The developing world in The New England Journal of Medicine.

BACKGROUND: Rampant disease in poor countries impedes development and contributes to growing North-South disparities; however, leading international medical journals underreport on health research priorities for developing countries. METHODS: We examined 416 weekly issues of the New England Journal of Medicine (NEJM) over an eight-year period, January 1997 to December 2004. A total of 8857 articles were reviewed by both authors. The content of each issue was evaluated in six categories: research, review articles, editorial, correspondence, book reviews and miscellaneous. If the title or abstract concerned a topic pertinent to any health issue in the developing world, the article was reviewed. RESULTS: Over the eight years covered in this study, 1997-2004, in the three essential categories of original research articles, review articles and editorials, less than 3.0 percent of these addressed health issues in the developing world. Publications relevant to DC were largely concerned with HIV and communicable diseases and constituted 135 of the 202 articles of which 63 were devoted to HIV. Only 23 articles addressed non-communicable disease in the DC and only a single article - a book review - discussed heart disease. CONCLUSION: The medical information gap between rich and poor countries as judged by publications in the NEJM appears to be larger than the gap in the funding for research. Under-representation of developing world health issues in the medical literature is a global phenomenon. International medical journals cannot rectify global inequities, but they have an important role in educating their constituencies about the global divide.

A Crise das Drogas III: Corrupção da ciência / The Drug Crisis III: Corruption of Science

A medicina moderna é baseada em novas medidas terapêuticas, nas quais o desenvolvimento de novos medicamentos é amplamente envolvido. Conviver com a polifarmácia é cada vez mais característica do idoso.O aumento astronômico do custo das prescrições de medicamentos está recebendo muita atenção, uma vez que está contribuindo com o desajuste do sistema de saúde. Pouca atenção está sendo dada ao efeito corrosivo da propaganda farmacêutica na alma da medicina - atingindo a integridade da ciência que alicerça a prática clínica.O ponto mais profundo é o efeito das forças desreguladas da propaganda na prática clínica, baseada em medidas nada desprezíveis da indústria farma-cêutica. As companhias farmacêuticas determinam muito do que está sendo investigado, desenham os protocolos, patrocinam e supervisionam os estudos clínicos, analisam os dados obtidos, escrevem os arti-gos e determinam o que as revistas cientí?cas devem publicar e o que deve ser mantido fora da publicação.Os médicos veementemente negam acusações de que sua relação com a indústria farmacêutica compro-meta sua objetividade. No entanto, existe considerável evidência de que pesquisadores ligados a empresas farmacêuticas tenham maior chance de relatar resul-tados favoráveis do que aqueles pesquisadores sem tais vínculos.Vale a pena examinar a verdadeira natureza dos estudos clínicos, uma vez que esses são os árbitros ?nais sobre a entrada ou não de um medicamento no mercado. No momento, milhões de americanos estão participando deles.Existe um número de outras práticas da indústria farmacêutica que são desconhecidas pelo público que, em última análise, paga a conta. Isso exige avaliação cuidadosa.

Unanswered ethical and scientific questions for trials of invasive interventions for coronary disease: The case of single vessel disease.

Trials in the 1990s demonstrated that medical therapy is as effective as invasive therapies for treating single-vessel coronary disease. Yet more recent studies enrolling patients with this condition have focused on evaluating only invasive approaches, namely, stenting versus coronary artery bypass surgery. Several ethical and scientific questions remain unanswered regarding the conduct of these later trials. Were they justified? Why wasn't a medical therapy arm included? Were subjects informed about the availability of medical therapy as an equivalent option? Was optimized medical therapy given prior to randomization? The absence of clear answers to these questions raises the possibility of serious bias in favor of invasive interventions. Considering that medical therapy is underutilized in patients with coronary disease, efforts should focus more on increasing utilization of medical therapy and proper selection of noninvasive interventions.

Long-term outcomes of optimized medical management of outpatients with stable coronary artery disease.

The objective of this study was to assess long-term clinical outcomes and their correlates in medically managed outpatients with stable angina pectoris, healed myocardial infarction (MI), or documented asymptomatic coronary artery disease (CAD). Management strategy emphasized maximally tolerated medical therapy and modification of coronary risk factors. Referral to invasive coronary interventions followed stricter criteria than standard published guidelines. Primary study outcomes were all-cause mortality or nonfatal myocardial infarction. Secondary study outcomes included cardiac death, unstable angina, or coronary revascularization. A total of 693 men and women with proved CAD (mean age 67 years at entry, 85% men, 41% with history of MI) were enrolled. The annual incidence of nonfatal MI, cardiac mortality, and total mortality was 2.2%, 0.8%, and 1.4%, respectively, during an average follow-up of 4.6 years. Coronary revascularization was performed in 24% of subjects; unstable or progressive anginal symptoms were the most common reasons for revascularization. In patients with documented stable CAD, a management strategy based on intensive medical therapy and modification of established coronary risk factors was associated with excellent long-term outcomes. Thus, coronary interventions can be safely delayed until clinical instability ensues, without increased risk of MI or death. This treatment approach represents a viable alternative to invasive strategies.