Earnings up at Imperial Tobacco

By GARETH EDWARDS

IMPERIAL Tobacco, the world's fourth-biggest cigarette maker, has posted a 15 per cent rise in annual earnings.

The British maker of Lambert and Butler, West and Gauloises cigarettes saw net tobacco revenue rise by 60 per cent to £5.2 billion, up from £3.28bn last year, with demand for tobacco remaining strong.

Imperial bought Franco-Spanish rival Altadis in January for £11bn to add brands such as Gauloises and Fortuna, and launched a £4.9bn rights issue in May to part fund the deal, with the rest covered by debt./.../

Sweet! Galactic Molecule Could Point to Alien Life

Galactic molecules. Credit: NASA

An organic sugar molecule which is directly linked to the origin of life has been detected in a region of our galaxy where habitable planets could exist. Using the IRAM radio telescope in France, an international team of scientists found the molecule in a massive star forming region of space, about 26,000 light years from Earth. “This is an important discovery, as it is the first time glycolaldehyde, a basic sugar, has been detected near a star-forming region where planets that could potentially harbour life may exist,” said Dr. Serena Viti, one of the paper’s authors. Glycolaldehyde can react to form ribose, a key constituent of the nucleic acid RNA, thought to be the central molecule in the origin of life./.../

Periodontal disease associated with elevated levels of Lp-PLA2

Periodontal disease associated with elevated levels of Lp-PLA₂

NOVEMBER 25, 2008 | Michael O'Riordan

New York, NY - Individuals with a history of periodontal disease also have increased levels of systemic inflammation, according to the results of a new study [1]. Investigators observed a significant association among those with periodontal disease and elevated levels of the inflammatory marker lipoprotein-associated phospholipase A₂ (Lp-PLA₂).

"To our knowledge, this is the first report of an association between oral health and Lp-PLA₂," write lead author Heidi Mochari (Columbia University Medical Center, New York) and colleagues in the December 1, 2008 issue of the American Journal of Cardiology. "These data support a possible independent association between oral health and inflammation, suggesting that inflammation may be a factor in the relation between oral health and cardiovascular disease."/.../

The Lessons of Success — Revisiting the Medicare Story

David Blumenthal, M.D., M.P.P., and James Morone, Ph.D.

President-elect Barack Obama waits to take the oath of office, and as predictably as sap rises in the New England spring, healthcare professionals and policymakers are posing the quadrennial questions: Will this be the time? Have Americans finally elected a president who can repair our ailing health care system?

Each presidential election sends analysts searching for lessons that might be gleaned from past — and usually futile — presidential attempts at health care reform. President Bill Clinton's maladroit effort to enact the Health Security Act in 1993 and 1994 offers a wealth of cautions about how not to manage comprehensive health care change, and for these warnings we refer readers to several pieces of excellent work,^1,2,3,4 as well as to President Clinton's own memoir.^5/.../

Socializando as perdas

Jornal ZERO HORA: 26 de novembro de 2008 | N° 15801

ARTIGOS

Socializando as perdas, por Aloyzio Achutti*

Primeiro era o G-7 (Estados Unidos, Canadá, Inglaterra, Japão, França, Alemanha e Itália), depois o G-8, com a entrada da Rússia, e o convite para Espanha e Holanda. Agora é o G-20, grupo do qual participam o Brasil e outros países ditos emergentes, até recentemente submersos (parafraseando a designação atual), trancados do lado de fora, sem direito a palpite.

O clube fechado inicial representava apenas 13% da população mundial. A expansão atual incorporou metade do mundo.

Eram sete ou oito amealhando a metade de todas as riquezas e decidindo pelo destino de quase 200 países, onde vivem mais de 6 bilhões de habitantes.

Agora sentam-se à mesa de negociações representantes da metade da população mundial, juntando mais um quarto da riqueza global. Se não fosse a crise atual, seria de se estranhar esta abertura, pois o esperado seria o fechamento do grupo para continuar concentrando capital.

Fala-se bastante sobre a surpreendente ressurreição do Estado intervindo no mercado, que deveria ser livre para se auto-regular; mas a tal da abertura para economias menores tem se contemplado apenas como uma vantagem da crise, dando chance aos emergentes para romper barreiras.

Uma explicação mais plausível poderá estar relacionada com a socialização das perdas, a modo da bem conhecida socialização da miséria...

Parece mais fácil pensar assim do que assumir que os donos do capital tenham se convertido com a crise, cometendo dois pecados mortais: o da intervenção do Estado sobre o mercado e o da abertura social.

Este panorama global também espelha nossa situação interna, pois de nossa riqueza nacional menos da metade é fruto do trabalho, o restante corresponde a aventuras financeiras semelhantes às que estão na raiz da crise mundial.

Não se trata apenas de dinheiro e especulação. Enquanto pouco mais de um dentre 10 habitantes do planeta consome a metade dos recursos energéticos, espoliando, poluindo e provocando o aquecimento global, há diferenças significativas na extensão e na qualidade de vida. Os privilegiados chegam a viver em média mais 10 a 20 anos, sem falar de incapacidade, sofrimento e doenças.

Enquanto o saldo era positivo, o acesso aos recursos ficava restrito, agora que há um déficit, buscam-se parceiros para dividir as perdas, esquecendo-se a falta de reservas dos que sobram, que também vêm pagando pesado tributo para manter a desigualdade.

*MÉDICO

AF: Catheter Ablation Versus Antiarrhythmic Drugs

Catheter Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation. The A4 Study

Pierre Jaïs MD^*, Bruno Cauchemez MD, Laurent Macle MD, Emile Daoud MD, Paul Khairy MD, PhD, Rajesh Subbiah BSc (Med), MBBS, PhD, Mélèze Hocini MD, Fabrice Extramiana MD, Fréderic Sacher MD, Pierre Bordachar MD, George Klein MD, Rukshen Weerasooriya MBBS, Jacques Clémenty MD, and Michel Haïssaguerre MDFrom the Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France (P.J., M.H., F.S., P.B., J.C., M.H.); Hôpital Larriboisière, Paris, France (B.C., F.E.); Montreal Heart Institute, Montreal, Canada (L.M., P.K.); Richard M. Ross Heart Hospital, Columbus, Ohio (E.D.); Department of Cardiology, St. Vincent's Hospital, Sydney, Australia (R.S.); University Hospital, London, Canada (G.K.); and University of Western Australia, Crawley, Western Australia (R.W.).
^* To whom correspondence should be addressed. E-mail: pierre.jais@chu-bordeaux.fr.
Background—The mainstay of treatment for atrial fibrillation (AF) remains pharmacological; however, catheter ablation has increasingly been used over the last decade. The relative merits of each strategy have not been extensively studied.
Methods and Results—We conducted a randomized multicenter comparison of these 2 treatment strategies in patients with paroxysmal AF resistant to at least 1 antiarrhythmic drug. The primary end point was absence of recurrent AF between months 3 and 12, absence of recurrent AF after up to 3 ablation procedures, orchanges in antiarrhythmic drugs during the first 3 months. Ablation consisted of pulmonary vein isolation in all cases, whereas additional extrapulmonary vein lesions were at the discretion of the physician. Crossover was permitted at 3 months in case of failure. Echocardiographic data, symptom score, exercise capacity, quality of life, and AF burden were evaluated at 3, 6, and 12 months by the supervising committee. Of 149 eligible patients, 112 (18 women [16%]; age, 51.1±11.1 years) were enrolled and randomized to ablation (n=53) or "new" antiarrhythmic drugs alone or in combination (n=59). Crossover from the antiarrhythmic drugs and ablation groups occurred in 37 (63%) and 5 patients (9%), respectively (P=0.0001). At the 1-year follow-up, 13 of 55 patients (23%) and 46 of 52 patients (89%) had no recurrence of AF in the antiarrhythmic drug and ablation groups, respectively (P<0 .0001=""> of life were significantly higher in the ablation group.
Conclusion—This randomized multicenter study demonstrates the superiority of catheter ablation over antiarrhythmic drugs in patients with AF with regard to maintenance of sinus rhythm and improvement in symptoms, exercise capacity, and quality of life.


Key words: ablation • antiarrhythmia agents • arrhythmia • fibrillation

SBPT: Diretrizes Cessação do Tabagismo 2008.

Smoking cessation guidelines – 2008

Jonatas Reichert1, Alberto José de Araújo2, Cristina Maria Cantarino Gonçalves3, Irma Godoy4,

José Miguel Chatkin5, Maria da Penha Uchoa Sales6, Sergio Ricardo Rodrigues de Almeida Santos7

Resumo

Estas diretrizes constituem uma ferramenta atualizada e abrangente para auxiliar o profissional de saúde na abordagem do tabagista, recomendando atitudes baseadas em evidências clínicas como a melhor forma de conduzir cada caso. De forma reduzida e mais objetiva possível, o texto final foi agrupado em dois grandes itens: Avaliação e Tratamento. Os dois itens apresentam comentários e níveis de recomendação das referências utilizadas, bem como algumas propostas de abordagem, como por exemplo, redução de danos, em situações específicas ainda pouco exploradas, como recaídas, tabagismo passivo, tabagismo na categoria médica e uso de tabaco em ambientes específicos.

Descritores: Tabagismo/efeitos adversos; Abandono do hábito de fumar/métodos; Guia.

Abstract

These guidelines are an up-to-date and comprehensive tool to aid health professionals in treating smokers, recommending measures and strategies for managing each case based on clinical evidence. Written in a simplified and objective manner, the text is divided into two principal sections: Evaluation and Treatment. The sections both present comments on and levels of evidence represented by the references cited, as well as some proposals for the reduction of damage and for intervening in specific and still poorly explored situations, such as relapse, passive smoking, physician smoking, and tobacco use in specific environments.

Keywords: Smoking/adverse effects; Smoking cessation/methods; Guideline.

Reframing Framingham:

Reframing Framingham: New evidence prompts another look at cardiovascular risk algorithms

Significant effort is focused on improving precision of the risk-scoring system based on Framingham Heart Study data.

By Victoria Stagg Elliott, AMNews staff. Dec. 1, 2008.

---

The Framingham Risk Score, the crystal ball that helps physicians determine who is most and least in need of intervention to reduce the chance of a heart attack, is the subject of increasing debate over how to make it more accurate.

"We are humbled when patients at low risk have events, and we know that the sensitivity of the score is a problem," said James De Lemos, MD, a cardiologist and associate professor of medicine at the University of Texas Southwestern Medical Center at Dallas./.../

Children of Centenarians May Follow in Parents' Footsteps

By Kristina Fiore, Staff Writer, MedPage Today Published: November 21, 2008 Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

BOSTON, Nov. 21 -- Children of centenarians live longer, with better profiles for myocardial infarction or stroke, than age-matched peers whose parents have average life spans, researchers reported here./.../

New anti-inflammatory compound promising in ACS

ACUTE CORONARY SYNDROME

New anti-inflammatory compound promising in ACS

NOVEMBER 21, 2008 | Lisa Nainggolan

New Orleans, LA - A new anti-inflammatory compound, VIA-2291 (VIA Pharmaceuticals), has shown promise in a phase 2 trial in patients with acute coronary syndrome (ACS), and the results provide sufficient basis to move forward with additional studies, the lead investigator, Dr Jean-Claude Tardif(Montreal Heart Institute, QC) told heartwire. Tardif reported the phase 2 data at the American Heart Association (AHA) 2008 Scientific Sessions last week.

"We know that inflammation is a significant component, in both atherosclerosis initiation and progression and perhaps even in the events leading to ACS, so to test a drug that focuses on one of these proinflammatory pathways makes a lot of sense," Tardif commented. VIA-2291 is a 5-lipoxygenase inhibitor, and it demonstrated significant and dose-related inhibition of leukotrienes in the study, "so we know we are hitting the target, and that's good. There are a lot of data pointing to leukotrienes as a significant player," he added./.../

We need a new world health order, post-G20

Monday, 17 November 2008
Fran Baum, David Woodward and Dave McCoy write:
In recent weeks, there has been magic in the air, and the previously impossible seemed possible. Following the election of Obama, in the wake of the financial crisis, some 400 international health academics, activists and officials recognised the possibility of a new economic order in which social justice is taken seriously.
The group had gathered at a meeting in London (hosted by the UK Department of Health) to discuss how to realise the recommendations from the recent report from the Commission on the Social Determinants of Health (CSDH).
Opening the conference, UK Prime Minister Gordon Brown impressed the audience with his stated commitment to global health equity, emphasising the need to strengthen, not weaken, our ambitions on global health in light of the current financial crisis.
This message, together with those of the CSDH report, offer clear directions for other G20 global leaders, including Kevin Rudd./.../

Cardiovascular effects of air pollution, even in the comfort of home

New Orleans - Researchers who fitted study subjects with "air-pollution vests" to continuously monitor exposure to both indoor and outdoor air pollutants say that people are probably exposed to much higher levels of pollutants than community monitoring stations typically indicate and that this exposure affects both endothelial function and systolic blood pressure.
Robert Bard
Dr Robert Brook (University of Michigan, Ann Arbor) and colleagues presented a poster with the results of their Detroit Exposure and Aerosol Research Study (DEARS) during the American Heart Association (AHA) 2008 Scientific Sessions. In an interview with heartwire, study coauthor Robert Bard said that the results should serve as a reminder to cardiologists, who tend to forget the extent to which air pollution can harm the heart.
"Cardiologists are really not aware of this as a risk factor," Bard said, despite a 2004 AHA scientific statement warning about the cardiovascular risks of air pollution. What's needed, Bard said, is "a greater awareness that air pollution is contributing to CVD."
"Air pollution is actually noted as the 13th leading cause of death worldwide," Bard reminded heartwire. "We already knew that air pollution is associated with adverse cardiovascular events, including increases in blood pressure, but the novel aspect here is that we were measuring pollution that people were directly exposed to and evaluating cardiovascular function. We found that the average person in our study had increased blood pressure and reduced endothelial function from the air they were exposed to in the previous 24 hours. And importantly, these results were shown despite levels of ambient air pollution that were at or below those recommended in the current EPA guidelines."/.../

Requiem for a Heavyweight:The Demise of Creatine Kinase-MB

Amy K. Saenger, PhD; Allan S. Jaffe, MD
The Mayo Clinic in Rochester recently removed CK-MB from its cardiac biomarker panel after extensive collaboration with clinicians. Several other institutions have taken similar actions without any discernible negative effects on clinical care. We suspect that clinical care would be simplified and improved if this step were taken more widely because, as we have attempted to underscore above, the clinical issues that we need to address are best addressed by the use of troponin, and try as we might, it has been hard to find situations in which CK-MB adds substantially. It adds only cost and, from our perspective, confusion. Accordingly, after >10 years of experience using troponin in the clinical arena, it is time for clinicians to learn how to use cardiac troponin properly and, in doing so, let our old friend CK-MB rest. /.../

STATE OF WORLD POPULATION 2008

United Nations Population Fund, November 12, 2008

Website: http://www.unfpa.org/swp/

 “…..As a fundamental part of people’s lives, culture must be integrated into development policy and programming. The State of World Population 2008 report from UNFPA, the United Nations Population Fund, shows how this process works in practice.

This year is the 60th anniversary of the Universal Declaration of Human Rights. The report’s starting point is that human rights reflect universal values. It calls for culturally sensitive approaches to development because they are essential for human rights in general, and women’s rights in particular.

Culturally sensitive approaches call for cultural fluency – familiarity with how cultures work, and how to work with them. The report suggests that partnerships – for example between UNFPA and local non-governmental organizations (NGOs) – can create effective strategies to promote human rights, such as women’s empowerment and gender equality, and end human rights abuses like female genital mutilation or cutting.

Culture influences how people manage their lives, the report says. Cultures affect how people think and act; but, they do not make everyone think and act alike. Cultures influence and are influenced by external circumstances, and they change in response. People are continually reshaping them, although some aspects of culture continue to influence choices and lifestyles for a long time…”

Classification of Care Metrics: Performance Measures and Quality Metrics

ACC/AHA Classification of Care Metrics: Performance Measures and Quality
Metrics: A Report of the American College of Cardiology/American Heart
Association Task Force on Performance Measures
Robert O. Bonow, Frederick A. Masoudi, John S. Rumsfeld, Elizabeth DeLong,
N. A. Mark Estes, III, David C. Goff, Jr, Kathleen Grady, Lee A. Green, Ann
R. Loth, Eric D. Peterson, Ileana L. Pina, Martha J. Radford, and David M.
Shahian
Circulation published 12 November 2008, 10.1161/CIRCULATIONAHA.108.191107
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.108.191107v1?papetoc

Abstract—The American College of Cardiology (ACC) and the American Heart Association (AHA) have provided leadership in enhancing the quality of cardiovascular care, including the development of clinical performance measures and clinical registries that permit the evaluation of quality of care and stimulate quality improvement. Compliance with ACC/AHA performance measures and metrics encourages the provision of the strongest evidence-based quality of care, including therapies that are life-extending or life-enhancing. Among quality metrics, only a subset should be considered performance measures—that is, those measures specifically suitable for public reporting, external comparisons, and possibly pay-for-performance programs, in addition to quality improvement. These performance measures have been developed using ACC/AHA methodology, often in collaboration with other organizations, and include the process of public comment and peer review. Quality metrics are those measures that have been developed to support self assessment and quality improvement at the provider, hospital, and/or health care system level.These metrics represent valuable tools to aid clinicians and hospitals in improving quality of care and enhancing patient outcomes, but may not meet all specifications of formal performance measures. These quality metrics may also be considered "candidate" measures that with further research or field testing would meet the criteria for formal performance measures in the future. This measure classification is intended to aid providers, hospitals, health systems, and payers in identifying those measures that the ACC and AHA formally endorse as performance measures, while at the same time promoting the broader range of clinical metrics that are useful for quality improvement efforts.

4º BOLETIM DA COBERTURA ONLINE DO AHA 2008 REALIZADO PELA SBHCI

Estamos realizando a cobertura do AHA 2008 através dos nossos enviados especiais:

Dr. Pedro Beraldo e Dr. Guilherme Attizzani. Neste 4º e último dia de cobertura nossos enviados se despedem com o destaque ao estudo I-PRESERVE e as entrevistas exclusivas com importantes nomes da cardiologia brasileira e internacional!/.../

Ethical Standard for Physician Self-Referral

AMA Sets Ethical Standard for Physician Self-Referral

By Emily P. Walker, Washington Correspondent, MedPage Today Published: November 11, 2008

ORLANDO, Nov. 11 -- It is unethical for physicians to self-refer to facilities where they have a financial stake unless they spell it all out to their patients, according to an opinion adopted this week by the American Medical Association's policy-making House of Delegates. The opinion emerged from the AMA's Council on Ethical and Judicial Affairs (CEJA), chaired by Regina M. Benjamin, M.D., M.B.A., of the Bayou La Batre (Ala.) Rural Health Clinic. It said that while business arrangements among physicians can benefit patients, they also "can be ethically challenging when they create opportunities for self-referral in which patients' medical interests can be in tension with the physicians' financial interests." Transparency is vital to keeping these relationships ethical, said Dr. Benjamin, a family physician. William Dolan, M.D., Rochester, N.Y., an orthopedic surgeon and a member of the AMA's board of trustees, agreed that a physician "must tell the patient what his or her interest is" in order for self-referral to be ethical./.../

The doctor as placebo

"Maria Inês Reinert Azambuja"  to Cardiovascular

Dear Dr. Lown
Very beautiful text, and a necessary reflection at a time when medical doctors seem to be completely taken by the pharmaceutic industry mermaid
song...
Best regards,
Maria Inês Azambuja

The Doctor as Placebo

I am now convinced that the  placebo effect is not limited to drugs or surgical procedures, that it is a far more universal phenomenon. The words of doctors and other health professionals are the most potent placebos of all...

Lown RCTs (Random Clinical Thoughts): The doctor as placebo
Bernard Lown, MD

We are living in a paradoxical age. From medicine we expect miracles; from doctors, brush-offs. Physicians, no longer revered figures, communicate less and less with their patients. History gathering is hurried and frustrating, and even these precious minutes are misspent. Instead of focusing on the patient, the doctor peruses electronic records. Frequently, he or she does so facing a computer screen instead of the patient. The scene recalls a robotic transaction. Eyes do not bind, voices do not connect, communication is at cross-purposes. After a brief séance, patients are sent for a panoply of tests, imaging procedures, and visits to indifferent specialists.

The present disjuncture in medicine results from a market-driven health care system wherein doctors sell services to optimize their bottom line. They envision themselves not as healers but as medical technologists qua scientists. Thereby they have put themselves at odds with professional doctoring.

I would like to help restore the former health professionalism of physicians. Such a reinvention requires that doctors resume their role as placeboist. Some will recoil. Aren't placebos a "pious fraud," as Thomas Jefferson suggested nearly two centuries ago? For many the word evokes an image of fake treatments, of charlatans dispensing snake oil. This has been my opinion as well. I believed that the handing out of inert sugar pills to the worried-well ran against the grain of scientific medicine. Fifty years of medical practice has altered my views.

Clinical Experience
My rethinking of this issue began with an anecdote I heard many years ago about Mark Twain. One sweltering summer night he was in a cheap hotel in Mississippi. Soaked in sweat from the oppressive heat, he tossed and turned in the stagnant, stale air. Though dead tired he could not sleep. Growing desperate, he hurled a shoe against the closed window. As the glass shattered, he felt a cool breeze wafting off the Mississippi River. Sound sleep was immediate. The next morning he found the shattered glass of a mirror adjoining the still-closed window. The listener of this tale usually nods knowingly, ascribing the imagined breeze to the power of the mind. Indeed we are not disembodied from our executive brains.

What mainly made me gain respect for the placebo was clinical experience. The more extensive my experience, the more evident was the power of the placebo effect.

When in fellowship training with that masterful clinician Dr. Samuel A. Levine, I was frequently provoked by his cavalier response to patients with intractable symptoms. He would fish in a pocket and hand out a pill that was either a bromide, a barbiturate, or a vitamin. By contrast, before prescribing any medication, I would scrupulously comb the scientific literature for the latest evidence-based remedies. The difference in outcome between Levine's patients and mine was stark. His improved promptly; mine did not fare as well. In later years, I came to suspect that the explanation lay in the placebo effect.

The more patients I saw, the more frequently I encountered the magical placebo. I recall a middle-aged man, Mr. B., with angina pectoris. This was before introduction of a host of effective anti-anginal drugs, coronary bypass surgery, angioplasty, or coronary artery stenting. Nitroglycerin was then the sole remedy. Anginal attacks totally immobilized him, as the slightest exertion intensified the pain. Mercifully, a nitro pill under the tongue consistently and promptly resolved the discomfort. One day while walking on a beach in bathing trunks, Mr. B. experienced angina. Unable to find the pillbox, which he'd left in a pants pocket, he panicked. Mounting anxiety intensified the pain, and he was unable to move. Mr. B. asked a passerby to fetch the pills, pointing to his trousers under a beach umbrella twenty yards away. The man readily found the pillbox, and as he waved it in the air, Mr. B.'s pain abated as though the nitro had already dissolved under his tongue. He later related that on many occasions, the angina disappeared when he took out the pillbox. Many other patients have noted that merely handling the small nitroglycerine bottle assuaged their discomfort. The container acted as a placebo.

Historical Record
The placebo has a long history. Indeed, it was supreme during several millennia of medical treatment. Already in Roman times, the famous Galen Pharmacopeia contained 820 placebo remedies. Galen insightfully observed, "He cures most successfully in whom the people have the most confidence." The pioneer placebo researcher, Arthur Shapiro, maintains that nearly all of the 16,842 ancient remedies, with but few exceptions, were placebos. (1)

The modern mind is unable to comprehend the extent of public gullibility. Over many centuries people succumbed to bizarre, unpalatable, sickening, and sometimes lethal pharmaceutical concoctions. The chemist-pharmacist of old would grind dust from precious stones together with a maddening hodgepodge consisting of scorpions, worms, or wood lice, the entrails of animals, and perhaps a bit of human placenta, admixed with saliva, the sexual organs of executed convicts, and all sorts of excreta. These remedies, deemed panaceas, were indiscriminately prescribed for a wide spectrum of maladies.

Even more remarkable was that patients submitted to bleeding, sweating, purging, puking, leeching, poisoning, cutting, cupping, blistering, freezing, burning, shocking, and a host of other bodily harms. While rehydration and the preservation of blood volume are now a focus of therapy, the very opposite was practiced before the advent of the scientific age. George Washington did not die from a tonsillar abscess, as is commonly believed, but to the leaching out of more than 2.5 quarts of blood within 12 hours. A similar fate of phlebotomy until death befell Giuseppe Mazzini, the founder of the modern Italian republic. One wonders why people accepted noxious methods. One also wonders why physicians were honored though their practice was often irrational and at times fatal.

Modern Clinical Experience
Back in the early 1950s, I came across a case report that left a lasting impression. A pregnant woman suffering from severe and intractable nausea had a balloon inflated in her stomach to record the gastric contractions that provoked the nausea. The vigorous contractions were observed to coincide with her complaint. She was given ipecac-a drug that causes vomiting-and assured that it would bring relief. Within minutes after the ipecac, the intense stomach contractions ceased and with it the nausea. (2)

Investigations by Dr. Henry Beecher, the distinguished Massachusetts General Hospital anesthesiologist, removed placebos from the realm of humbug. As a surgeon in World War II, he observed that the pain experienced by severely wounded soldiers was relieved by small doses of opiates. This contrasted with his civilian experience. At times even massive doses of narcotics failed to ease the pain of young victims injured in car accidents. Beecher concluded that analgesia involved more than the pharmacological action of drugs. The wounded soldier was a hero who no longer had to face the frightening ordeal of battle and the possibility of being killed. The victim of a car crash foresaw no such redemption. He was more likely to face parental censure and perhaps punishment for wrecking the family car.

These observations intrigued Beecher and led him to an extensive exploration of the role of the placebo. (3) He studied 1082 patients with pain from diverse causes. Placebos afforded satisfactory relief in 35% of the cases, (4) a result that has since been consistently confirmed. Beecher was persuaded that placebos activate physiological and biochemical mediators that alter brain function and affect perception of noxious stimuli. He suggested that some of the benefits of surgery are due to placebo mechanisms. Beecher concluded that all drugs exert dual effects, one related to intrinsic pharmacological properties and the other inseparable from placebo action.

Just like drugs, placebo pills exert stronger effects when prescribed in larger doses. The effect is more marked when the capsules are bigger. Relief is greater when the dose is doubled and is more marked when the placebo is injected than when taken orally.(5) Pills colored red, yellow, or orange are likely to stimulate; while blue or green tend to tranquilize.(6,7)

Knowing of the reputed benefit of a remedy is itself likely to increase the efficacy of a placebo. A doctor's affirmation of the value of a prescribed measure will promote a positive placebo effect, especially if the clinician is highly reputed and conveys the aura of long experience and authority.

Patient confidence in the placebo treatment enhances its curative effect. It has long been known that patients who rigorously comply with instructions for taking a drug fare better than those who do not. And those who have faith in a treatment are more likely to comply. What is astonishing, though, is that patients who comply with a placebo regimen also do better than those who haphazardly take the pills. In a large randomized placebo-controlled trial of cholesterol-lowering drugs among coronary heart disease patients, those who took the placebo pills consistently had a lower mortality than those who did not. (8) Even more striking is that the imagined effects of a substance can sometimes directly countermand its actual pharmacology. For example, if a stimulant is given but the patient is informed that it is a sedative, the response will be relaxation and sleep rather than agitation and wakefulness.

Notwithstanding the indubitable power as well as potential benefits of placebos, many physicians harbor a distrust of placebos and contempt for patients who are "fooled" by them, as though responding to an imaginary medication stems from a character defect. A prevailing impression is that the poorly educated, the less intelligent, and the submissive are placebo prone. Psychological studies provide no support for these assumptions. Response to a placebo appears to be far more related to immediate situational and interpersonal factors such as the quality of the doctor-patient relationship, the gravity and type of illness, the severity of symptoms, and a host of others. (9)

Words and doctors as placebos
I am now convinced that the placebo effect is not limited to drugs or surgical procedures, that it is a far more universal phenomenon. The words of doctors and other health professionals are the most potent placebos of all. The capacity of a doctor's word, either to heal or to maim, is determined by the physician's demeanor, the certainty with which information is communicated, the level of empathy displayed, and above all a readiness to listen.

The placeboic power of words was brought home to me by a critically ill patient. (10) Two weeks after a heart attack, he was still in a coronary intensive care unit. He had experienced nearly every complication in the book. The problem was easy to define: More than half of his myocardium was infarcted. He was in florid congestive heart failure. Severe hypotension reflected a markedly reduced ventricular ejection fraction. He could not sit up due to dizziness and near syncope. Breathless and weak, he had no energy to eat; he also lacked appetite, as the smell of food provoked nausea. Sleep was restless and disrupted. He was cyanotic and periodically gasped for air as though drowning.

Each morning, medical rounds were like visitations from a morose bunch of undertakers. We had exhausted all the encouraging platitudes. In any case, I believed that any reassurance would have insulted the patient's intelligence and further undermined his trust. We sped up the morning visits to avoid his scared, questioning stare. Every day the situation deteriorated. His family agreed to a DNR status.

One morning he looked better, he claimed to feel better, and indeed his vital signs were improved. I could not account for the change. The prognosis was nonetheless grim, whatever the temporary improvement. Believing that a change to a less turbulent environment than the CCU would be less stressful and would afford him a night's sleep, I had him transferred to a step-down care unit. I lost track of the patient when he was discharged a week later.

After about six months he showed up in my office. Free of lung congestion and largely asymptomatic, he looked remarkably fit. I was astonished and puzzled. "A miracle, a miracle!" I exclaimed. "Hell no, this was no miracle," he responded. I was taken aback by his certainty that divine intervention had played no role in the miraculous recovery. "What happened?" I asked.

He stated emphatically that he knew exactly when the so-called miracle happened. He was aware that we were at our wits' end, blundering and confused, and did not seem to know how to help him. We had convinced him that we had given up hope and that "his goose was cooked."

He continued, "One Thursday morning, April 25th, you come in with your gang, surround the bed, and look as though I was already in a casket. You put your stethoscope on my chest and urge everyone to listen to the 'wholesome gallop.' I figured that if my heart was still capable of a healthy gallop, I couldn't be dying, and so I got well. So you see doc, it was no miracle. It was mind over matter." The patient was of course unaware that a gallop was a bad sign. A wholesome gallop is an oxymoron.

Words are the most powerful resource a doctor possesses. Patients crave caring, which is dispensed largely with words. Talk can be therapeutic. It is one of the most underrated tools in the physician's armamentarium. Medical experience provides constant reminders of the healing power of words. I know of few remedies more effective than a carefully chosen word. (10)

But the doctor's possibility of acting as a placebo is not limited to words. Minimizing the waiting time begins the process. Greeting a patient with a warm handshake followed by an unhurried, uninterrupted visit further enhances the placebo effect. A careful history, taken without interrupting the patient, fosters trust. An affirmative demeanor, a ready smile, a positive word, speech that is direct rather than equivocating, helps a doctor connect with another human being and form an enduring relationship.

In the most cloudy situation, one can discover a silver lining. This has little to do with truth or falsehood. It flows from the deepest intent of doctoring, to help a patient cope with a condition. Even when a cure is impossible, that does not mean healing is impossible. The very sick are not taken in by phony optimism, but they are eager for a warm touch and the caress of human concern. While medical science has limits, hope does not. I believe the maxim proposed by the physician Edward Trudeau about a century ago: "To cure sometimes, to relieve often, to comfort always." Miracles reside in the capacity for comforting and healing. Doctors can reclaim medical professionalism by resuming the role of a "placeboist."

Citations:
1. Shapiro AK, Shapiro E. The placebo: Is it much ado about nothing? In The Placebo Effect, edited by Anne Harrington. Cambridge, Mass.: Harvard University Press, 1997:12.
2. Wolf S. Effects of suggestions and conditioning on the action of chemical agents in human subjects: the pharmacology of placebos. J Clin Inv1950; 29: 100-109.
3. Beecher HK. The powerful placebo. JAMA. 1955;159:1602.
4. Beecher HK. Surgery as placebo. JAMA 1961;176:1102.
5. Blackwell B, et al. Demonstration to medical students of placebo responses and non-drug factors. Lancet 1972; I; 12:79-82.
6. Buckalew LW, et al. An investigation of drug expectancy as a function of capsule color, size and preparation form. J Clin Psychopharmacol 1982; 2: 245-48.
7. de Craen AJM, et al. Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. BMJ 1996; 313: 1624.
8. Coronary drug project research group. Influence of adherence to treatment and response of cholesterol on mortality in the coronary drug project. NEJM 1980; 303: 1038-41.
9. Frank J and Frank JB. Persuasion and Healing. 3rd ed.. Baltimore, Md.: Johns Hopkins University Press; 1991.
10. Lown B. The Lost Art of Healing. New York: Random House; 1999.

ACC/AHA 2008 Statements

Do úlimo Circulation -- Publish Ahead of Print Alert

New Circulation "Publish Ahead of Print" articles have been made available
(for the period 9 Nov 2008 to 10 Nov 2008):

Performance Measurement and Reperfusion Therapy.

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.108.191100v1?papetoc

Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction. 

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.108.191099v1?papetoc

Drug-Eluting or Bare-Metal Stenting in Patients With Diabetes Mellitus. Results From the Massachusetts Data Analysis Center Registry

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.108.820159v1?papetoc

3º BOLETIM DA COBERTURA ONLINE DO AHA 2008 REALIZADO PELA SBHCI

No 3º dia de cobertura do AHA 2008, a SBHCI inova mais uma vez, com entrevistas exclusivas com importantes nomes da cardiologia brasileira e internacional!

Além das tradicionais resenhas e das apresentações dos slides do dia, os repórteresPedro Beraldo e Guilherme Attizani entrevistam os Drs. Eugene Braunwald, Gregg Stone, James Ferguson, Álvaro Avezum e Ari Timerman sobre os temas abordados hoje no congresso e qual sua implicação para nossa prática clínica diária.

Este é mais um diferencial da cobertura de congressos da SBHCI, que fornece uma visão única e individualizada dos resultados dos estudos internacionais dentro da perspectiva da cardiologia brasileira. /.../

World Development Report 2009: Reshaping Economic Geography

 

World Bank, November 6, 2008

 

Website: http://www.worldbank.org/wdr2009.

 “…..Economic growth will be unbalanced, but development still can be inclusive. That is the main message of this year's World Development Report. The report proposes that spatial transformations along the following three dimensions will be necessary:

Higher density as seen in the growth of cities. Tokyo, the world's largest city is home to 35 million--a quarter of Japan's population--but stands on just four percent of its land.

Shorter distances as firms and workers migrate closer to economic opportunities. Eight million Americans change states every year, migrating to reduce distance to economic opportunity.

 

Fewer divisions as countries thin their economic borders to enter world markets to take advantage of specialization and scale. Border restrictions to flows of goods, capital, ideas, and people continue to prevent progress in Africa, in contrast with Western Europe….”

 

“….The new World Development Report challenges the assumption that economic activities must be spread geographically to benefit the world’s most poor and vulnerable.  Trying to spread out economic activity can hinder growth and does little to fight poverty. For rapid, shared growth, governments must promote economic integration which, at its core, is about the mobility of people, products, and ideas…”

 

Overviews (multilingual) English PDF file [32p.] at:   http://siteresources.worldbank.org/INTWDR2009/Resources/4231006-1225840759068/WDR09_01_Overviewweb.pdf  Coming soon: Arabic, Chinese, French Spanish, and Portuguese

Table of Contents & front matter Complete report Part 1 | Part 2

Available online at: http://go.worldbank.org/O4MD5RGAF0

Sim, nós podemos...,

10 de novembro de 2008 | N° 15785

ARTIGOS (Publicado por ZH no dia de Hoje e postado no BLOG no dia 06 do corrente)

 por Aloyzio Achutti *

Confesso ter me emocionado ouvindo o discurso do novo presidente dos Estados Unidos. Afinal compartilhamos do mesmo planeta nesta viagem sideral e em se tratando de nossos irmãos do Norte tudo que lá acontece termina refletindo no resto do mundo./.../

The Climate for Change

By AL GORE

Published: November 9, 2008

THE inspiring and transformative choice by the American people to elect Barack Obama as our 44th president lays the foundation for another fateful choice that he — and we — must make this January to begin an emergency rescue of human civilization from the imminent and rapidly growing threat posed by the climate crisis./.../

Gout May Protect Against Risk of Parkinson's Disease

VANCOUVER, British Columbia, Nov. 7 -- Patients with gout were less likely to develop Parkinson's disease, a cohort study found, supporting the purported protective role of uric acid.

The risk of Parkinson's disease was 30% lower among patients with a history of gout, independent of age, sex, prior medical conditions, and the use of diuretics, Hyon Choi, M.D., of the University of British Columbia, and colleagues reported online in Arthritis Care & Research.

Several epidemiologic studies have suggested that higher serum uric acid levels lead to a lower risk of Parkinson's disease, possibly because uric acid exerts antioxidant effects on neurons, the investigators said.

Uric acid can scavenge superoxide, hydroxyl radical, and singlet oxygen, as well as chelate transition metals, they said. With these antioxidant properties, uric acid has been hypothesized to protect against oxidative stress, a prominent contributor to dopaminergic neuron degeneration in Parkinson's disease./.../

AHA: Flu Shot Reduces Venous Clot Risk

By Crystal Phend, Staff Writer, MedPage Today
Published: November 09, 2008
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

NEW ORLEANS, Nov. 9 -- Vaccination against the flu may also protect against venous thromboembolism, researchers found.

In a case-control study, adults who got their immunizations were 26% less likely to develop venous thromboembolism over the next year, Joseph Emmerich, M.D., Ph.D., of the University Paris Descartes, and colleagues reported at the American Heart Association meeting here.

The effect was greatest -- a 48% reduction -- before age 52, they added.

The influenza virus increases blood viscosity, while the systemic inflammation caused by such infections can also trigger a thrombotic response, the researchers noted.

Dr. Emmerich's group speculated that this might have been the mechanism for the protective effect of influenza vaccination, but they noted that clotting events did not vary by season of the year for vaccinated or unvaccinated patients./.../

Cardiologia no Hospital e Faculdade de Medicina da PUCRS

No dia 03 de outubro p.p., durante uma Jornada Internacional de Cardiologia organizada pelo Serviço de Cardiologia do Hospital São Lucas da Pontifícia Universidade Católica do RS, fomos homenageados através de seu Diretor Dr. Luiz Carlos Bodanese e da Dra. Ana Maria Britto Medeiros. Ele ex-aluno e ela colega do Serviço de Prevenção das Doenças Cardiovasculares da Secretaria da Saúde e do Meio Ambiente do Estado, na década de 70 e 80.

Numa das fotos a entrega da placa comemorativa, e na outra um grupo de ex-colaboradores.

 

Died Ronald M. Davis

Ronald M. Davis, M.D., immediate past president of the American Medical Association and a relentless anti-tobacco advocate, has died of pancreatic cancer at the age of 52. 

"The healthcare community has lost an extraordinary leader," said AMA President Nancy Nielsen, M.D. "To his fellow physicians and the patients they serve, Ron's legacy as a public health advocate will not be forgotten." 

I worked with him as senior Editor of the 1992 Surgeon General Report: "Smoking in the Americas"

2º BOLETIM DA COBERTURA ONLINE DO AHA 2008 REALIZADO PELA SBHCI

Varsão de colegas da SBHCI sobre notícias do Congresso da AHA

Aspirin for Primary Prevention

Aspirin for Primary Prevention of Cardiovascular Events in Diabetes

Still an Open Question

Antonio Nicolucci, MD 

JAMA. 2008;300(18):(doi:10.1001/jama.2008.625).

The use of aspirin for primary prevention of cardiovascular events in individuals with diabetes is widely recommended byexisting guidelines, but the evidence supporting its efficacy is surprisingly scarce.¹ Recommendations seem based mainly onextrapolations from data from other high-risk groups, rather than on solid data derived from studies conducted specifically in patients with diabetes. Indeed, an increasing amount of evidence suggests that the efficacy of antiplatelet therapy in patients with diabetes may be lower than in individuals without diabetes.²

C-Reactive Protein and Parental History: Reynolds Risk Score

C-Reactive Protein and Parental History Improve Global Cardiovascular Risk Prediction. The Reynolds Risk Score for Men

Paul M Ridker MD^*, Nina P. Paynter PhD, Nader Rifai PhD, J. Michael Gaziano MD, and Nancy R. Cook ScD

From the Donald W. Reynolds Center for Cardiovascular Research and the Center for Cardiovascular Disease Prevention, Divisions of Preventive Medicine and Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, and MAVERIC, VA Boston Health Care System, all in Boston, Mass.

^* To whom correspondence should be addressed. E-mail: pridker@partners.org.

Background—High-sensitivity C-reactive protein and family history are independently associated with future cardiovascular events and have been incorporated into risk prediction models for women (the Reynolds Risk Score for women); however, no cardiovascular risk prediction algorithm incorporating these variables currently exists for men.

Methods and Results—Among 10 724 initially healthy American nondiabetic men who were followed up prospectivelyover a median period of 10.8 years, we compared the test characteristics of global model fit, discrimination, calibration, and reclassification in 2 prediction models for incident cardiovascular events, one based on age, blood pressure, smoking status, total cholesterol, and high-density lipoprotein cholesterol (traditional model) and the other based on these risk factors plus high-sensitivity C-reactive protein and parental history of myocardial infarction before age 60 years (Reynolds Risk Score for men). A total of 1294 cardiovascular events accrued during study follow-up. Compared with the traditional model, the Reynolds Risk Score had better global fit (likelihood ratio test P<0.001),> Bayes information criterion, and a larger C-index (P<0.001). For the end point of all cardiovascular events, the Reynolds Risk Score for men reclassified 17.8% (1904/10 724) of the study population (and 20.2% [1392/6884] of those at 5% to 20% 10-year risk) into higher- or lower-risk categories, with markedly improved accuracy among those reclassified. For this model comparison, the net reclassification index was 5.3%, and the clinical net reclassification index was 14.2% (both P<0.001).> based on the Adult Treatment Panel III preferred end point ofcoronary heart disease and limited to men not taking lipid-lowering therapy, 16.7% of the study population (and 20.1% of those at 5% to 20% 10-year risk) were reclassified to higher- or lower-risk groups, again with significantly improved global fit, larger C-index (P<0.001),>reclassified. For this model, the net reclassification index was 8.4% and the clinical net reclassification index was 15.8% (both P<0.001).

Conclusions—As previously shown in women, a prediction model in men that incorporates high-sensitivity C-reactive protein and parental history significantly improves global cardiovascular risk prediction.

Key words: epidemiology • prevention • inflammation • genetics • risk factors

Vitamins E and C in the Prevention of Cardiovascular Disease in Men

The Physicians' Health Study II Randomized Controlled Trial

Howard D. Sesso, ScD, MPH; Julie E. Buring, ScD; William G. Christen, ScD; Tobias Kurth, MD, ScD; Charlene Belanger, MA;Jean MacFadyen, BA; Vadim Bubes, PhD; JoAnn E. Manson, MD, DrPH; Robert J. Glynn, ScD; J. Michael Gaziano, MD, MPH JAMA. 2008;300(18):(doi:10.1001/jama.2008.600).

Context  Basic research and observational studies suggest vitamin E or vitamin C may reduce the risk of cardiovasculardisease. However, few long-term trials have evaluated men at initially low risk of cardiovascular disease, and no previous trial in men has examined vitamin C alone in the prevention of cardiovascular disease.

Objective  To evaluate whether long-term vitamin E or vitamin C supplementation decreases the risk of major cardiovascular events among men.

Design, Setting, and Participants  The Physicians' Health Study II was a randomized, double-blind, placebo-controlled factorial trial of vitamin E and vitamin C that began in 1997 and continued until its scheduled completion on August 31, 2007. There were 14 641 US male physicians enrolled, who were initially aged 50 years or older, including 754 men (5.1%) with prevalent cardiovascular disease at randomization.

Intervention  Individual supplements of 400 IU of vitamin E every other day and 500 mg of vitamin C daily.

Main Outcome Measures  A composite end point of major cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, andcardiovascular disease death).

Results  During a mean follow-up of 8 years, there were 1245 confirmed major cardiovascular events. Compared with placebo, vitamin E had no effect on the incidence of major cardiovascular events (both active and placebo vitamin E groups, 10.9 events per 1000 person-years; hazard ratio [HR], 1.01 [95% confidence interval {CI}, 0.90-1.13]; P = .86), as well as total myocardial infarction (HR, 0.90 [95% CI, 0.75-1.07];P = .22), total stroke (HR, 1.07 [95% CI, 0.89-1.29]; P = .45), and cardiovascular mortality (HR, 1.07 [95% CI, 0.90-1.28]; P = .43). There also was no significant effect of vitamin C on major cardiovascular events (active and placebo vitamin E groups, 10.8 and 10.9 events per 1000 person-years, respectively; HR, 0.99 [95% CI, 0.89-1.11]; P = .91), as well as total myocardial infarction (HR, 1.04 [95% CI, 0.87-1.24]; P = .65), total stroke (HR, 0.89 [95% CI, 0.74-1.07]; P = .21), and cardiovascular mortality (HR, 1.02 [95% CI, 0.85-1.21]; P = .86). Neither vitamin E (HR, 1.07 [95% CI, 0.97-1.18]; P = .15) nor vitamin C (HR, 1.07 [95% CI, 0.97-1.18]; P = .16) had a significant effect on total mortality but vitamin E was associated with an increased risk of hemorrhagic stroke (HR, 1.74 [95% CI, 1.04-2.91]; P = .04).

Conclusions  In this large, long-term trial of male physicians, neither vitamin E nor vitamin C supplementation reduced the risk of major cardiovascular events. These data provide no support for the use of these supplements for the prevention of cardiovascular disease in middle-aged and older men.

Trial Registration  clinicaltrials.gov Identifier: NCT00270647