Clinical trial design in non-invasive brain stimulation psychiatric research

Major depressive disorder (MDD) trials - investigating either non-pharmacological or pharmacological interventions - have shown mixed results. Many reasons explain this heterogeneity, but one that stands out is the trial design due to specific challenges in the field. We aimed therefore to review the methodology of non-invasive brain stimulation (NIBS) trials and provide a framework to improve clinical trial design. We performed a systematic review for randomized, controlled MDD trials whose intervention was transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) in MEDLINE and other databases from April 2002 to April 2008. We created an unstructured checklist based on CONSORT guidelines to extract items such as power analysis, sham method, blinding assessment, allocation concealment, operational criteria used for MDD, definition of refractory depression and primary study hypotheses. Thirty-one studies were included. We found that the main methodological issues can be divided in to three groups: (1) issues related to phase II/small trials, (2) issues related to MDD trials and, (3) specific issues of NIBS studies. Taken together, they can threaten study validity and lead to inconclusive results. Feasible solutions include: estimating the sample size a priori; measuring the degree of refractoriness of the subjects; specifying the primary hypothesis and statistical tests; controlling predictor variables through stratification randomization methods or using strict eligibility criteria; adjusting the study design to the target population; using adaptive designs and exploring NIBS efficacy employing biological markers. In conclusion, our study summarizes the main methodological issues of NIBS trials and proposes a number of alternatives to manage them. Copyright (C) 2011 John Wiley & Sons, Ltd.

Is production the core competence for the internationalization of emerging country firms?

The rise of new multinationals in countries like Brazil provides an opportunity to revisit and carefully construct theories of how firms internationalize, a topic on which extant theory is weak. Brazilian firms are "infant multinationals", unlike developed country firms that are "mature multinationals". They are also internationalizing in a very different global context, and can do so on the basis of different competitive advantages than multinationals that came before. Therefore, this study aims at creating subsidies for theory building about early-stage internationalization. Emerging country firms have Production competences as main competitive asset to internationalize, what reflects their competitive positioning in home markets and their entry strategy in international markets. In the case of early-entrants - Western multinationals in the 1950s and Japanese in the 1980s - the Production competence played a key role for successful internationalization. Thus, the focus of the study is the role that the Production competence plays in the internationalization of late-entrants, the emerging country multinationals. The research design considers not only the position of the headquarters but also the initiatives of the subsidiaries and the dynamic interplay between both. The paper allows a better understanding of internationalization processes and the role of Production, when firms start building their own international networks. It brings relevant insights about the paths that are being followed by emerging country multinationals, the difficulties they find, the solutions they develop. These are important inputs not only for new theory building but also for managerial practice. (C) 2012 Elsevier B.V. All rights reserved.

In Patients With Acute Myocardial Infarction, the Impact of Hyperglycemia as a Risk Factor for Mortality Is Not Homogeneous Across Age-Groups

OBJECTIVE To assess the impact of hyperglycemia in different age-groups of patients with acute myocardial infarction (AM I). RESEARCH DESIGN AND METHODS A total of 2,027 patients with AMI were categorized into one of five age-groups: <50 years (n = 301), >= 50 and <60 (n = 477),>= 60 and <70 (n = 545), >= 70 and <80 (n = 495), and years (n = 209). Hyperglycemia was defined as initial glucose >= 115 mg/dL. RESULTS The adjusted odds ratios for hyperglycemia predicting hospital mortality in groups 1-5 were, respectively, 7.57 (P = 0.004), 3.21 (P 0.046), 3.50 (P = 0.003), 3.20 (P < 0.001.), and 2.16 (P = 0.021). The adjusted P values for correlation between glucose level (as a continuous variable) and mortality were 0.007, <0.001, 0.043, <0.001, and 0.064. The areas under the ROC curves (AUCs) were 0.785, 0.709, 0.657, 0.648, and 0.613. The AUC in group 1 was significantly higher than those in groups 3-5. CONCLUSIONS The impact of hyperglycemia as a risk factor for hospital mortality in AMI is more pronounced in younger patients.

Prevalence of adults with type 1 diabetes who meet the goals of care in daily clinical practice: A nationwide multicenter study in Brazil

Objective: To determine the prevalence of patients with type 1 diabetes mellitus who meet the glycemic and cardiovascular (CV) risk factors goals and the frequency of screening for diabetic complications in Brazil according to the American Diabetes Association guidelines. Research design and methods: This was a cross-sectional, multicenter study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. Data were obtained from 1774 adult patients (56.8% females, 57.2% Caucasians) aged 30.3 +/- 9.8 years with diabetes duration of 14.3 +/- 8.8 years. Results: Systolic blood pressure was at goal in 40.3% and diastolic blood pressure was at goal in 26.6% of hypertensive patients. LDL cholesterol and HbA1c were at the goal in 45.2% and 13.2% of the patients, respectively. Overweight was presented in 25.6% and obesity in 6.9%. Among those with more than 5 years of disease, screening for retinopathy was performed in the preceding year in 70.1%. Nephropathy and feet complications were screened in 63.1% and 65.1%, respectively. Conclusions: The majority of patients did not meet metabolic control goals and a substantial proportion was not screened for diabetic complications. These issues may increase the risk of chronic complications and negatively impact public health. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Effects of Gastric Bypass Surgery in Patients With Type 2 Diabetes and Only Mild Obesity

OBJECTIVE-Roux-en-Y gastric bypass (RYGB) ameliorates type 2 diabetes in severely obese patients through mechanisms beyond just weight loss, and it may benefit less obese diabetic patients. We determined the long-term impact of RYGB on patients with diabetes and only class 1 obesity. RESEARCH DESIGN AND METHODS-Sixty-six consecutively selected diabetic patients with BMI 30-35 kg/m(2) underwent RYGB in a tertiary-care hospital and were prospectively studied for up to 6 years (median 5 years [range 1-6]), with 100% follow-up. Main outcome measures were safety and the percentage of patients experiencing diabetes remission (HbA(1c) <6.5% without diabetes medication). RESULTS-Participants had severe, longstanding diabetes, with disease duration 12.5 +/- 7.4 years and HbA(1c) 9.7 +/- 1.5%, despite insulin and/or oral diabetes medication usage in everyone. For up to 6 years following RYGB, durable diabetes remission occurred in 88% of cases, with glycemic improvement in 11%. Mean HbA(1c) fell from 9.7 +/- 1.5 to 5.9 +/- 0.1% (P < 0.001), despite diabetes medication cessation in the majority. Weight loss failed to correlate with several measures of improved glucose homeostasis, consistent with weight-independent antidiabetes mechanisms of RYGB. C-peptide responses to glucose increased substantially, suggesting improved beta-cell function. There was no mortality, major surgical morbidity, or excessive weight loss. Hypertension and dyslipidemia also improved, yielding 50-84% reductions in predicted 10-year cardiovascular disease risks of fatal and nonfatal coronary heart disease and stroke. CONCLUSIONS-This is the largest, longest-term study examining RYGB for diabetic patients without severe obesity. RYGB safely and effectively ameliorated diabetes and associated comorbidities, reducing cardiovascular risk, in patients with a BMI of only 30-35 kg/m(2).

Processo de formação de tenistas talentosos

O objetivo do presente estudo foi obter informações a respeito do processo de formação de tenistas talentosos e os consequentes fatores que contribuíram para o alcance do profissionalismo. Para tanto, se utilizou uma amostra de cinco tenistas brasileiros profissionais, caracterizados por terem pontos na ATP (Associação dos Tenistas Profissionais). A pesquisa foi constituída através de um delineamento qualitativo, que utilizou como instrumento uma entrevista composta por três perguntas abertas, elaboradas para explorar o contexto de formação do talento. Para a análise dos resultados foi utilizado o “Discurso do Sujeito Coletivo”. De acordo com os resultados, pode-se observar a importância que os professores tiveram no desenvolvimento destes tenistas talentosos, tanto na iniciação como no treinamento. No que se diz respeito ao planejamento dos treinos, o presente estudo demonstra a falta de profissionalismo nas fases iniciais do processo de formação, e a posterior preocupação apenas quando este atleta demonstra possuir algum potencial para seguir carreira profissional.

Topical Insulin Accelerates Wound Healing in Diabetes by Enhancing the AKT and ERK Pathways: A Double-Blind Placebo-Controlled Clinical Trial

Background: Wound healing is impaired in diabetes mellitus, but the mechanisms involved in this process are virtually unknown. Proteins belonging to the insulin signaling pathway respond to insulin in the skin of rats. Objective: The purpose of this study was to investigate the regulation of the insulin signaling pathway in wound healing and skin repair of normal and diabetic rats, and, in parallel, the effect of a topical insulin cream on wound healing and on the activation of this pathway. Research Design and Methods: We investigated insulin signaling by immunoblotting during wound healing of control and diabetic animals with or without topical insulin. Diabetic patients with ulcers were randomized to receive topical insulin or placebo in a prospective, double-blind and placebo-controlled, randomized clinical trial (NCT 01295177) of wound healing. Results and Conclusions: Expression of IR, IRS-1, IRS-2, SHC, ERK, and AKT are increased in the tissue of healing wounds compared to intact skin, suggesting that the insulin signaling pathway may have an important role in this process. These pathways were attenuated in the wounded skin of diabetic rats, in parallel with an increase in the time of complete wound healing. Upon topical application of insulin cream, the wound healing time of diabetic animals was normalized, followed by a reversal of defective insulin signal transduction. In addition, the treatment also increased expression of other proteins, such as eNOS (also in bone marrow), VEGF, and SDF-1 alpha in wounded skin. In diabetic patients, topical insulin cream markedly improved wound healing, representing an attractive and cost-free method for treating this devastating complication of diabetes.

Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the Duke Anticoagulation Satisfaction Scale

Aim. The aim of this study was to evaluate the internal reliability and validity of the BrazilianPortuguese version of Duke Anticoagulation Satisfaction Scale (DASS) among cardiovascular patients. Background. Oral anticoagulation is widely used to prevent and treat thromboembolic events in several conditions, especially in cardiovascular diseases; however, this therapy can induce dissatisfaction and reduce the quality of life. Design. Methodological and cross-sectional research design. Methods. The cultural adaptation of the DASS included the translation and back-translation, discussions with healthcare professionals and patients to ensure conceptual equivalence, semantic evaluation and instrument pretest. The BrazilianPortuguese version of the DASS was tested among subjects followed in a university hospital anticoagulation outpatient clinic. The psychometric properties were assessed by construct validity (convergent, known groups and dimensionality) and internal consistency/reliability (Cronbachs alpha). Results. A total of 180 subjects under oral anticoagulation formed the baseline validation population. DASS total score and SF-36 domain correlations were moderate for General health (r = -0.47, p < 0.01), Vitality (r = -0.44, p < 0.01) and Mental health (r = -0.42, p < 0.01) (convergent). Age and length on oral anticoagulation therapy (in years) were weakly correlated with total DASS score and most of the subscales, except Limitation (r = -0.375, p < 0.01) (Known groups). The Cronbachs alpha coefficient was 0.79 for the total scale, and it ranged from 0.76 (hassles and burdens)0.46 (psychological impact) among the domains, confirming the internal consistency reliability. Conclusions. The BrazilianPortuguese version of the DASS has shown levels of reliability and validity comparable with the original English version. Relevance to clinical practice. Healthcare practitioners and researchers need internationally validated measurement tools to compare outcomes of interventions in clinical management and research tools in oral anticoagulation therapy.

The Bigger, the Better: Coalitions in the GATT/WTO

What does it take to make a coalition successful? Bigger coalitions are more likely to be successful because the GATT/WTO is a consensus-based institution and countries are informally penalized if they isolate themselves. Through a Bayesian statistical analysis, the article corroborates the above hypothesis. To further investigate the research question, qualitative case studies of the G-10 in the Uruguay Round and the Public Health Coalition in the Doha Round are conducted. These cases show that the more convincing the framing of a position, the better are the chances of coalitions keeping a large number of followers and supporters, thereby affecting their odds of success. By building a unique database and applying a new research design to the topic, the study rigorously tests theories about coalitions that had previously only been proposed but not empirically analyzed.

Does carbohydrate supplementation enhance tennis match play performance?

Abstract Background Carbohydrate (CHO) ingestion may be an interesting approach to avoid significant decrement to the tennis match performance. The aim of the present investigation was to assess the effects of CHO supplementation on tennis match play performance. Methods Twelve young tennis players (18.0 ± 1.0 years; 176 ± 3.4 cm; 68.0 ± 2.3 kg; body fat: 13.7 ± 2.4%) with national rankings among the top 50 in Brazil agreed to participate in this study, which utilized a randomized, crossover, double blind research design. The experiment was conducted over a 5-day period in which each player completed two simulated tennis matches of a 3-hour duration. The players received either a CHO or a placebo (PLA) drinking solution during simulated tennis matches. Athlete’s performance parameters were determined by filming each match with two video cameras. Each player was individually tracked for the entire duration of the match to measure the following variables: (1) games won; (2) rally duration; (3) strokes per rally; (4) effective playing time (%); (5) aces; (6) double faults; (7) first service in; (8) second service in; (9) first return in and (10) second return in. Results There were no differences between trials in any of the variables analyzed. Conclusions CHO supplementation did not improve tennis match play performance under the present experimental conditions.