The need for adequate ethical guidelines for qualitative health research

O artigo discute a adequação de aplicar a Resolução 196/961 do Conselho Nacional de Saúde - CNS, às pesquisas qualitativas em saúde, que se baseiam em paradigmas não positivistas. Nestas pesquisas, freqüentemente as decisões sobre a pesquisa são tomadas conjuntamente com a comunidade em estudo. Há a preocupação de favorecer a justiça e a mudança social. E, uma vez que a subjetividade pode ser considerada seu instrumento privilegiado, busca-se o balanço entre objetividade e subjetividade, e discute-se como superar a visão do pesquisador. Estudamos o âmbito de aplicação e a concepção de pesquisa presentes nas diretrizes éticas internacionais e brasileiras. Verificamos que elas adotam uma concepção positivista de pesquisa, que prevê: teste de hipótese, definição prévia de todos os procedimentos pelo pesquisador e neutralidade do pesquisador e do conhecimento produzido. Serão apresentadas algumas características das pesquisas qualitativas, as implicações éticas da maneira como a pesquisa qualitativa é concebida nos paradigmas não positivistas e um breve histórico dos documentos sobre ética em pesquisa. Concluímos que não é adequado analisar estas pesquisas com base nestes documentos e sugerimos a elaboração de diretrizes específicas

DOES THE CHRONOTYPE CLASSIFICATION NEED TO BE UPDATED? PRELIMINARY FINDINGS

Traditionally, chronotype classification is based on the Morningness-Eveningness Questionnaire (MEQ). It is implicit in the classification that intermediate individuals get intermediate scores to most of the MEQ questions. However, a small group of individuals has a different pattern of answers. In some questions, they answer as ""morning-types"" and in some others they answer as ""evening-types,"" resulting in an intermediate total score. ""Evening-type"" and ""Morning-type"" answers were set as A(1) and A(4), respectively. Intermediate answers were set as A(2) and A(3). The following algorithm was applied: Bimodality Index = (Sigma A(1) x Sigma A(4))(2) - (Sigma A(2) x Sigma A(3))(2). Neither-types that had positive bimodality scores were classified as bimodal. If our hypothesis is validated by objective data, an update of chronotype classification will be required. (Author correspondence: brunojm@ymail.com)

The Absence of Coronary Calcification Does Not Exclude Obstructive Coronary Artery Disease or the Need for Revascularization in Patients Referred for Conventional Coronary Angiography

Objectives This study was designed to evaluate whether the absence of coronary calcium could rule out >= 50% coronary stenosis or the need for revascularization. Background The latest American Heart Association guidelines suggest that a calcium score (CS) of zero might exclude the need for coronary angiography among symptomatic patients. Methods A substudy was made of the CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors) multicenter trial comparing the diagnostic performance of 64-detector computed tomography to conventional angiography. Patients clinically referred for conventional angiography were asked to undergo a CS scan up to 30 days before. Results In all, 291 patients were included, of whom 214 (73%) were male, and the mean age was 59.3 +/- 10.0 years. A total of 14 (5%) patients had low, 218 (75%) had intermediate, and 59 (20%) had high pre-test probability of obstructive coronary artery disease. The overall prevalence of >= 50% stenosis was 56%. A total of 72 patients had CS = 0, among whom 14 (19%) had at least 1 >= 50% stenosis. The overall sensitivity for CS = 0 to predict the absence of >= 50% stenosis was 45%, specificity was 91%, negative predictive value was 68%, and positive predictive value was 81%. Additionally, revascularization was performed in 9 (12.5%) CS = 0 patients within 30 days of the CS. From a total of 383 vessels without any coronary calcification, 47 (12%) presented with >= 50% stenosis; and from a total of 64 totally occluded vessels, 13 (20%) had no calcium. Conclusions The absence of coronary calcification does not exclude obstructive stenosis or the need for revascularization among patients with high enough suspicion of coronary artery disease to be referred for coronary angiography, in contrast with the published recommendations. Total coronary occlusion frequently occurs in the absence of any detectable calcification. (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]; NCT00738218) (J Am Coll Cardiol 2010;55:627-34) (C) 2010 by the American College of Cardiology Foundation

Neurological Patients Need Evidence-Based Urological Care

Aims: To report the conclusion of the Think Thank on Neurourology discussions during the first ICI-RS meeting in 2009. Methods: During a 3-day meeting a group of specialists discussed evidence-based medicine in neurourology and made suggestions for future research. Results: In the vast majority of patients with neurological disease bladder dysfunction occurs. The actual rules of diagnosis and treatment lack a study related evidence base. From a long list of possible research subjects, prevalence, detrusor pressure, imaging, catheterization and surgery have been first discussed. Conclusion: In each of these subjects, research items are suggested which can help to improve the care in this patient group. Neurourol. Urodynam. 29:662-669, 2010. (C) 2010 Wiley-Liss, Inc.

The need for effective radiosentitizing agents: experience in patients with complete pathological response

Chemoradiation therapy is now considered the preferred initial treatment strategy for distal rectal cancer because of the observation of better local disease control and significant tumor downstaging. Downstaging has become an important clinical outcome as patients with complete pathological response are associated with improved survival. Even though radiation alone may result in low local recurrence rates, the use of additional radiosensitizing agents may provide an increase in local disease control in addition to improved tumor regression rates. Several compounds have been investigated in the setting of neoadjuvant multimodality treatment of rectal cancer with variable rates of treatment-related toxicity and complete pathological response. The balance between complete pathological response and toxicity should aid in the management decision for the use of radiosensitizing agents in the neoadjuvant setting for the treatment of rectal cancer. Anti-Cancer Drugs 22: 308-310 (C) 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Factors predicting the need for insulin therapy in patients with gestational diabetes mellitus

Aim: To determine the possible factors predicting the insulin requirement in pregnancies complicated by gestational diabetes mellitus (GDM). Method: A total of 294 patients with GDM diagnosed by the 100-g/3-h oral glucose tolerance test (OGTT) were studied. The following factors were analyzed: maternal age, nulliparity, family history of diabetes, prepregnancy BMI, prior GDM, prior fetal macrosomia, multiple pregnancy, polyhydramnios, gestational age at diagnosis of GDM, smoking, hypertension, number of abnormal 100-g/3-h OGTT values, and glycated hemoglobin (HbA1c). The association between each factor and the need for insulin therapy was then analyzed individually. The performance of these factors to predict the probability of insulin therapy was estimated using a logistic regression model. Results: Univariate analysis showed a positive correlation between insulin therapy and prepregnancy BMI, family history of diabetes, hypertension, prior GDM, prior fetal macrosomia, number of abnormal 100-g/3-h OGTT values, and HbA1c (P < 0.05). Prepregnancy BMI, family history of diabetes, number of abnormal 100-g/3-h OGTT values and HbA1c were statistically significant variables in the logistic regression model. Conclusions: The probability of insulin therapy can be estimated in pregnant women with GDM based on prepregnancy BMI, family history of diabetes, number of abnormal 100-g/3-h OGTT values, and HbA1c concentration. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Left main stenting: do we need another study?

Coronary artery bypass graft (CABG) surgery has long been adopted as the treatment of choice for patients with left main (LM) coronary obstructions. In the past, randomised trials and observational studies have shown an advantage in survival of CABG against medical treatment. Recent studies comparing CABG with percutaneous coronary intervention (PCI) suggested that angioplasty may play a role as an alternative choice. However, well designed randomised trials to evaluate the relative merits of both therapeutic approaches are lacking. In this article, we review the current scientific evidences and outline issues that currently still need to be addressed in comparing CABG versus PCI for the treatment of LM disease.

Clinical and molecular characterization of Brazilian families with von Hippel-Lindau disease: a need for delineating genotype-phenotype correlation

von Hippel-Lindau (VHL) disease is an autosomal dominant hereditary cancer syndrome that predisposes to the development of a variety of benign and malignant tumours, especially cerebellar haemangioblastomas, retinal angiomas and clear-cell renal cell carcinomas (RCC). The etiology and manifestations are due to germline and somatic mutations in the VHL tumour suppressor gene. VHL disease is classified into type 1 and type 2, showing a clear genotype-phenotype correlation, as type 2 is associated with phaeochromocytoma and essentially caused by missense mutations. The aim of this study is to characterize the phenotype and genotype of families with VHL disease. Eighteen of twenty patients from ten unrelated families underwent genetic testing, nine of them fulfilled VHL disease criteria and one had an apparently sporadic cerebellar haemangioblastoma. Four different germline mutations in the VHL gene were identified: c.226_228delTTC (p.Phe76del); c.217C > T (p.Gln73X); IVS1-1 G > A and IVS2-1 G > C. The first three mutations were associated with type 1 disease and the last one with type 2B, which had never been identified in the germline. The transcriptional processing of a novel splice-site mutation was characterised. Three type 1 VHL families showed large deletions of the VHL gene, two of them encompassed the FANCD2/C3orf10 genes and were not associated with renal lesions. We also suggest that such families should be subclassified according to the risk of RCC and the extent of the VHL gene deletions. This study highlights the need for a through clinical and molecular characterisation of families with VHL disease to better delineate its genotype-phenotype correlation.

Hydrocephalus in posterior fossa tumors in children. Are there factors that determine a need for permanent cerebrospinal fluid diversion?

We searched for factors that could predispose towards persistent hydrocephalus in children with posterior fossa (PF) tumors in order to determine the need for permanent cerebrospinal fluid (CSF) diversion. The clinical records of 64 children who underwent surgery for PF tumors in the Pediatric Neurosurgery division of the Hospital of Clinics, Ribeirao Preto, Brazil, from 1990 to 2006, were retrospectively reviewed. The patients` ages ranged from 3 months to 18 years. The factors evaluated included age at surgery, severity of hydrocephalus (ventricular index), tumor location, size of the tumor, extent of tumor resection, and histology. Ventricular index, measured from the initial neuroradiological image, age at surgery, and location of the tumor were significantly associated with definitive postoperative CSF diversion (shunt or endoscopic third ventriculostomy), which was necessary for 34% of the patients. Young children with severe preoperative hydrocephalus and a midline tumor should be considered at risk when preoperative treatment decisions are made.

Telehealth in audiology: The need and potential to reach underserved communities

Permanent hearing loss is a leading global health care burden, with 1 in 10 people affected to a mild or greater degree. A shortage of trained healthcare professionals and associated infrastructure and resource limitations mean that hearing health services are unavailable to the majority of the world population. Utilizing information and communication technology in hearing health care, or tele-audiology, combined with automation offer unique opportunities for improved clinical care, widespread access to services, and more cost-effective and sustainable hearing health care. Tele-audiology demonstrates significant potential in areas such as education and training of hearing health care professionals, paraprofessionals, parents, and adults with hearing disorders; screening for auditory disorders; diagnosis of hearing loss; and intervention services. Global connectivity is rapidly growing with increasingly widespread distribution into underserved communities where audiological services may be facilitated through telehealth models. Although many questions related to aspects such as quality control, licensure, jurisdictional responsibility, certification and reimbursement still need to be addressed; no alternative strategy can currently offer the same potential reach for impacting the global burden of hearing loss in the near and foreseeable future.

Phylogenetic position of Dendropsophus gaucheri (Lescure and Marty 2000) highlights the need for an in-depth investigation of the phylogenetic relationships of Dendropsophus (Anura: Hylidae)

Dendropsophus gaucheri is a recently described species which inhabits open areas of the eastern part of the Guiana Shield and is currently assigned to the D. parviceps species group based on the presence of a subocular cream spot. Herein we investigate its phylogenetic position including material from the type locality and newly documented populations from Suriname and Brazil based on mtDNA sequences. The species, as well as D. riveroi which is assigned to the D. minimus species group, were recovered nested within the D. microcephalus species group which implies the paraphyly of the three Dendropsophus species groups. Such result, along with other evidences, highlights the need for a thorough revision of the genus. The genetic distances among D. gaucheri samples studied are low confirming their conspecificity and suggesting recent connections among populations from open areas currently isolated by rainforest in the lowlands of the Guiana Shield.