Friday, February 27, 2009
Abstract—Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A -hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by combining clinical judgment with diagnostic test results, the criterion standard of which is the throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) is the treatment of choice, because it is cost-effective, has a narrow spectrum of activity, and has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. For penicillin-allergic individuals, acceptable alternatives include a narrow-spectrum oral cephalosporin, oral clindamycin, or various oral macrolides or azalides. The individual who has had an attack of rheumatic fever is at very high risk of developing recurrences after subsequent GAS pharyngitis and needs continuous antimicrobial prophylaxis to prevent such recurrences (secondary prevention). The recommended duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is again the agent of choice for secondary prophylaxis, but sulfadiazine or a macrolide or azalide are acceptable alternatives in penicillin-allergic individuals. This report updates the 1995 statement by the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee. It includes new recommendations for the diagnosis and treatment of GAS pharyngitis, as well as for the secondary prevention of rheumatic fever, and classifies the strength of the recommendations and level of evidence supporting them.
Monday, February 23, 2009
Sunday, February 22, 2009
The new journal Amanar, in Tifinagh, is distributed in Agadez, Niger©Jacques Roure
UNESCO's Atlas of the World's Languages in Danger is intended to raise awareness about language endangerment and the need to safeguard the world’s linguistic diversity among policy-makers, speaker communities and the general public, and to be a tool to monitor the status of endangered languages and the trends in linguistic diversity at the global level.
The latest edition of the Atlas (2009) lists about 2,500 languages (among which 230 languages extinct since 1950), approaching the generally-accepted estimate of some 3,000 endangered languages worldwide. For each language, the Atlas provides its name, degree of endangerment (see below) and the country or countries where it is spoken.
Wednesday, February 18, 2009
Marcia Angell, M.D. (born 1939) is an American physician, author, and the first woman to serve as editor-in-chief of the New England Journal of Medicine (NEJM). She currently is a Senior Lecturer in theDepartment of Social Medicine at Harvard Medical School, in Boston, Massachusetts.
São Paulo, terça-feira, 17 de fevereiro de 2009
COQUETEL ANTI-AIDS Farmanguinhos entrega 1º lote de Efavirenz nacional ITALO NOGUEIRA DA SUCURSAL DO RIO
A entrega das primeiras unidades do Efavirenz -remédio do coquetel contra a Aids- de produção brasileira serviu como palanque para o diretor da Farmanguinhos, Eduardo Costa, defender mudanças na gestão da unidade da Fiocruz. Costa listou dificuldades na produção do medicamento e pediu que a Farmanguinhos deixe "de ser suporte ao programa de atenção básica para desenvolver e produzir medicamentos de alto valor". O ministro José Gomes Temporão (Saúde) criou um grupo de trabalho para estudar a flexibilização da gestão da unidade. O Efavirenz, um dos 17 medicamentos do coquetel anti-Aids, foi produzido pela Farmanguinhos com o laboratório Lafepe e consórcio privado após polêmico licenciamento compulsório. Criado pelo laboratório Merck, foi declarado objeto de interesse público pelo governo federal em 2007. Neste ano, serão produzidos 15 milhões de comprimidos, metade da demanda nacional (completada com produto da Índia, usado desde 2007) -todo o consumo deve ser atendido em 2010. A produção brasileira será 32,6% mais cara do que a indiana (R$ 1,35 o preço do comprimido contra R$ 1,04), mas Temporão diz que, com a iniciativa, o Brasil "reduz a dependência de tecnologia de fora e passa a desenvolver a sua própria".
Demanda federal A Farmanguinhos só pode produzir sob demanda do ministério e vender o raro excedente dessa produção. Costa afirma que, com uma produção em larga escala, os remédios ficariam mais baratos e poderiam ser enviados para a África e vendidos a baixo custo para países do Mercosul, além de outros Estados e municípios. A unidade é vinculada à Fiocruz -fundação ligada ao Ministério da Saúde-, que tem verba definida pelo orçamento e depende da liberação por parte do governo federal. Ele está estimado neste ano em R$ 1,5 bilhão, dos quais R$ 250 milhões para a Farmanguinhos. O governo pretende produzir outros dois medicamentos do coquetel anti-Aids: o tenofovir e o atazanavir -este último patenteado.
High Coffee Consumption Linked to Lower Stroke Risk for Women
MADRID, Feb. 17 -- Drinking caffeinated coffee regularly may lower the stroke risk for women, according to data from the Nurses' Health Study.
Women who drank two to three cups a day had a 19% reduction in the risk of all strokes, with greater consumption lowering the risk even further (P=0.003 for trend), found Esther Lopez-Garcia, Ph.D., of the Universidad Autonoma de Madrid, and Harvard colleagues.
The association was weakened after adjusting for high blood pressure, hypercholesterolemia, and type 2 diabetes, and was not statistically significant among current smokers, the investigators reported in the Feb. 17 issue of Circulation: Journal of the American Heart Association.
"These results should be supported by further research before the possible implications for public health and clinical practice are considered," the researchers said.
Previous studies have linked coffee consumption to a lower risk of diabetes. (See: Perk Up -- Coffee May Give a Break on Type 2 Diabetes)/.../
Inadequate Dissemination of Phase I Trials: A Retrospective Cohort Study
1 Hospices Civils de Lyon, Pôle Information Médicale et Evaluation en Recherche, Lyon, France, 2 Université de Lyon, Laboratoire Santé Individu Société (EA SIS), Lyon, France, 3 Université Lyon 1, Lyon, France, 4 Comité de Protection des Personnes, CPP Sud-Est III, Lyon, France, 5 Mayo Clinic, Rochester, Minnesota, United States, 6 Université Lyon 1, Réseau d'Épidémiologie Clinique International Francophone (RECIF), Lyon, France
Drug development is ideally a logical sequence in which information from small early studies (Phase I) is subsequently used to inform and plan larger, more definitive studies (Phases II–IV). Phase I trials are unique because they generally provide the first evaluation of new drugs in humans. The conduct and dissemination of Phase I trials have not previously been empirically evaluated. Our objective was to describe the initiation, completion, and publication of Phase I trials in comparison with Phase II–IV trials./.../
Monday, February 16, 2009
Sunday, February 15, 2009
On Bioethics (& the Social Determinants of Health)
One of the central aims of MH Blog is to explore the relationship between bioethics and the medical humanities. The relationship is complex, and in many ways MH Blog itself is on ongoing dialogue on the matter. On the one hand, there are persistent, vocal, and, to my mind, persuasive criticisms of some of the dominant traditions of bioethics practice and scholarship coming from the medical humanities (and from other places, of course). On the other hand, if the medical humanist is not at least somewhat interested in ethics related to health, illness, medicine, and health care, it is hard to see the purpose of the medical humanities. I am using the term "ethics" here in its most expansive sense, a sense that two great questions help explicate:
What is the good?
How shall I live?/.../
Thursday, February 12, 2009
Methods We conducted a multicenter trial to evaluate the use of dronedarone in 4628 patients with atrial fibrillation who had additional risk factors for death. Patients were randomly assigned to receive dronedarone, 400 mg twice a day, or placebo. The primary outcome was the first hospitalization due to cardiovascular events or death. Secondary outcomes were death from any cause, death from cardiovascular causes, and hospitalization due tocardiovascular events.
Results The mean follow-up period was 21±5 months, with the study drug discontinued prematurely in 696 of the 2301 patients (30.2%) receiving dronedarone and in 716 of the 2327 patients (30.8%) receiving placebo, mostly because of adverse events. The primary outcome occurred in 734 patients (31.9%) in the dronedarone group and in 917 patients (39.4%) in the placebo group, with a hazard ratio for dronedarone of 0.76 (95% confidence interval [CI], 0.69 to 0.84; P<0 .001=""> (5.0%) in the dronedarone group and 139 (6.0%) in the placebo group (hazard ratio, 0.84; 95% CI, 0.66 to 1.08; P=0.18). There were 63 deaths from cardiovascular causes (2.7%) in the dronedarone group and 90 (3.9%) in the placebo group (hazard ratio, 0.71; 95% CI, 0.51 to 0.98; P=0.03), largely due to a reduction in the rate of death from arrhythmia with dronedarone. The dronedaronegroup had higher rates of bradycardia, QT-interval prolongation, nausea, diarrhea, rash, and an increased serum creatinine level than the placebo group. Rates of thyroid- and pulmonary-related adverse events were not significantly different between the two groups.0>
Conclusions Dronedarone reduced the incidence of hospitalization due to cardiovascular events or death in patients with atrial fibrillation. (ClinicalTrials.gov number, NCT00174785 [ClinicalTrials.gov] .)
BURLINGTON, Vt., Feb. 11 -- For patients with a history of colorectal adenomas, aspirin may prevent a recurrence, a meta-analysis showed.
Patients taking daily aspirin for at least a year had a 17% reduced risk of developing recurrent adenomas, precursors of colorectal cancer (RR 0.83, 95% CI 0.72 to 0.96), Bernard Cole, Ph.D., of the University of Vermont here, and colleagues found in a review of four randomized placebo-controlled trials.
This corresponded to an absolute risk reduction of 6.7% (95% CI 3.2% to 10.2%), they reported in the Feb. 18 issue of the Journal of the National Cancer Institute./.../
© 2009 American Academy of Neurology
Predictors of driving safety in early Alzheimer disease
From the Department of Biostatistics (J.D.D., E.D.), Division of Neuroergonomics, Department of Neurology (J.D.D., S.W.A., E.Y.U., E.D., M.R.), Department of Mechanical and Industrial Engineering (M.R.), and Public Policy Center (M.R.), University of Iowa; and VA Medical Center (E.Y.U.), Iowa City, IA.
Address correspondence and reprint requests to Dr. Jeffrey D. Dawson, Department of Biostatistics, University of Iowa College of Public Health, 200 Hawkins Dr., C-22 GH, Iowa City, IA 52242 firstname.lastname@example.org
Objective: To measure the association of cognition, visual perception, and motor function with driving safety in Alzheimer disease (AD).
Methods: Forty drivers with probable early AD (mean Mini-Mental State Examination score 26.5) and 115 elderly drivers without neurologic disease underwent a battery of cognitive, visual, and motor tests, and drove a standardized 35-mile route in urban and rural settings in an instrumented vehicle. A composite cognitive score (COGSTAT) was calculated for each subject based on eight neuropsychological tests. Driving safety errors were noted and classified by a driving expert based on video review.
Results: Drivers with AD committed an average of 42.0 safety errors/drive (SD = 12.8), compared to an average of 33.2 (SD = 12.2) for drivers without AD (p <> errors were lane violations. Increased age was predictive of errors, with a mean of 2.3 more errors per drive observed for each 5-year age increment. After adjustment for age and gender, COGSTAT was a significant predictor of safety errors in subjects with AD, with a 4.1 increase in safety errors observed for a 1 SD decrease in cognitive function. Significant increases in safety errors were also found in subjects with AD with poorer scores on Benton Visual Retention Test, Complex Figure Test-Copy, Trail Making Subtest-A, and the Functional Reach Test.
Conclusion: Drivers with Alzheimer disease (AD) exhibit a range of performance on tests of cognition, vision, and motor skills. Since these tests provide additional predictive value of driving performance beyond diagnosis alone, clinicians may use these tests to help predict whether a patient with AD can safely operate a motor vehicle.
AD = Alzheimer disease; AVLT = Auditory Verbal Learning Test; Blocks = Block Design subtest; BVRT = Benton Visual Retention Test; CFT = Complex Figure Test; CI = confidence interval; COWA = Controlled Oral Word Association; CS = contrast sensitivity; FVA = far visual acuity; JLO = Judgment of Line Orientation; MCI = mild cognitive impairment; MMSE = Mini-Mental State Examination; NVA = near visual acuity; SFM = structure from motion; TMT = Trail-Making Test; UFOV = Useful Field of View.
Wednesday, February 11, 2009
Publicado originalmente na:
Revista Brasileira de Ciências do Esporte 29 (1): 35-48, 2007.
Luiz Oswaldo Carneiro Rodrigues
in a General Population
1 University of Leuven;
2 Center for Applied Medical Research, Pamplona;
3 University of Leuven and University of Maastricht
4 E-mail: email@example.com
Background—Because the process of myocardial remodelling starts before the onset of symp-toms, recent heart failure (HF) guidelines place special emphasis on the detection of subclinical left ventricular (LV) systolic and diastolic dysfunction and the timely identification of risk factors for HF. Our goal was to describe the prevalence and determinants (risk factors) of LV diastolic dysfunction in a general population and to compare the amino terminal-pro-brain natriuretic peptide (NT-proBNP) level across groups with and without diastolic dysfunction.
Methods and Results—In a randomly recruited population sample (n=539; 50.5% women; mean age, 52.5 years), we measured early and late diastolic peak velocities of mitral inflow (E and A), and pulmonary vein (PV) flow by pulsed wave Doppler, and the mitral annular velocities (Ea and Aa) at four sites by Tissue Doppler Imaging. A healthy subsample of 239 subjects (mean age, 43.7 years) provided age-specific cut-off limits for normal E/A, E/Ea ratios, and the differences in duration between the mitral A and the reverse PV flows during atrial systole (Ad – ARd). The number of subjects in diastolic dysfunction groups 1 (impaired relaxation), 2 (elevated LV end-diastolic filling pressure) and 3 (elevated E/Ea and abnormally low E/A) were 53 (9.8%), 76 (14.1%), and 18 (3.4%), respectively. We used (Ad <> pressures in group 2. Compared to subjects with normal diastolic function (n=392, 72.7%), group 1 (209 vs 251 pmol/L; P=0.015) and group 2 (209 vs 275 pmol/L; P=0.0003), but not group 3 (209 vs 224 pmol/L; P=0.65) had a significantly higher adjusted NT-proBNP. Higher age, body mass index, heart rate, systolic blood pressure, serum insulin and creatinine were significantly associated with a higher risk of LV diastolic dysfunction.
Conclusions—The overall prevalence of LV diastolic dysfunction in a random sample of a general population, as estimated from echocardiographic measurements was as high as 27.3%.
Tuesday, February 10, 2009
On February 12, 2009, we celebrate the 200th anniversary of the birth of Charles Darwin. He has earned the scientific reputation as being the most influential naturalist-biologist of his generation and perhaps of all time. Achievement of his esteemed status resulted initially from studying the geographical distribution of wildlife and fossils collected on his 5-year voyage on the Beagle and concluding that the "transmutation of species" was due to natural selection.1 In 1858, he was in the process of documenting his research when he received an essay from Alfred Russel Wallace putting forth the same concept of natural selection as the mechanism for generation of new species, resulting in a joint publication that same year.2On the Origin of Species3 was published by Darwin in 1859, making it now the 150th anniversary of its publication. This book proposed evolution as the scientific basis of diversity and species generation produced through the effects of natural selection. Evolution has been proven to be the mechanism for species generation and the engine for change is natural selection, providing the evolved species, beginning from a common organism, adaptation and fitness to maximize reproductionand survival. Dobzhansky put it succinctly by saying that "nothing in biology makes sense except in the light of evolution."4Darwin expressed it eloquently in 1859:
There is grandeur in this view of life, with its several powers, having been originally breathed into a few forms or into one;and that, whilst this planet has gone cycling on according to the fixed law of gravity, from so simple a beginning endlessforms most beautiful and most wonderful have been, and are being evolved.3/.../
The Politicization of Professional Practice Guidelines
The Infectious Diseases Society of America (IDSA) issued updated clinical practice guidelines in 2006 for the diagnosis and treatment of Lyme disease.1 Within days, the Connecticut attorney general launched an investigation, alleging IDSA had violated state antitrust law by recommending against the use of long-term antibiotics to treat "chronic Lyme disease (CLD)," a label applied by advocates to a variety of nonspecific symptoms for which frequently no evidence suggests the etiologic agent of Lyme disease is responsible. The IDSA was forced to settle the claim to avoid exorbitant litigation costs, even though the society's guidelines were based on sound science. The case exemplifies the politicization of health policy, with elected officials advocating for health policies against the weight of scientific evidence./.../
Monday, February 09, 2009
© 2009 American Heart Association, Inc.
Basic Science for Clinicians
Some of the People, Some of the Time
Penelope A. Bryant; Roy Robins-Browne; Jonathan R. Carapetis; Nigel Curtis
From the Departments of Paediatrics (P.A.B., N.C.), and Microbiology and Immunology (R.R.-B.), University of Melbourne, Parkville, Australia; Infectious Diseases Unit, Department of General Medicine (P.A.B., N.C.), and Infection, Immunity and Environment Theme, Murdoch Children’s Research Institute (P.A.B., R.R.-B., N.C.), Royal Children’s Hospital Melbourne, Parkville, Australia; and Menzies School of Health Research (J.R.C.), Charles Darwin University, Casuarina, Australia.
Correspondence to Professor Nigel Curtis, University Department of Paediatrics, Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia. E-mail firstname.lastname@example.org
Acute rheumatic fever is a major cause of heart disease in large parts of the world, but it remains unknown why only a smallfraction of those who are infected with rheumatogenic group A streptococci develop an abnormal immune response that leads to acute rheumatic fever. An understanding of the mechanisms underlying host susceptibility can provide important insights into pathogenesis that in turn can inform new treatments. Extensive searches for susceptibility factors have been undertaken, including human leukocyte antigens, B-cell alloantigens, and cytokinegenes. Although significant associations have been found between genetic factors and acute rheumatic fever, study results often conflict with each other. This review explores current understanding about host susceptibility to acute rheumatic fever and provides an overall perspective to the number of studies that have recentlyaddressed this subject.
Data de Publicação: 06/02/2009
Nos últimos dias, acompanhamos o polêmico caso do campeão olímpico de natação Michael Phelps. O atleta americano de 23 anos foi fotografado fumando maconha numa festa, enquanto estava de férias. Mesmo estando longe das piscinas, sua atitude foi punida pela Federação Norte-Americana de Natação com a suspensão de três meses do esporte. Além disso, Phelps perdeu o patrocínio de uma gigante do ramo alimentício, certamente porque a empresa não quer sua marca associada às drogas.
Nestas circunstâncias, surge uma questão: por que um jovem que é recordista olímpico e que se tornou o maior esportista da história em sua modalidade fez uso de uma substância ilícita? É difícil apontar os motivos que levaram Phelps a agir de tal forma. Mas fica claro, mais uma vez, que as drogas não seguem um perfil de usuário. Não escolhem classe social.
Crianças e adolescentes que praticam algum esporte tendem a admirar e seguir como exemplo o maior atleta da modalidade. Na natação, é Michael Phelps. Neste ponto, sua ação traz pontos negativos. Mas é também verdade que ao perceber o que causou, o nadador tratou de pedir desculpas e disse ter agido de forma pueril e inadequada, passando longe do que as pessoas esperam dele.
Em contrapartida a tudo isso, não é difícil encontramos artistas, estrangeiros e nacionais, que têm seus nomes associados a marcas de cerveja e cigarros. Ícones da música, da televisão e do cinema que faturam alto apenas por tornarem-se garotos propagandas de empresas que fabricam drogas lícitas. Como se essas substâncias não acarretassem nenhum tipo de mal ao indivíduo que as consome e à sociedade que os abriga. Esquecem-se deste pequeno detalhe que traz desastrosas consequências para todos.
Analice Gigliotti e Sabrina Presman
Coronaries And Controversy -
A number of studies have been published recently showing a decline in admissions to hospital for heart attack following the implementation of smokefree laws in various countries. Many of these studies, including one on the impact of the Scottish smoking ban  have also been the subject of criticism by so-called "dissidents" who claim that the research is nothing more than 'junk' science. In a recently published review  ASH's Director of Policy and Research, Martin Dockrell, looks behind the scenes to see what has prompted this criticism and to what extent it is justified. The analysis finds parallels with those who were in denial about the causes of AIDS long after the scientific debate was over.
The focus of the analysis was a study by Pell and colleagues of the impact of the Scottish smoke-free legislation which found that there was a 17% reduction in hospitalizations for acute coronary syndrome compared with a 4% reduction in England (which had not enacted smokefree legislation).
The ASH review acknowledges that many of the studies have differing strengths and that no single study can ever demonstrate causation. However, even before the Scottish study was published, the headline figures attracted criticism for being "over-hasty" and constituting "junk science".
So who was behind the protest and was it justified? Dockrell's review reveals that the strongest critics - Blastland and Dilnot  had in fact rejected the research before they had had the opportunity to examine it. Furthermore, ASH believes that all of their criticisms are unfounded and bear close resemblance to the views put forward by tobacco industry proponents. 
Commenting on the dissidents, Martin Dockrell said:
"While careful analytical critiques of research are welcome, the recent unwarranted attacks on the authors of the smokefree research suggest an ulterior motive. We found an unholy alliance of conspiracy theorists, tobacco industry lobbyists and journalists impatient for a good story." /.../
Sunday, February 08, 2009
Volume 56, Number 1 · January 15, 2009 New York Review of Books
Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial
by Alison Bass
Algonquin Books of Chapel Hill, 260 pp., $24.95
Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs
by Melody Petersen
Sarah Crichton/Farrar, Straus and Giroux, 432 pp., $26.00
Shyness: How Normal Behavior Became a Sickness
by Christopher Lane
Yale University Press, 263 pp., $27.50; $18.00 (paper)
Recently Senator Charles Grassley, ranking Republican on the Senate Finance Committee, has been looking into financial ties between the pharmaceutical industry and the academic physicians who largely determine the market value of prescription drugs. He hasn't had to look very hard.
Friday, February 06, 2009
NEW YORK, Feb. 5 -- Call these chemicals "his" and "her" endocrine disruptors.
Although they have been linked to reproductive problems in both sexes, bisphenol A (BPA) and phthalates -- common chemicals found in household plastics -- have gender-specific effects.
BPA mimics estrogen, while phthalates block testosterone action, Hugh S. Taylor, M.D., of Yale University, said at a press briefing.
"BPA looks like estrogen," Dr. Taylor, whose research focuses on uterine development and endocrine disruption, said of its chemical structure. "By itself it is a very weak estrogen."
The chemical stimulates uterine growth, he said, and animal studies have revealed other estrogen-like effects./.../