Thursday, April 30, 2015

Federalism, the Economic-Industrial Health Care Complex and High-Cost Pharmaceutical Assistance in Brazil

 2015 Apr;20(4):1165-1176.

Federalism, the Economic-Industrial Health Care Complex and High-Cost Pharmaceutical Assistance in Brazil.

[Article in English, Portuguese]

Author information

  • 1Escola de Administração de Empresas de São Paulo, Fundação Getúlio Vargas, São Paulo, SP, Brasil,
  • 2Escola Nacional de Saúde Pública, Fiocruz.


Brazil has a relevant, although relatively unknown, special medicines programme that distributes high-cost products, such as drugs needed for cancer treatments. In 2009, the purchase of these medicines became the responsibility of the Brazilian Federal Government. Until then, there were no clear norms regarding the responsibilities, in terms of the management/financing of these medicines, of the Brazilian Federal Government and of the states themselves. This qualitative study analyses the policy process needed to transfer this programme to the central government. The study examines the reports of the Tripartite Commission between 2000 and 2012, and in-depth interviews with eleven key informants were conducted. The study demonstrates that throughout the last decade, institutional changes have been made in regard to the federal management of these programmes (such as recentralisation of the purchasing of medicines). It concludes that these changes can be explained because of the efficiency of the coordinating mechanisms of the Federal Government. These findings reinforce the idea that the Ministry of Health is the main driver of public health policies, and it has opted for the recentralisation of activities as a result of the development project implicit in the agenda of the Industrial and Economic Heal.

The uncomfortable truth behind Chipotle's GMO ban

The uncomfortable truth behind Chipotle's GMO ban

"If its centerpiece can be a foil-wrapped obesity bomb — a barbacoa burrito on a flour tortilla with rice, sour cream and guacamole contains 995 calories and 53 grams of fat, according to the company’s Web site — well, that’s the customer’s choice.
The pork comes from free-range pigs!"

Read more:

Depression Literacy Among American Indian Older Adults

 2015 Apr 29:1-14. [Epub ahead of print]

Depression Literacy Among American Indian Older Adults.

Author information

  • 1a School of Social Work, University of South Dakota , Sioux Falls , South Dakota , USA.


Older American Indians experience high rates of depression and other psychological disorders, yet little research exist on the depression literacy of this group. Depression literacy is fundamental for individuals seeking help for depression in a timely and appropriate manner. In the present study the authors examine levels and predictors of knowledge of depression symptoms in a sample of rural older American Indians (N = 227) living in the Midwestern United States. Data from self-administered questionnaires indicate limited knowledge of depression and negative attitudes toward seeking help for mental health problems. Additional findings and implications for social work practice and policy are discussed.

"...apart from ethics, what is the role of philosophy 'at the bedside'?"

 2015 Jun;21(3):357-364. doi: 10.1111/jep.12370.

Diseases, patients and the epistemology of practice: mapping the borders of health, medicine and care.

Author information

  • 1Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK.


Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition.

Wednesday, April 29, 2015

Concussion under-reporting and pressure from coaches, teammates, fans, and parents

 2015 Apr 20;134:66-75. doi: 10.1016/j.socscimed.2015.04.011. [Epub ahead of print]

Concussion under-reporting and pressure from coaches, teammates, fans, and parents.

Author information

  • 1Harvard School of Public Health, Department of Social and Behavioral Science, USA; National Collegiate Athletic Association, Sport Science Institute, USA; Harvard University, Edmond J. Safra Center for Ethics, USA. Electronic address:
  • 2University of Vermont, College of Education and Social Services, Department of Education, USA. Electronic address:
  • 3Clark University, Department of Clinical Psychology, USA. Electronic address:
  • 4Harvard University, Edmond J. Safra Center for Ethics, USA; Harvard University, Interfaculty Initiative in Health Policy, USA; Boston Children's Hospital, Division of Sports Medicine, USA. Electronic address:
  • 5Boston Children's Hospital, Division of Adolescent & Young Adult Medicine, USA; Harvard Medical School, Department of Pediatrics, USA. Electronic address:


Concussions from sport present a substantial public health burden given the number of youth, adolescent and emerging adult athletes that participate in contact or collision sports. Athletes who fail to report symptoms of a suspected concussion and continue play are at risk of worsened symptomatology and potentially catastrophic neurologic consequences if another impact is sustained during this vulnerable period. Understanding why athletes do or do not report their symptoms is critical for developing efficacious strategies for risk reduction. Psychosocial theories and frameworks that explicitly incorporate context, as a source of expectations about the outcomes of reporting and as a source of behavioral reinforcement, are useful in framing this problem. The present study quantifies the pressure that athletes experience to continue playing after a head impact-from coaches, teammates, parents, and fans-and assesses how this pressure, both independently and as a system, is related to future concussion reporting intention. Participants in the study were 328 male and female athletes from 19 teams competing in one of seven sports (soccer, lacrosse, basketball, softball, baseball, volleyball, field hockey) at four colleges in the northeast region of the United States. Results found that more than one-quarter of the sample had experienced pressure from at least one source to continue playing after a head impact during the previous year. Results of a latent profile mixture model indicated that athletes who experienced pressure from all four of the measured sources were significantly more likely to intend to continue playing in the future than were athletes who had not experienced pressure from all sources, or only pressure from coaches and teammates. These findings underscore the importance of designing interventions that address the system in which athletes make decisions about concussion reporting, including athletes' parents, rather than focusing solely on modifying the individual's reporting cognitions.

Obesity risk soars after one hour of TV

Obesity risk soars after one hour of TV

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives

Int Clin Psychopharmacol. 2015 Apr 23. [Epub ahead of print]

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives.

Author information

  • 1Department of Psychological Medicine, University of Otago Wellington, Wellington, New Zealand.


Given the longstanding controversy about hypnosedative use, we aimed to investigate the attitudes of prescribing psychiatrists and service users towards long-term use of hypnosedative medication, and their perceptions of barriers to evidence-based nonmedication alternatives. Qualitative data from focus groups in Aotearoa/NZ were analysed thematically. A novel research design involved a service user researcher contributing throughout the research design and process. Service users and psychiatrists met to discuss each other's views, initially separately, and subsequently together. Analysis of the data identified four key themes: the challenge, for both parties, of sleep disturbance among service users with mental health problems; the conceptual and ethical conflicts for service users and psychiatrists in managing this challenge; the significant barriers to service users accessing evidence-based nonmedication alternatives; and the initial sense of disempowerment, shared by both service users and psychiatrists, which was transformed during the research process. Our results raise questions about the relevance of the existing guidelines for this group of service users, highlight the resource and time pressures that discourage participants from embarking on withdrawal regimes and education programmes on alternatives, highlight the lack of knowledge about alternatives and reflect the complex interaction between sleep and mental health problems, which poses a significant dilemma for service users and psychiatrists.

Tuesday, April 28, 2015



Max Ehrmann

"Be yourself. Especially, do not feign affection. Neither be cynical about love; for in the face of all aridity and disenchantment, it is as perennial as the grass...."


Saturday, April 25, 2015

Zombie allusions: They just keep on coming™: "the grabbiest new role"

What Role Do You Want to Play?

"From 2000 to 2020, the grabbiest new role is that of zombie. This popularity raises a disquieting, not to say humiliating, question: Why should we let TV producers play a role in our self-formation? After all, we know TV shows exist to sell products or subscriptions to Netflix. But if not from television or the movies, where are we supposed to get the roles we play to fill the fleeting days of our lives? Are we expected to be able just to tear them out of our brains, like zombies?"

Cancer: The Emperor of All Maladies

Cancer: The Emperor of All Maladies

Cancer: The Emperor of All Maladies, based on the Pulitzer Prize-winning book by Siddhartha Mukherjee, tells the complete story of cancer, from its first description in an ancient Egyptian scroll to the gleaming laboratories of modern research institutions. At six hours, the film interweaves a sweeping historical narrative; with intimate stories about contemporary patients; and an investigation into the latest scientific breakthroughs that may have brought us, at long last, to the brink of lasting cures.

"...increased physical associated with a reduced risk of prostate cancer..."

 2015 Apr 24. doi: 10.1111/bju.13157. [Epub ahead of print]

Physical activity as a risk factor for prostate cancer diagnosis: a prospective biopsy cohort analysis.



To assess the association between physical activity, evaluated by the Physical activity scale for elderly (PASE) questionnaire, and prostate cancer (PC) risk in a consecutive series of men undergoing prostate biopsy.


From 2011 onwards, a consecutive men undergoing 12-core prostate biopsy were enrolled into a prospective database. Indications for a prostatic biopsy were a PSA value ≥ 4 ng/ml and/or a positive digital rectal examination (DRE). Body mass index (BMI) and waist circumferences were measured before the biopsy. Fasting blood samples were collected before biopsy and tested for: total PSA, glucose, HDL, trygliceridemia levels. Blood pressure was recorded. Metabolic syndrome (MetS) was defined according to the Adult Treatment panel III. PASE questionnaire was collected before the biopsy.


286 patients were enrolled with a median age and PSA of 68 (IQR 62/74) years and 6.1 ng/ml (IQR 5/8.8) respectively. Median BMI was26.4 kg/m2 (IQR: 24.6/29); median waist circumference was 102 cm (IQR: 97/108) and 75 patients (26%) presented a Metabolic syndrome. One-hundred and six patients (37%) had prostate cancer on biopsy. Patients with PC presented an higher PSA (6.7 ng/ml, IQR: 5/10 vs 5.6 ng/ml, IQR: 4.8/8; p= 0.007) and a lower LogPASE score (2.03 (1.82/2.18) vs 2.10 (1.92/2.29); p=0.005). On multivariate analysis, in addition to well-recognized risk factors such as age, PSA, prostate volume, LogPASE score was an independent risk factor for prostate cancer diagnosis (OR: 0.146, 95%CI: 0.037 - 0.577; p= 0.006). Log PASE was also an independent predictor of high-grade cancer (OR: 0.07, 95% CI: 0.006-0.764; p= 0.029).


In our single centre study, an increased physical activity evaluated by the PASE questionnaire is associated with a reduced risk of PC and of high-grade prostate cancer on biopsy. Further studies should clarify the molecular pathways behind this association. 

"The total estimated cost of diabetes, direct and indirect, is $245 billion."

Diabetes Follows Obesity's Lead: Trends Reveal Worsening Problems Across US


"Some of the epidemic comes from will power, but research is finding most of the blame lies with external factors. Low-income families are more obese because healthier food is expensive. Americans work longer hours than most other countries and get too little sleep, which can leave them with neither the time nor the energy to cook. Even if people did have the time, finding healthy food on the cheap has been a struggle. Government programs were recently found ineffective in promoting healthier food choices in grocery stores.
These conflicts translate into unhealthier citizens and a burdened health care system. Diabetes makes that effect clear: The total estimated cost of diabetes, direct and indirect, is $245 billion."

Hamlet's BlackBerry: Building a Good Life in the Digital Age

Hamlet's BlackBerry: Building a Good Life in the Digital Age


Liquid biopsy. It's here.


When doctors got a clean blood DNA test from MarySusan Sabini, they were afraid to rely on it because the test was so new. CreditÁngel Franco/The New York TimesContinue reading the main story

In the usual cancer biopsy, a surgeon cuts out a piece of the patient’s tumor, but researchers in labs across the country are now testing a potentially transformative innovation. They call it the liquid biopsy, and it is a blood test that has only recently become feasible with the latest exquisitely sensitive techniques. It is showing promise in finding tiny snippets of cancer DNA in a patient’s blood.

"...Dr. Oz is a symptom, not the problem."

Dr. Oz and the Pathology of 'Open-Mindedness'

In the pursuit of scientific discovery, where is the line between alternative therapies and "quackademic" medicine?

"One need not even look beyond the walls of Oz’s own university. Woodson C. Merrell, an assistant professor at Columbia Medical School and executive director of Mount Sinai Beth Israel’s Center for Health and Healing, lists homeopathy as one of his clinical interests—despite a scientific consensus that homeopathy is inconsistent with some of the basic laws of chemistry and physics.

Indeed, a vocal minority of physicians and scientists have long claimed that Dr. Oz is a symptom, not the problem. Most prominent among them are the Yale neurologist Steven Novella and the Wayne State University surgical oncologistDavid Gorski, who refer to the problem as “quackademic medicine.” For Novella and Gorski, the concern is not merely that people will waste money on homeopathic sugar pills or fruitless miracle diets. They emphasize that Dr. Oz and universities alike endanger public health by legitimating alternative medical traditions such as naturopathy and chiropractic. This, in turn, can lead people to reject standard medical care. Vaccination is a classic case: Though most people are unaware of it, the official position of the American Chiropractic Association supports “providing an alternative elective course of action regarding vaccination.” Similarly, the New York University medical ethicist Arthur Caplan expresses concern that naturopaths—who practice an unstandardized mix of therapies including traditional Chinese medicine, homeopathy, craniosacral therapy, iridology, and reiki— routinely grant vaccine exemptions, and are licensed to do so in 17 states."

Do We Really Need Physician Re-Certification Testing?

Do We Really Need Physician Re-Certification Testing?

There has to be a better way.

"Personally, I spent $1,720 in 2010 to enroll in the maintenance of certification program and take the internal medicine exam (the current fee is $1,940) and another $775 to take the infectious diseases exam, a total of $2,495. Doesn’t it seem reasonable that the ABIM should be able to administrate a re-certification program that is more efficient and streamlined for that amount of money per person?"

Uber, Lyft refuse to require driver fingerprints

    Uber, Lyft refuse to require driver fingerprints

    "But the ride-hailing companies, which use smartphone apps to connect passengers and drivers, have avoided doing fingerprint checks of drivers, and that rankles officials like Rep. Alan Powell, R-Hartwell, sponsor of HB 225, which came to be known as the "Uber" bill even though it applies to all companies.
    He says fingerprinting is the best way to ensure drivers don't have criminal records, but compromised on that point to ensure his bill's passage."

    Worrisome: Rapid Emergence of Multidrug Resistant, H58-Lineage Salmonella Typhi in Blantyre, Malawi

     2015 Apr 24;9(4):e0003748. doi: 10.1371/journal.pntd.0003748. eCollection 2015.

    Rapid Emergence of Multidrug Resistant, H58-Lineage Salmonella Typhi in Blantyre, Malawi.

    Author information

    • 1Malawi Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, United Kingdom; Wellcome Trust Sanger Institute, Hinxton, United Kingdom.
    • 2Malawi Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
    • 3Wellcome Trust Sanger Institute, Hinxton, United Kingdom.
    • 4Malawi Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; University of Malawi College of Medicine, Blantyre, Malawi.
    • 5University of Malawi, The Polytechnic, Blantyre, Malawi.
    • 6University of Malawi College of Medicine, Blantyre, Malawi.
    • 7Malawi Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Institute for Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.
    • 8Institute for Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.
    • 9Malawi Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, United Kingdom.



    Between 1998 and 2010, S. Typhi was an uncommon cause of bloodstream infection (BSI) in Blantyre, Malawi and it was usually susceptible to first-line antimicrobial therapy. In 2011 an increase in a multidrug resistant (MDR) strain was detected through routine bacteriological surveillance conducted at Queen Elizabeth Central Hospital (QECH).


    Longitudinal trends in culture-confirmed Typhoid admissions at QECH were described between 1998-2014. A retrospective review of patient cases notes was conducted, focusing on clinical presentation, prevalence of HIV and case-fatality. Isolates of S. Typhi were sequenced and the phylogeny of Typhoid in Blantyre was reconstructed and placed in a global context.


    Between 1998-2010, there were a mean of 14 microbiological diagnoses of Typhoid/year at QECH, of which 6.8% were MDR. This increased to 67 in 2011 and 782 in 2014 at which time 97% were MDR. The disease predominantly affected children and young adults (median age 11 [IQR 6-21] in 2014). The prevalence of HIV in adult patients was 16.7% [8/48], similar to that of the general population (17.8%). Overall, the case fatality rate was 2.5% (3/94). Complications included anaemia, myocarditis, pneumonia and intestinal perforation. 112 isolates were sequenced and the phylogeny demonstrated the introduction and clonal expansion of the H58 lineage of S. Typhi.


    Since 2011, there has been a rapid increase in the incidence of multidrug resistant, H58-lineage Typhoid in Blantyre. This is one of a number of reports of the re-emergence of Typhoid in Southern and Eastern Africa. There is an urgent need to understand the reservoirs and transmission of disease and how to arrest this regional increase.

    A novel approach to training students in delivering evidence-based obesity treatment

     2015 May;47(5):378-82.

    A novel approach to training students in delivering evidence-based obesity treatment.

    Author information

    • 1Medical University of South Carolina.



    Obesity is a major public health concern because of its prevalence, serious health consequences, and costs. Many health care providers believe they have been inadequately trained to treat obesity and, as a result, often do not address patients' weight. Despite recommendations to improve knowledge and skills so they can more effectively address obesity, health care educational curricula are already overburdened with content and have been slow to respond to these recommendations.


    Interprofessional health care students voluntarily participated in an extracurricular service-learning opportunity to learn about the evidence-based treatment of obesity. A multidisciplinary team of weight management professionals taught didactic lessons and oversaw the service-learning component of training. An essential element of the training was the students' delivery of a free 10-week weight management intervention to low-income overweight and obese community residents.


    Patients in both the student-led (n=25) and professional-led (n=21) programs lost a statistically and clinically significant amount of weight. Additionally, there was no significant difference in weight loss between the two programs, even after taking into account differences in attendance between the two programs.


    An extracurricular service-learning program pairing brief didactic instruction with experiential learning appears to be a viable strategy for accomplishing the important dual objectives of preparing health care students to treat obesity and providing much-needed treatment to those in our community who are least able to afford it.