Redução das desigualdades no uso de consultas médicas no Brasil: análise das regiões Nordeste e Sudeste entre 2003 e 2008 / Reduction of inequalities in medical visits in Brazil: analysis of the Northeastern and Southeastern regions between 2003 and 2008

OBJETIVO: Analisar as desigualdades socioeconômicas na utilização de consultas médicas (CM) no último ano no Brasil. MÉTODOS: Dados da Pesquisa Nacional por Amostra de Domicílios (≥ 20 anos de idade) das Regiões Nordeste (2003, n = 75.652 e 2008, n = 79.779) e Sudeste (2003, n = 76.029 e 2008, n = 79.356) foram analisados segundo CM. Compararam-se as prevalências de CM segundo as variáveis exploratórias demográficas e de saúde no primeiro (D1) e último (D10) decil de renda familiar per capita. As análises consideraram o desenho amostral complexo. RESULTADOS: A proporção de pessoas com CM aumentou no período na Região Nordeste (61,2 para 66,9%) e Sudeste (67,9 para 73,5%). A diferença absoluta de CM, segundo D1 e D10 no período, foi de 6,4 pontos percentuais (pp) no Nordeste e 4,2 pp no Sudeste. Houve importante redução das desigualdades entre os homens; naqueles sem doenças crônicas; naqueles que tinham uma percepção positiva da sua saúde e naqueles sem plano de saúde com direito a CM. A Região Sudeste ainda apresentou redução entre aqueles com apenas uma morbidade autorreferida (8 pp) e com percepção negativa da saúde (6 pp). CONCLUSÃO: Houve aumento de CM no Brasil. Observa-se ainda persistente desigualdade entre os mais pobres e os mais ricos, maior no Nordeste do que no Sudeste. Políticas para a redução da desigualdade em saúde mais eficazes e equânimes devem ser adotadas no Brasil. .

OBJECTIVE: To analyze the socioeconomic inequalities in medical visits (MV) in the past year in Brazil. METHODS: Data from adults aged ≥ 20 years old who participated in the Brazilian National Household Surveys and living in the Northeastern (2003; n = 75,652 and 2008, n = 79,779) and Southeastern (2003; n = 76,029 and 2008; n = 79,356) regions were analyzed according to MV. We compared MVs according to demographic and health variables in the first (D1) and last (D10) per capita family income deciles. All analyses considered the complex cluster design. RESULTS: The proportion of people who had MV during this period increased in the Northeastern (from 61.2 to 66.9%) and the Southeastern (from 67.9 to 73.5%) regions. The absolute difference (AD) in the use of MV, according to D1 and D10 in this period, was equal to 6.4 percentage points (pp) in the Northeastern and 4.2 pp in the Southeastern regions. Significant reduction in inequalities was observed among men without chronic diseases, in those who had a positive perception of their health, and among those without health insurance which included MV. The Southeastern region has also showed significant reduction among those with chronic disease (8 pp) and with negative health self-perception (6 pp). CONCLUSION: The increasing number of MVs was found in Brazil. However, persistent inequalities were observed between the poorest and the richest, higher in the Northeastern than in the Southeastern region. More effective and equitable policies to reduce health inequalities should be adopted in Brazil. .

Waiting times for surgical and diagnostic procedures in public hospitals in Mexico / Tiempos de espera para procedimientos quirúrgicos y diagnósticos en hospitales públicos de México

Objective. A retrospective evaluation of waiting times for elective procedures was conducted in a sample of Mexican public hospitals from the following institutions: the Mexican Institute for Social Security (IMSS), the Institute for Social Security and Social Services for Civil Servants (ISSSTE) and the Ministry of Health (MoH). Our aim was to describe current waiting times and identify opportunities to redistribute service demand among public institutions. Materials and methods. We examined current waiting times and productivity for seven elective surgical and four diagnostic imaging procedures, selected on the basis of their relative frequency and comparability with other national health systems. Results. Mean waiting time for the seven surgical procedures in the three institutions was 14 weeks. IMSS and ISSSTE hospitals showed better performance (12 and 13 weeks) than the MoH hospitals (15 weeks). Mean waiting time for the four diagnostic procedures was 11 weeks. IMSS hospitals (10 weeks) showed better average waiting times than ISSSTE (12 weeks) and MoH hospitals (11 weeks). Conclusion. Substantial variations were revealed, not only among institutions but also within the same institution. These variations need to be addressed in order to improve patient satisfaction.

Objetivo. Se llevó a cabo una evaluación retrospectiva de los tiempos de espera para procedimientos electivos en una muestra de hospitales públicos en México de las siguientes instituciones: Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) y Secretaría de Salud (SS). El propósito era describir la situación actual en materia de tiempos de espera e identificar oportunidades de redistribución de la demanda de servicios entre instituciones públicas. Material y métodos. Se analizaron los tiempos de espera y la productividad para siete procedimientos quirúrgicos y cuatro procedimientos diagnósticos seleccionados sobre la base de su frecuencia relativa y comparabilidad con otros sistemas de salud nacionales. Resultados. El tiempo de espera promedio para los siete procedimientos quirúrgicos en las tres instituciones fue de 14 semanas. Los hospitales del IMSS y el ISSSTE mostraron un mejor desempeño (12 y 13 semanas) frente a los hospitales de la SS (15 semanas). El tiempo de espera promedio para los cuatro procedimientos diagnósticos fue de 11 semanas. Los hospitales del IMSS mostraron un tiempo de espera promedio mejor (10 semanas) que los hospitales del ISSSTE (12 semanas) y la SS (11 semanas). Conclusión. Se identificaron variaciones importantes no sólo entre instituciones sino también al interior de cada una de ellas. Estas variaciones deben atenderse para así mejorar la satisfacción de los usuarios de los servicios.

Effect of precursors feeding and media manipulation on production of novel anticancer pro-drug camptothecin from endophytic fungus

We have established methodology for the isolation and characterization of a novel endophytic fungus from the inner bark of medicinal plant Nothapodytes foetida, which produced camptothecin in Sabouraud broth (SB) under shake flask conditions. Camptothecin and its related compounds are at present obtained by extraction from intact plants, but fungal endopytes may be an alternative source of production. In present study we have observed the effect of different nutrient combinations and precursors (tryptophan, tryptamine, geraniol, citral, mevalonic acid and leucine) on the accumulation of camptothecin by endophytic fungus Entrophospora infrequens. The precursors were fed either alone or in combinations (tryptophan and geraniol, tryptophan and citral, tryptophan and mevalonic acid, tryptophan and leucine). The highest camptothecin content was observed in the range of 503 ± 25µg/100g dry cell mass in Sabouraud medium. Camptothecin content in the medium was increased by 2.5 folds by the presence of tryptophan and leucine whereas the production with trytophan was also significantly different from other treatments. Furthermore, the effect of fungal camptothecin on the morphology of human cancer cell lines was also studied. The treated cells showed reduction in size, condensation of nucleus and the protoplasmic extensions were reduced. All these characteristics are found in apoptotic cells.

Examination of camptothecin and 10-hydroxycamptothecin in Camptotheca acuminata plant and cell culture, and the affected yields under several cell culture treatments

Camptothecin and its derivatives are monoterpenoid indole alkaloids exhibiting significant anti-tumor actions. With the aim of improving the production of these pharmaceuticals, the contents of camptothecin and 10-hydroxycamptothecin in different tissues including roots, stems, leaves, young flower buds, opening flowers, fading flowers and seeds from Camptotheca acuminata, were investigated. The young flower buds had the highest alkaloid concentrations (camptothecin, 2.46 mg/g of dry weight; 10-hydroxycamptothecin, 1.41 mg/g of dry weight). Callus showed lower concentrations but it should also be considered as a potential source of these pharmaceuticals. In the present study, the growth rate of Camptotheca acuminata cells in culture did not correlate with contents of camptothecin and 10-hydroxycamptothecin. Alkalo id accumulation by cells under various treatments (heavy metal ions, UV-B), methyl-jasmonate, abscisic acid, salicylic acid and hydrogen peroxide was examined, and the most notable effects appeared in the cells induced by UV-B light (which showed an 11-fold increase in camptothecin concentration) and by salicylic acid (which showed a 25-fold increase in 10-hydroxycamptothecin concentration). These results are significant in the context of the production of both pharmaceuticals.

Alternativas terapéuticas actuales de las metástasis hepáticas: [revisión] / Current therapeutic options for liver metastasis: [review]

The liver is a common site of hematogenous metastasis, especially from gastrointestinal malignancies. Liver metastasis are generally classified as stage IV disease. Previously treatment in such patients was met with great skeptiscism. However, advances in surgical and medical therapies during the last two decades have provided effective therapeutic options for selected patients. Since major hepatic resections are now performed with acceptable morbidity and a mortality rate <3 percent, colorectal cancer metastasis to the liver are associated with 5-year survival rates of 30 percent or more. Meanwhile, a variety of new therapies have been developed, including hepatic artery infusion of chemotherapy; alcoholic, crio and radiofrequency ablation and novel strategies of systemic chemotherapy with the development of molecular targeted new products. These new therapeutic armamentarium have been used mostly in liver metastasis from colorectal cancer patients. However, liver metastasis of neuroendocrine tumors and selected cases of non colorectal cancer liver metastasis are benefited from the same strategies. This report summarizes the different therapeutic tools, their advantages and results mainly on colorectal cancer liver metastasis. These results are expected to improve even further with multimodality approaches.

Una variedad genética de la UDP-glucuronosil transferasa asociada a toxicidad gastrointestinal por irinotecan / A prevalent genetic variety of UDP-glycuronosyl transferase predicts high risk of irinotecan toxicity

Los avances en genética y biología molecular han impulsado la aparición de nuevas áreas de estudio en la medicina, como la farmacogenómica, la cual intenta predecir la respuesta y toxicidad a drogas en función de la variabilidad genética de cada individuo, constituyendo los llamados síndromes fármacogenómicos. La oncología podría beneficiarse debido a la gran toxicidad de sus fármacos. Hay varios loci genéticos que se están analizando por su potencial valor predictivo y hasta ahora sólo tres de ellos demostraron cierto grado de utilidad clínica. En especial, el estudio del número de repeticiones del dinucleótido timina-adenina (TA) en el promotor de la enzima UDP-glucuronosil-transferasa (UGT) mostró ser capaz de predecir neutropenia severa en pacientes expuestos a dosis intermedias y altas de irinotecan. Comunicamos el caso de una paciente con cáncer de pulmón de células pequeñas que padeció toxicidad hematológica y gastrointestinal grave tras haber sido tratada con dosis relativamente bajas (65 mg/m2) de irinotecan, y en quien un análisis del ADN leucocitario mostró la presencia de homocigosis para siete repeticiones de TA. Este caso es un ejemplo de aplicabilidad clínica del test, se discute su utilidad como predictor de toxicidad y la conducta a tomar frente a pacientes con estas características.

The advances in genetics and molecular biology have raised new areas in medicine, such as pharmacogenomics, which tries to predict drug responses and toxicities based on the individual genetic variability, describing the so called: pharmacogenomic syndromes. Oncology would find this development extremely useful because of the severe toxicity of chemotherapy. There are a lot of genetic loci under investigation for their potential in predicting drug toxicity, but only three of them have showed clinical usefulness up to now. In particular, quantification of the number of thymine-adenine (TA) dinucleotics in the promoter region of the UDP-glucuronosyl-transferase 1A1 enzime (TA indel) proved to be capable of predicting severe neutropenia in patients exposed to intermediate or high doses of irinotecan. Herein we report a case of a patient with small cell lung cancer who suffered severe hematological and gastrointestinal toxicity after being treated with relatively low doses (65 mg/m2) of irinotecan and whose leucocyte DNA analysis showed the presence of seven TA repetitions in both alleles. This case is an example of the clinical applicability and the utility of the test as a toxicity predictor. We also discuss the clinical decisions that may be taken with these patients.

O emprego de sistemas de liberação como estratégia para melhorar as propriedades terapêuticas de fármacos de origem natural: o exemplo da camptotecina e seus derivados / Drug delivery systems as a way to improve the therapeutic properties of natural drugs: the example of camptothecin and its derivatives

As plantas têm sido utilizadas para a obtenção de um grande número de substâncias biologicamente ativas. Entretanto, muitos compostos naturais quando empregados sem qualquer modificação química não resultaram em medicamentos eficazes, por não apresentarem as características desejáveis para administração. Neste sentido, a melhoria das propriedades terapêuticas de compostos isolados de plantas por meio da sua incorporação em sistemas de liberação de fármacos consiste em uma importante estratégia na obtenção de novos medicamentos, na qual ainda existe muito a ser explorado. Tais sistemas são caracterizados por apresentar a capacidade de prolongar e controlar a liberação de substâncias ativas, proteger as moléculas frente à degradação no meio biológico, veicular fármacos hidrofóbicos e reduzir os efeitos colaterais indesejáveis. A camptotecina, um alcalóide proveniente do arbusto Camptotheca acuminata (Descaisne, Nyssaceae), é um fármaco que apresenta elevada atividade antitumoral, cujo mecanismo envolve a inibição da topoisomerase I, uma enzima altamente expressa nos tumores. Entretanto, a utilização deste fármaco na terapêutica foi limitada, durante anos, em virtude de suas características de baixa solubilidade aquosa, elevada instabilidade em meio fisiológico e elevada toxicidade. Neste artigo é realizada uma revisão sobre o potencial terapêutico da camptotecinae seus análogos no tratamento do câncer, dando ênfase aos estudos conduzidos com o intuito de contornar as limitações da administração destes fármacos e que resultaram na melhoria das propriedades terapêuticas. Estratégias como a microencapsulação, nanoencapsulação e solubilização em micelas poliméricas, entre outras, são discutidas e os principais resultados de atividade antitumoral in vitro e in vivo são apresentados.

Vias de inibição da apoptose em macrófagos J774 infectados com Leishmania (Leishmania) chagasi / Apoptosis inhibition pathways in 774 macrophages infected by Leishmania (L) chagasei

Macrófagos J774 privados de nutrientes ou tratados com fator de necrose tumoral recombinante (rTNF) ou camptotecina sofrem apoptose que é inibida quando infectadas por Leishmania (Leishmania) chagasi in vitro. A infecção interfere tanto na via intrínseca quanto na extrínseca da apoptose. A perda do potencial de membrana de mitocôndria observada com a privação de nutrientes ou com rTNF, assim como a atividade da caspase 3 e a geração de caspase 3 clivada com o uso de H2O2 são revertidos com a infecção. Nas células infectadas, a expressão de poli (ADP-ribose) polimerase (PARP) de 116 kDa e fragmento de 24 kDa estão diminuídas. Identificamos Heat shock protein de 83kDa de Leishmania (L.) infantum como um dos possíveis componentes da Leishmania responsáveis pela inibição da apoptose em macrófagos...

J774 macrophages undergo apoptosis under nutrient deprivation or recombinant tumor necrosis factor (rTNF) or camptothecin treatment which is inhibited by Leishmania (L.) chagasi infection in vitro. Both intrinsic or extrinsic apoptosis pathways are affected by infection. The loss of mitochondrial membrane potential observed by nutrient deprivation or rTNF induction, and activity and clivage of caspase 3 by H2O2 are reversed by infection. 116 kDa poly (ADP-ribose) polymerase and a 24 kDa fragment expressions are diminished in the infected cells. We point to a Leishmania (L.) infantum Heat shock protein of 83 kDa as one the possible Leishmania component responsible for inhibition of macrophage apoptosis...

Inhibition of focal adhesion kinase by antisense oligonucleotides enhances the sensitivity of breast cancer cells to camptothecins

This study shows a strong association between cell attachment to substratum and activation of beta 1-integrin-signaling with resistance to the camptothecin derivative topotecan (TPT) in breast cancer cells. We propose a mechanistic-driven approach to sensitize the cells to camptothecins. ZR-75-1 anchorage-dependent breast cancer cell line, its derivative 9D3S suspension cells (9D3S-S), and 9D3S cells attached to fibronectin-coated plates (9D3S-A) were treated with TPT (1 microM) or CPT-11 (40 microM) for 48 h. Programmed cell death (PCD), as shown by poly(ADP-ribose) polymerase (PARP), pro-caspase-3 and pro-caspase-9 cleavage, was observed in 9D3S-S cells but not in ZR-75-1 or 9D3S-A cells. Because p125 focal adhesion kinase (FAK) is a transducer in the beta 1-integrin signaling pathway, it is essential to cell adhesion and it is overexpressed in metastatic breast cancer, we hypothesized that attenuation of FAK might enhance the sensitivity of breast cancer cells to camptothecins. Moreover, inhibition of FAK gene expression by a phosphorothioated antisense oligodeoxynucleotide targeting the portion of the gene encoding amino acids 262-268, increased the sensitivity of ZR-75-1, MDA-MB-231 and MCF7 breast cancer cells to treatment with TPT or CPT-11.

Irinotecan and oxaliplatin: an overview of the novel chemotherapeutic options for the treatment of advanced colorectal cancer

Colorectal cancer is one of the most frequent malignancies in humans and an important cause of cancer death. Metastatic colorectal cancer remains incurable with available systemic therapeutic options. The most active cytotoxic drug against this malignancy, the antimetabolite 5-fluorouracil, was developed more than forty years ago, and as a single agent produces responses in only 10 to 15 percent of patients which in general last less than one year. Efforts to ameliorate these poor results resulted in the 5-fluorouracil/leucovorin combination, which enhances response rates about two-fold, without, however, significantly improving survival rates. The recent emergence of a handful of new 5-fluorouracil analogues and folate antagonists, as well as the topoisomerase I inhibitor irinotecan, and the third-generation platinum compound oxaliplatin, is likely to alter this gloomy scenario. These agents are at least as effective as 5-fluorouracil in patients with advanced colorectal carcinoma, both untreated and previously treated with 5-fluorouracil-based regimens. This has led to the approval of irinotecan as second-line treatment for 5-fluorouracil-refractory disease, while the use of oxaliplatin has been suggested for patients having a defective 5-fluorouracil catabolism. Recently, FDA approved the combination of irinotecan with 5-fluorouracil and leucovorin for first-line treatment of advanced colon cancer. Based on the synergistic preclinical antitumor effects of some of these agents, their meaningful single-agent activity, distinct mechanisms of cytotoxicity and resistance, and only partially overlapping toxicity profiles, effective combination regimens are now being developed, which are likely to lead to a new, more hopeful era for patients suffering from advanced colorectal carcinoma