Systematic reviews showed insufficient evidence for clinical practice in 2004: What about in 2011? the next appeal for the evidence-based medicine age

Rationale and aim The aims of the Cochrane systematic reviews are to make readily available and up-to-date information for clinical practice, offering consistent evidence and straightforward recommendations. In 2004, we evaluated the conclusions from Cochrane systematic reviews of randomized controlled trials in terms of their recommendations for clinical practice and found that 47.83% of them had insufficient evidence for use in clinical practice. We proposed to reanalyze the reviews to evaluate whether this percentage had significantly decreased. Methods A cross-sectional study of systematic reviews published in the Cochrane Library (Issue 7, 2011) was conducted. We randomly selected reviews across all 52 Cochrane Collaborative Review Groups. Results We analyzed 1128 completed systematic reviews. Of these, 45.30% concluded that the interventions studied were likely to be beneficial, of which only 2.04% recommended no further research. In total, 45.04% of the reviews reported that the evidence did not support either benefit or harm, of which 0.8% did not recommend further studies and 44.24% recommended additional studies; the latter has decreased from our previous study with a difference of 3.59%. Conclusion Only a small number of the Cochrane collaboration's systematic reviews support clinical interventions with no need for additional research. A larger number of high-quality randomized clinical trials are necessary to change the 'insufficient evidence' scenario for clinical practice illustrated by the Cochrane database. It is recommended that we should produce higher-quality primary studies in active collaboration and consultation with global scholars and societies so that this can represent a major component of methodological advance in this context. © 2012 John Wiley & Sons Ltd.

Clinical Practice: Vocal nodules in dysphonic children

Common among children, vocal symptoms are a cause of concern for parents who seek elucidation of their diagnosis and treatment. Vocal nodules are the major cause of dysphonias in children and are related to vocal abuse. We conducted a literature review considering clinical, physiopathological, epidemiological, and histological aspects of vocal nodules, as well as diagnostic methods, highlighting the main studies addressing this issue. The controversial points of treatments were also discussed.

Evaluation of dentists' knowledge of the use of oral exfoliative cytology in clinical practice

Oral exfoliative cytology (EC) is a rapid and practical complementary test that can be used in the diagnosis of various diseases. The objectives of this study were to assess dentists'knowledge of EC and to disseminate information on the technique. The study included 240 dentists from the city of Anapolis (Goias, Brazil) who answered a questionnaire regarding demographic data and data relating to EC and who then received information on the technique. The data revealed that 26.92% of the dentists did not know about EC. Among those who reported knowledge of EC, 33.91% did not know the procedures for performing the technique, and 85.38% had no experience with EC. In addition, 54.09% of the answers regarding the instrument used to collect the material and 56.82% of the answers concerning suitable fixatives were inappropriate. Although 73.02% of the dentists adequately identified the pathologies for which EC is recommended, it was concluded that the respondents had poor knowledge of EC. There is a need to increase dentists'awareness of this subject and of EC's use in diagnostic practices.

Anti-dementia medications: current prescriptions in clinical practice and new agents in progress

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Avaliacao da necessidade da dosagem rotineira de hematocrito, hemoglobina, ureia e creatinina sericos durante a avaliacao pre-anestesica

Background and Objectives - There are many questions and opinions about the value of routine preoperative tests as an integral part of the preanesthetic evaluation. Current trends suggest that such tests should be based on detailed clinical and physical evaluation. Since such tests are still routinely performed and questions about their real value still persist, the aim of this study was to assess the value of routine hematocrit (Ht), hemoglobin concentration (Hb), blood urea nitrogen (BUN) and serum creatinine results in patients undergoing elective surgery, to establish when they are needed and aiming at answering such questions. Methods - 1065 patients aged 12 years and above, physical status ASA I, II and III, scheduled for elective surgery were studied. Patients were divided into 7 different age groups with randomized distribution of gender. Ht, Hb, BUN and serum creatinine results, routinely asked by our surgical departments, were observed and analyzed. Variance Analysis was used for each variable, and the Bonferroni Multiple Comparison Test was used to compare group to group. Differences were considered significant when p < 0.05 (5%). Results - For all patients, 4025 laboratory tests were obtained. The number of tests was the same for each group. There were no differences in Ht and Hb values which remained within normal ranges. Considering BUN and serum creatinine, there was a difference between younger and older patients, but the results were normal in all groups. Conclusions - We concluded that mean Ht, Hb, BUN and serum creatinine values in all age groups were all acceptable for surgical patients in general. However, they are barely useful if performed regardless of clinical evaluation. Thus, such preoperative routine tests should be abandoned and the good clinical practice with common sense should prevail in indicating them.

Como desenhar e escrever um protocolo de pesquisa clínica em Cosmiatria

Cosmetic Dermatology is a growing subspecialty. High-quality basic science studies have been published; however, few double-blind, randomized controlled clinical trials, which are the major instrument for evidence-based medicine, have been conducted in this area. Clinical research is essential for the discovery of new knowledge, improvement of scientific basis, resolution of challenges, and good clinical practice. Some basic principles for a successful researcher include interest, availability, persistence, and honesty. It is essential to learn how to write a protocol research and to know the international and national regulatory rules. A complete clinical trial protocol should include question, background, objectives, methodology (design, variable description, sample size, randomization, inclusion and exclusion criteria, intervention, efficacy and safety measures, and statistical analysis), consent form, clinical research form, and references. Institutional ethical review board approval and financial support disclosure are necessary. Publication of positive or negative results should be an authors' commitment. © 2013 by Anais Brasileiros de Dermatologia.

Avaliação crítica da pesquisa clínica no Brasil

Pós-graduação em Patologia - FMB

Statistical methods for assessing agreement between double readings of clinical measurements

Statistical analysis of data is crucial in cephalometric investigations. There are certainly excellent examples of good statistical practice in the field, but some articles published worldwide have carried out inappropriate analyses. Objective: The purpose of this study was to show that when the double records of each patient are traced on the same occasion, a control chart for differences between readings needs to be drawn, and limits of agreement and coefficients of repeatability must be calculated. Material and methods: Data from a well-known paper in Orthodontics were used for showing common statistical practices in cephalometric investigations and for proposing a new technique of analysis. Results: A scatter plot of the two radiograph readings and the two model readings with the respective regression lines are shown. Also, a control chart for the mean of the differences between radiograph readings was obtained and a coefficient of repeatability was calculated. Conclusions: A standard error assuming that mean differences are zero, which is referred to in Orthodontics and Facial Orthopedics as the Dahlberg error, can be calculated only for estimating precision if accuracy is already proven. When double readings are collected, limits of agreement and coefficients of repeatability must be calculated. A graph with differences of readings should be presented and outliers discussed.

Discrepancies between clinical diagnoses and autopsy findings

Autopsy examination is considered to be an essential element for medical auditing and teaching. Despite the significant progress in diagnostic procedures, autopsy has not always confirmed the clinical diagnosis. In the present study, we compared the diagnosis recorded on medical charts with reports of 96 autopsies performed at the University Teaching Hospital of the Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil, between 1975 and 1982, and of 156 autopsies performed at the same institution between 1992 and 1996. The clinical diagnosis of the basic cause of death was confirmed at autopsy in 77% of cases. The percent confirmation fell to 60% when the immediate terminal cause of death was considered, and in 25% of cases, the terminal cause was only diagnosed at autopsy. The discrepancies between clinical and autopsy diagnosis were even larger for secondary diagnoses: 50% of them were not suspected upon clinical diagnosis. Among them, we emphasize the diagnosis of venous thromboses (83%), pulmonary embolisms (80%), bronchopneumonias (46%) and neoplasias (38%). Iatrogenic injuries were very frequent, and approximately 90% of them were not described in clinical reports. Our results suggest that highly sensitive and specific diagnostic tests are necessary but cannot substitute the clinical practice for the elaboration of correct diagnoses.

Incidence of retromolar foramen in human mandibles: ethnic and clinical aspects

The retromolar foramen allows the passage of the neurovascular bundles that contribute to nutrition and innervation of the pulp and periodontium of the lower teeth. Knowledge of this anatomical variation may prevent complications in the anesthesia and surgical procedures in this area and serve as an anatomical landmark for ethnic identification. The aim of this study was to evaluate the impact of the retromolar foramen in human mandibles of adult Brazilians and discuss the clinical and ethnic related to the presence of this foramen. Were evaluated 222 human mandibles, dry, adults, Brazilians, independent of gender. The evaluation was performed by two examiners who standardized search from a previous anatomical study. The mandibles were analyzed: the presence of the retromolar foramen (bilateral or unilateral), the presence of the foramen on right and left sides, and the number of foramens present on each side. It was found that 59 had at least one mandible retromolar foramens resulting in an incidence of 26.58%. The retromolar foramen was present unilaterally in 41 mandibles and 18 bilaterally, with incidences of 18.47% and 12.16% respectively. on the right side, the retromolar foramen was present in incidences of 16.22% and 18.92% respectively The analysis of the right side of the mandibles revealed that 47.46%, 21.21% and 3.03% had one, two and three foramens, respectively The left side showed 55.93%, 16.22% and 8.11% of the 222 mandibles with one, two and three retromolar foramens, respectively The incidence of retromolar foramen in the Brazilian population is significant and should be considered in the planning and execution of procedures in several areas of clinical practice dentistry in order to avoid complications. Moreover, it was found that the incidence of retromolar foramen contributes to differentiation of ethnic groups in the area of forensic anthropology.

The performance of conventional and fluorescence-based methods for occlusal caries detection An in vivo study with histologic validation

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Incômodo causado pelo zumbido medido pelo Questionário de Gravidade do Zumbido

OBJETIVO: O Tinnitus Handicap Inventory é um questionário para avaliar as conseqüências do zumbido, quantificando os déficits psicoemocionais e funcionais provocados pelo sintoma. O objetivo do estudo foi apresentar e testar a adaptação para o português brasileiro desse questionário, denominado Questionário de Gravidade do Zumbido. MÉTODOS: O questionário traduzido foi aplicado em 135 indivíduos com queixa de zumbido atendidos em dois ambulatórios de audiologia da cidade de Bauru, SP, encaminhados para avaliação audiológica. A consistência interna foi avaliada pelos coeficientes a de Cronbach, comparados aos obtidos para a versão original. RESULTADOS: Obteve-se boa confiabilidade tanto para as escalas (0,76

Morphology and bacterial colonisation of tooth/ceramic restoration interface after different cement excess removal techniques

Objectives: To evaluate the influence of different protocols for resin cement removal during cementation on biofilm formation.Methods: Twenty-eight ceramic blocks, which were injected under pressure, were placed over enamel blocks obtained from freshly extracted bovine incisors. The ceramic blocks were cemented to the enamel blocks using a dual-cured resin cement and the excess resin was removed according to the experimental group: TS: Teflon spatula; BR: brush; BR+: brush and polishing; SB+: scalpel blade and polishing. After autoclaving, the samples were colonised by incubation in a sucrose broth suspension standardised with Streptococcus mutans in microaerophilic stove. Specimens were quantitatively analysed for bacterial adherence at the adhesive interface using confocal laser scanning microscopy and counting the colony forming units, and qualitatively analysed using SEM. The roughness (Ra/Rz/RSm) was also analysed. Data were analysed by 1-way ANOVA and Tukey's test (5%).Results: The roughness values ranged from 0.96 to 1.69 mu m for Ra (p > 0.05), from 11.59 to 22.80 mu m for Rz (p = 0.02 < 0.05) and from 293.2 to 534.3 mu m for RSm (p = 0.00). Bacterial adhesion varied between 1,974,000 and 2,814,000 CFU/ml (p = 0.00). Biofilm mean thickness ranged from 0.477 and 0.556 mu m (p > 0.05), whilst the biovolume values were between 0.388 and 0.547 mu m(3)/mu m(2) (p = 0.04). Lower values for roughness, bacterial adhesion, biofilm thickness and biovolume were found with BR, whilst TS presented the highest values for most of the parameters. SEM images confirmed the quantitative values.Conclusions: The restoration margin morphology and interface roughness affects bacterial accumulation. The brush technique promoted less bacterial colonisation at the adhesive interface than did the other removal methods.Clinical significance: The brush technique seems to be a good option for removing the excess resin cement after adhesive cementation in clinical practice, as indicated by its better results with lower bacterial colonisation. (C) 2012 Elsevier Ltd. All rights reserved.

Clinical applications of non-culture based methods for the diagnosis and management of opportunistic and endemic mycoses

Nonculture based methods for the detection of infections caused by fungal pathogens are becoming more important tools in the management of infected patients. Detection of fungal antigens and DNA appear to be the most promising in this respect for both opportunistic and endemic mycoses. In this article we present an overview of the most recent developments in nonculture based methods and examine their value in clinical practice.

Low-level laser therapy for pain relief after episiotomy: a double-blind randomised clinical trial

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)