes, partially fried items, and all other foods containing artificial trans fat. The ban affects all food service establishments that are required to hold a permit from Boston’s Inspectional Services Department. These include restaurants, grocery stores, delis, cafeterias in schools and businesses, caterers, senior-center meal programs, children’s institutions, mobile food-vending units and commissaries that supply them, bakeries, park concessions, street-fair food booths, and other establishments. The ban does not apply to food or beverages served in the manufacturer’s original sealed package, such as a package of cookies or a bag of potato chips. It also does not apply to food or beverage items that contain less than 0.5 grams of trans fat per serving.

dicas dos amigos (1): Gapminder

Dica de Vitor Kawabata. O site é o Gapminder. http://www.gapminder.com/

Consegue atrapalhar um pouca a vida de demógrafos e epidemiologistas, não porque traz pronto uma sériede informações, mas porque permite cruzá-las. Vejam ao lado a relação entre infecção pelo HIV e renda per capital: façam o triângulo Brasil, África do Sul e Estados Unidos e, comparem a capacidade de manusear a epidemia de cada um dos três países.

Bem, o GapMinder é muito interessante. Aguardo comentários dos meus amigos demógrafos plugados na rede do Taquinho.

Um cordão sanitário ao redor da China não será nada mal.

Brinquedos, rações de animais, heparina e agora o leite. Alguém precisa contabilizar o fator chinês na redução de seres humanos e animais somente no último ano. Como a Organização Mundial do Comércio não fará nada para conter a China, e a Organização Mundial da Saúde é dirigida por uma chinesa, resta aos governos de países democráticos e que defendem a saúde dos seus cidadãos tomar a atitude necessária para evitar mais danos. Abaixo, reproduzo a situação na África, descrito em despacho da agência Reuters, onde mostra o comércio entre países africanos e China. DAKAR (Reuters) - Bans on imports of Chinese milk products by African states fearing contamination have highlighted the growing presence of Chinese goods in Africa's markets and raised worries over depending on them too heavily. From Ivory Coast in the west to Tanzania in the east, governments have joined the list of countries blocking Chinese milk imports over concerns they could be contaminated with deadly melamine. Since the start of the decade, African leaders have been keen to strike often controversial deals with China which guarantee supply of oil or metals from Africa in return for billions of dollars in loans and infrastructure projects. These deals have opened the door to imports of cheap Chinese goods, including food, which African consumers have come to rely on as they struggle with high prices. Chinese exports to Africa rose 40 percent to $23 billion year-on-year in the first half of 2008. Chinese powdered milk laced with industrial chemical melamine has been blamed for causing four deaths in China so far and making thousands more ill. The health scare means African authorities and shoppers are now also worried about what's in Chinese dairy products. Togo became the latest African country to ban them on Wednesday. Burundi, Gabon and Ghana also have bans. "Chinese products are all over the place and the prices are very attractive, so we must be careful," said Maame Abdallah, a grandmother in Ghana's capital Accra. "Chinese milks are the most affordable and they help a lot," said Ghanaian mother Jane Morkeh. "There are a lot of others in the market, but I use the new ones, including those made in China, because I can afford to buy in bulk," she added.

A necessidade de ambientes livres do cigarro

Mais uma informação sobre tabagismo passivo. Agora, um estudo chines publicado em Circulation revela que mulheres que nunca fumaram, mas que moram ou trabalham em ambientes com fumantes, tiveram risco maior em 60% de doença cerebrovascular, 70% de doença coronariana e em 80% em doença cerebrovascular.

Passive Smoking and Risk of Peripheral Arterial Disease and Ischemic Stroke in Chinese Women Who Never Smoked Yao He MD, PhD*, Tai Hing Lam MD, Bin Jiang MD, PhD, Jie Wang MD, PhD, Xiaoyong Sai MD, PhD, Li Fan MD, Xiaoying Li MD, Yinhe Qin MD, and Frank B. Hu MD, PhD* Background—The association between secondhand smoke (SHS) and risk of peripheral arterial disease (PAD) and stroke remains uncertain. Methods and Results—We examined the relationship between SHS and cardiovascular diseases, particularly PAD and stroke, in Chinese women who never smoked from a population-based cross-sectional study in Beijing, China. SHS exposure was defined as exposure to another person's tobacco smoke at home or in the workplace. Cardiovascular disease events included coronary heart disease, stroke, and PAD. PAD was defined by signs of intermittent claudication as measured by the World Health Organization Rose questionnaire and an ankle-brachial index of <0.90.>

ELSA lançado e, uma nova proposta

Estou no Congresso Internacional de Epidemiologia em Porto Alegre. Participei de uma atividade sobre o Estudo Longitudinal de Saúde do Adulto, onde juntamente com Isabela Bensenor comparamos o maior estudo brasileiro em epidemiologia cardiovascular e do diabetes com o Study of Latinos, apresentado por Gerardo Heiss, da Universidade da Carolina do Norte. O ELSA foi lançado oficialmente pelo Ministério da Saúde, ontem . (clique aqui) Ontem, assisti a um mesa-redonda com os ministros da saúde da Comunidade de Países de Língua Portuguesa. Estavam presentes Cabo Verde, Guiné-Bissau, Moçambique, Timor Leste, Portugal e Brasil. Da platéia, apresentei a proposta de estudo multinacional verificando a particular situação da hipertensão arterial e da doença cerebrovascular. O Ministro Temporão elogiou a proposta e, a levará à nova reunião dos ministros da saúde.

Dirigindo um hospital: um blogue diferente

Abaixo, reproduzo um dos posts do blogue Running a Hospital, de Paul Levy, diretor do Beth Israel and Deaconnes Medical Center, localizado em Boston. O texto copiado traz uma mensagem interessante relacionado ao sistema de faturamento. Mas, o mais interessante é o próprio blog.

O autor não poupa os próprios subordinados exigindo decisões mais incisas e rápidas.

Wednesday, September 17, 2008 Some ads I get Notwithstanding our excellent spam control program, I get tons of broadcast emails sent to me as CEO of a hospital, selling all kinds of services -- but especially services related to coding patient treatments to get the highest payment from insurers and Medicare. I suppose this is just a sign of the times and indicative of the structure of the health care industry.I confess that I do not understand many of these ads. I'm not saying that I don't understand why I get them. I am saying that I literally don't understand most of the terminology. Here are some excerpts from a small sample of those I received yesterday. I guess the one I really need is the last one listed . . .

Um relato no WSJ para entender a medicina defensiva

My nurse practitioner came to me with the case of a 40-year-old patient complaining about aches and pains from an auto accident. Just three days before, he had been released by the trauma center with instructions to see his family doctor. That turned out to be me. He was new to my practice. What impressed my nurse practitioner more than his injuries was the way he knocked the doctors and the hospital where he had been treated. Everything he said seemed negative, with a particularly hostile edge. "I wonder what he's going to say about us," my nurse practitioner said. So did I. An exam of the patient revealed some general soreness and a little extra tenderness in the abdomen. I ordered a CT scan. I wasn't all that worried about internal injuries. Still, the small chance of missing something on a dissatisfied patient was too big a risk for my professional comfort. His scan came back normal, as I expected. But doctors learn early to play defense. I've never been sued, but I've seen doctors accused of malpractice when there is a bad outcome, regardless of whether they seemed to have done anything wrong. There is an expectation after a patient does badly that the doctor should have ordered another test or done something else. But sometimes things go wrong no matter what you do -- or don't do. Defensive medicine is part of the cost of doing business, and also, unfortunately, a large part of the unnecessary expense of health care. In my experience, I'd estimate it accounts for 10% of the waste. Some days I think that's probably conservative. Unlike defensive driving where slowing down and being less aggressive saves lives, defensive medicine means doing more tests, ordering more consults from specialists and exposing patients to the risks of radiation, invasive tests and treatments. It transcends being cautious or careful for the patient's sake. It has everything to due with protecting the practice from the legal system. I try not to order expensive or risky tests to chase down minor lab or X-ray findings. Some physicians feel compelled to do this. One thing that we doctors hate almost as much as a faulty diagnosis is winding up in court to defend our decisions. Once a doctor has had his judgment questioned in a lawsuit, his documentation and test ordering will never be the same. A typical line of legal attack is that you didn't order a test or refer a patient to a specialist fast enough. A general surgical colleague used to handle elderly patients with higher medical risks. He was good at his job and never turned anyone away for lack of insurance. After being sued, he transferred many patients with problems he used to take care of himself to bigger hospitals for care. The change was expensive, adding ambulance or helicopter costs, and it delayed some surgeries. Another sign of the times can be found in patient files, which have become more suited to legal defense than medical communication. The modern medical chart often contains reams of normal data kept to satisfy auditors and show that doctors are comprehensive in taking a history and performing an exam. To ward off critics, we put in comments like, "The patient denies other complaints." Electronic medical records provide even more opportunities to pack in boilerplate entries. The notes from specialists about my patients are now four to five pages long, and I have to search for the nugget of useful information and advice, usually toward the end. Patients are defensive, too. They look up their symptoms on the Internet and then insist on testing and consultations for symptoms that can be safely observed and frequently go away on their own. What can we do? Building better relationships between doctors and patients would help, though that's a tall order given the brief visits that have become the norm. If you are going into the hospital, think about leaving your most confrontational family member at home. When the family questions every detail of care to the Nth degree, you're going to get more testing, more specialists poking you and more cost. If that type of evaluation and treatment is what you are after, most doctors will oblige. Just make sure to factor in the extra doses of radiation from scans, the extra medication you might be allergic to, and the extra procedures the specialist is likely to recommend. Speak up if you suspect a test is just being ordered to cover the doctor's derriere. The defensive among us will document your informed refusal and our estimation that your lack of compliance might hurt you. The rest of us would probably agree with you. Due to his schedule and the volume of email he receives, Dr. Brewer may not be able to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsoffice@wsj.com.

O sarampo nos Estados Unidos

Se ocorresse em Terra Brasilis, o que estaria acontecento na imprensa? Falência da Saúde Pública!!!

Mas, é na terra de Tio Sam. Notem que há crianças não vacinadas por crenças dos pais, filosóficas ou religiosas.

Measles Outbreaks Continue at Record Pace CDC Officials Warn of Increasing Levels of Viral Transmission By Cindy Borgmeyer 9/12/2008 In May, AAFP News Now reported on a series of measles outbreaks that had racked up a total of 64 cases between Jan. 1 and April 25 -- the most cases seen in the United States since 2001. According to CDC officials, that tally had reached 131 by the end of July -- the highest year-to-date number since 1996. As of the end of April, nine states had reported cases of the disease; now, 15 states and the District of Columbia have reported measles cases.But those figures only begin to scratch the surface of the problem. This boy with measles displays the characteristic red blotchy rash that typically appears on the third day of the illness. Of the 131 total cases reported to the CDC, 123 occurred in U.S. residents. Five of these residents had received a single dose of measles-mumps-rubella, or MMR, vaccine; six had received two MMR doses; and 112 were unvaccinated or had unknown vaccination status. Of those 112 cases, 16 occurred in patients who were too young to be vaccinated and one occurred in a patient who was born before 1957 and, therefore, was presumed to have immunity. Finally, of the 95 remaining patients eligible for vaccination, 63 had not been immunized because of their parents' philosophical or religious beliefs

Erros médicos: por que não notificar?

O blogueiro do The Wall Street Journal repercute matéria do Philadelphia Inquirer sobre a notificação de erros médicos. Alguns estados americanos adotaram a notificação de erros hospitalares. Lá, como cá há um pavor em dizer que há problemas nos processos de trabalho que levam a erros. Prova da estúpida onipotência do setor hospitalar e dos médicos.

Pennsylvania and New Jersey, like several other states, have passed laws in recent years requiring hospitals to report serious errors. But lots of important mistakes may still be going unreported, the Philadelphia Inquirer reports this morning. In New Jersey, for example, five of the state’s 80 hospitals didn’t report any preventable mistakes last year. And some Pennsylvania hospitals didn’t report any errors or near misses, which are also supposed to be reported. It’s unlikely the hospitals operated flawlessly. “I don’t know how many is enough, but zero is a bad number,” said James Bagian, head of the Department of Veterans Affairs’ National Center for Patient Safety, told the Inquirer. “Anybody that is supposed to report close calls and has zero reports is clueless. … Management is asleep at the switch and just waiting until they kill someone.” The laws are part of a nationwide push to recognize medical errors and improve patient safety by preventing them. But the laws aren’t in step with another big trend in medicine these days: transparency. In general, the error reports aren’t available to the public, and the agencies wouldn’t tell the Inquirer how many error reports each hospital had filed. The New Jersey Hospital Association supports reporting but opposes making the reports public. “It may present an unfair picture of what is actually going on . . . when we have some hospitals that are not reporting and other hospitals that are reporting,” a hospital association official told Inquirer.

Medicina: a ciência das verdades transitórias, transformadas em dogmas para fins didáticos

No blogue auxiliar Ensaios Clínicos , postei os dois abstracts publicados hoje no The New England Journal of Medicine. Trata-se da continuidade de dois ensaios clínicos sobre diabetes encerrados e publicados há dez anos, o UKPDS (United Kingdom Prospective Diabetes Study). Agora, eles avaliam o efeito do ensaio sem a intervenção, dez anos depois. Os resultados praticamente mudaram o publicado inicialmente, o que implica discutir cada vez mais o mundo dos ensaios clínicos e o mundo real. Fica para outro momento.

O título do post é homenagem ao filósofo, médico, endocrinologista e diabetólogo, Arnaldo Caleiro Sandoval, autor dessa e de outras máximas.

Quem é mais citado?

Um artigo simples, de fácil realização, publicado no Circulation pela equipe da Harvard Medical School revela que artigos financiados pela indústria são mais citados do que aqueles por outras fontes, independente da qualidade. O mesmo vale para artigo mostrando que a proposta nova é mais efetiva do que a existente.

Leitura obrigatória em seminários de médicos-residentes e pós-graduandos.

Differential Citation Rates of Major Cardiovascular Clinical Trials According to Source of Funding. A Survey From 2000 to 2005

David Conen MD, Jose Torres BA, and Paul M Ridker MD* Background—Prior work indicates that therapeutic trials funded by for-profit organizations are more likely to report positive findings than trials funded by not-for-profit organizations. What impact, if any, funding source has on subsequent dissemination of trial data is uncertain. To address this issue, we used the number of citations per publication per year to assess differences in trial dissemination according to funding source. Methods and Results—We assessed 303 consecutive superiority trials of cardiovascular medicine published between January 1, 2000, and July 30, 2005, in the Journal of the American Medical Association, The Lancet, and the New England Journal of Medicine. The primary outcome measure was the number of citations per publication per year up to December 31, 2006. Overall, the median number of citations per publication per year was 46 for trials funded exclusively by for-profit organizations, 37 for trials jointly funded, and 29 for trials funded by not-for-profit organizations (P=0.0007). Higher citation rates for trials funded by for-profit organizations were consistently observed in analyses stratified by journal and various trial design features and were most striking when the new intervention was favored over the standard of care; in this subgroup, the median number of citations per publication per year was 52 for trials funded by for-profit organizations compared with 25 for trials funded by not-for-profit organizations (P=0.0006). In marked contrast, in analyses limited to trials in which the new intervention was significantly worse than the standard of care, an inverse pattern was observed with fewer citations per publication per year for trials funded by for-profit organizations compared with not-for-profit organizations (33 versus 41; P=0.048). Higher citation rates were observed for industry-funded trials than for federally funded trials even when the trials dealt with similar issues and were published back-to-back in the same journal. Conclusions—Dissemination of clinical trial results is important for clinical practice but appears to be biased in favor of for-profit entities. Consideration should be given to more extensive promotion of clinical trial results that are funded by not-for-profit organizations.

Não fui embora !

Reforma do Pronto-Socorro do Hospital, estrutura nova para ambulatórios de especialidade, relatórios e proposições a agências de pesquisas, aulas e seminários, início do ELSA, submissão de manuscritos... O blog ficou sozinho..

Um idéia excelente: compartilhar banco de dados

Towards a Data Sharing Culture: Recommendations for Leadership from Academic Health Centers. (texto completo, clique aqui) Sharing biomedical research and health care data is important but difficult. Recognizing this, many initiatives facilitate, fund, request, or require researchers to share their data. These initiatives address the technical aspects of data sharing, but rarely focus on incentives for key stakeholders. Academic health centers (AHCs) have a critical role in enabling, encouraging, and rewarding data sharing. The leaders of medical schools and academic-affiliated hospitals can play a unique role in supporting this transformation of the research enterprise. We propose that AHCs can and should lead the transition towards a culture of biomedical data sharing. Benefits of Data Sharing for Academic Health Centers The benefits of data sharing and reuse have been widely reported. We summarize them here, from the perspective of an AHC. The predominant benefit of data sharing is accelerated scientific progress. Advances are clearly valuable to an AHC when translated into improved patient outcomes, reduced research costs, and decreased time in moving discoveries from the bench to the bedside. Of more immediate benefit to AHCs and their researchers, sharing data increases the visibility and relevance of research output. Sharing data generates opportunities for additional publications through collaboration, and may increase the citation rate of primary publications. Since publication history and citation impact are often considered in future funding decisions, these benefits are likely to accelerate research programs, and thus enhance the reputation of the academic institutions. Data sharing can also benefit an AHC in its roles of educator and employer. Health care professionals trained in clinical informatics benefit from exposure to real-world data. By embracing data sharing goals, an AHC becomes more appealing to cutting-edge researchers, and thereby more able to recruit the talent required for future successes. Finally, the widespread adoption of a data sharing culture needs leaders, and thus provides an opportunity for AHCs to demonstrate excellence. A Leadership Role Despite the anticipated benefits, sharing research data has yet to be widely adopted in biomedicine. Through their interwoven roles in education, research, and policy, AHCs can lead the development of best practices for establishing a data sharing culture. Practical steps with potentially powerful impact are discussed below and summarized in Box 1. Box 1: Recommendations for Academic Health Centers to Encourage Data Sharing Commit to sharing research data as openly as possible, given privacy constraints. Streamline IRB, technology transfer, and information technology policies and procedures accordingly. Recognize data sharing contributions in hiring and promotion decisions, perhaps as a bonus to a publication's impact factor. Use concrete metrics when available. Educate trainees and current investigators on responsible data sharing and reuse practices through class work, mentorship, and professional development. Promote a framework for deciding upon appropriate data sharing mechanisms. Encourage data sharing practices as part of publication policies. Lobby for explicit and enforceable policies in journal and conference instructions, to both authors and peer reviewers. Encourage data sharing plans as part of funding policies. Lobby for appropriate data sharing requirements by funders, and recommend that they assess a proposal's data sharing plan as part of its scientific contribution. Fund the costs of data sharing, support for repositories, adoption of sharing infrastructure and metrics, and research into best practices through federal grants and AHC funds. Publish experiences in data sharing to facilitate the exchange of best practices.

Agora é polícia que mostra a máfia das ações judiciais.

Ações Judiciais para liberação de medicamentos. Quando ninguém falava, eu denunciei. Recebi de um médico, uma ação no CREMESP que foi arquivada e, outra em Conselho de Ética. Outra ação movida contra mim , na esfera do Judiciário foi retirada de início. Agora, somente cabe ler os jornais e, observar detalhes da maior drenagem de dinheiro público na área da saúde ocorrida nos últimos tempos.