Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.

Economic forecasting in a changing world

This article explains the basis for a theory of economic forecasting developed over the past decade by the authors. The research has resulted in numerous articles in academic journals, two monographs, Forecasting Economic Time Series, 1998, Cambridge University Press, and Forecasting Nonstationary Economic Time Series, 1999, MIT Press, and three edited volumes, Understanding Economic Forecasts, 2001, MIT Press, A Companion to Economic Forecasting, 2002, Blackwells, and the Oxford Bulletin of Economics and Statistics, 2005. The aim here is to provide an accessible, non-technical, account of the main ideas. The interested reader is referred to the monographs for derivations, simulation evidence, and further empirical illustrations, which in turn reference the original articles and related material, and provide bibliographic perspective.

Molecular targets of cannabidiol in neurological disorders

Cannabis has a long history of anecdotal medicinal use and limited licensed medicinal use. Until recently, alleged clinical effects from anecdotal reports and the use of licensed cannabinoid medicines are most likely mediated by tetrahydrocannabinol by virtue of: 1) this cannabinoid being present in the most significant quantities in these preparations; and b) the proportion:potency relationship between tetrahydrocannabinol and other plant cannabinoids derived from cannabis. However, there has recently been considerable interest in the therapeutic potential for the plant cannabinoid, cannabidiol (CBD), in neurological disorders but the current evidence suggests that CBD does not directly interact with the endocannabinoid system except in vitro at supraphysiological concentrations. Thus, as further evidence for CBD’s beneficial effects in neurological disease emerges, there remains an urgent need to establish the molecular targets through which it exerts its therapeutic effects. Here, we conducted a systematic search of the extant literature for original articles describing the molecular phar- macology of CBD. We critically appraised the results for the validity of the molecular targets proposed. Thereafter, we considered whether the molecular targets of CBD identified hold therapeutic potential in relevant neurological diseases. The molecular targets identified include numerous classical ion channels, receptors, transporters, and enzymes. Some CBD effects at these targets in in vitro assays only manifest at high concentrations, which may be difficult to achieve in vivo, particularly given CBD’s relatively poor bioavailability. Moreover, several targets were asserted through experimental designs that demonstrate only correlation with a given target rather than a causal proof. When the molecular targets of CBD that were physiologically plausible were considered for their potential for exploitation in neurological therapeu- tics, the results were variable. In some cases, the targets identified had little or no established link to the diseases considered. In others, molecular targets of CBD were entirely consistent with those already actively exploited in relevant, clinically used, neurological treatments. Finally, CBD was found to act upon a number of targets that are linked to neurological therapeutics but that its actions were not consistent with modulation of such targets that would derive a therapeutically beneficial outcome. Overall, we find that while >65 discrete molecular targets have been reported in the literature for CBD, a relatively limited number represent plausible targets for the drug’s action in neurological disorders when judged by the criteria we set. We conclude that CBD is very unlikely to exert effects in neurological diseases through modulation of the endocannabinoid system. Moreover, a number of other molecular targets of CBD reported in the literature are unlikely to be of relevance owing to effects only being observed at supraphysiological concentrations. Of interest and after excluding unlikely and implausible targets, the remaining molecular targets of CBD with plausible evidence for involvement in therapeutic effects in neurological disorders (e.g., voltage-dependent anion channel 1, G protein-coupled receptor 55, CaV3.x, etc.) are associated with either the regulation of, or responses to changes in, intracellular calcium levels. While no causal proof yet exists for CBD’s effects at these targets, they represent the most probable for such investigations and should be prioritized in further studies of CBD’s therapeutic mechanism of action.

Exercício resistido no cardiopata: revisão sistemática

INTRODUÇÃO: A perda de massa muscular secundária à idade e à inatividade física é clinicamente relevante na população cardíaca; contudo, a prescrição do exercício resistido dinâmico para esses pacientes apresenta-se inconclusiva na literatura. OBJETIVOS: Reunir informações e apresentar as principais diretrizes relacionadas à prescrição de exercícios resistidos em cardiopatas. MATERIAIS E MÉTODOS: Foi realizada busca sistemática de literatura, a partir das bases de dados LILACS, SciELO e MEDLINE, utilizando os seguintes descritores na língua portuguesa: força muscular, exercício isométrico, esforço físico, cardiopatia e coronariopatia, e seus correspondentes na língua inglesa (muscle strength, isometric exercise, physical effort, heart disease e artery coronary disease), os quais foram pesquisados separadamente e em cruzamentos, sendo considerados para esta revisão apenas artigos publicados entre 2005 e 2010. RESULTADOS E DISCUSSÃO: de um total de 806 artigos foram selecionados 22 para integrar a revisão, sendo 14 estudos classificados como artigos originais, 2 artigos de atualização da literatura e 6 artigos de revisão, além do capítulo 8 do livro intitulado Diretrizes do ACSM (American College of Sports Medicine) para os testes de esforço e sua prescrição, publicado em 2007. CONCLUSÃO: O exercício resistido, independente da variada metodologia utilizada na prescrição dos componentes específicos do treinamento, mostrou-se eficiente para aumentar a força muscular de membros superiores e inferiores em cardiopatas e sua aplicação pode ser considerada segura para esses pacientes, desde que prescrito corretamente.

Authorship, Collaboration, and Funding Trends in Implantology Literature: Analysis of Five Journals From 2005 to 2009

Purpose: To identify the trend of authorship in dental implant by exploring the prevalence of coauthored articles and to investigate the collaboration efforts, trends in funding involved in original articles, and their relationships. Materials: Articles published in the Clinical Oral Implants Research, International Journal of Oral & Maxillofacial Implants, Clinical Implant Dentistry and Related Research, Implant Dentistry, and Journal of Oral Implantology from 2005 to 2009 were reviewed. Nonoriginal articles were excluded. For each included articles, number of authors, collaboration efforts, and extramural funding were recorded. Descriptive and analytical statistics (alpha = 0.05), including logistic regression analysis and chi(2) test, were used. Results: From a total of 2085 articles, 1503 met the inclusion criteria. Publications with 5 or more authors increased over time (P = 0.813). The amount of collaboration among different disciplines, institutions, and countries all increased. The greatest increase of collaboration was seen among institutions (P = 0.09). Non-funding studies decreased over time (P = 0.031). There was a strong association between collaboration and funding for the manuscripts during the years studied (OR, 1.5). Conclusion: The number of authors per articles and collaborative studies increased over time in implant-related journals. Collaborative studies were more likely to be funded. (Implant Dent 2011;20:68-75)

Alterações orais em crianças prematuras e de baixo peso ao nascer: a importância da relação entre pediatras e odontopediatras

OBJETIVO: Apresentar uma revisão de literatura sobre as alterações orais em crianças prematuras e de baixo peso ao nascer. FONTES DE DADOS: Foram selecionados artigos em inglês e português, desde 1976 até 2009, pesquisados no PubMed, Lilacs e na Bibliografia Brasileira de Odontologia (BBO), além de livros e consensos nacionais e internacionais. As palavras-chave utilizadas foram: prematuro, recém-nascido de baixo peso, cárie dentária, hipoplasia do esmalte dentário, manifestações bucais e dentição primária. Selecionaram-se artigos avaliando incidência, prevalência e etiologia das alterações orais, além de revisões de literatura e relatos de casos clínicos. SÍNTESE DOS DADOS: As alterações orais mais comuns em crianças prematuras e de baixo peso ao nascer são os defeitos no esmalte dentário (hipoplasias e hipocalcificações), a predisposição ao desenvolvimento de lesões de cárie dentária, as alterações na cronologia de erupção dentária e as alterações no palato com consequente aparecimento de maloclusão. Outras alterações também são relatadas, como diferenças nas dimensões das coroas dentárias e na espessura e porosidade do esmalte dentário. A interação entre pediatras e odontopediatras é fundamental no manejo dessas crianças. CONCLUSÕES: O conhecimento das alterações orais em crianças pré-termo e de baixo peso ao nascer por parte dos pediatras e odontopediatras favorece a atuação multidisciplinar com o objetivo de educar, prevenir e atenuar as possíveis mudanças físicas e dentárias nessas crianças.

Mnitoramento do desenvolvimento infantil realizado no Brasil

Objective: To review scientific literature in order to check how infant development surveillance is being carried out in Brazil. Data sources: Search on databases (PubMed, Medline, SciELO and CAPES Database Thesis) for studies on medical practices related to surveillance and monitoring of child development in Brazil from 2000 to 2011. The terms used for research were: child development surveillance, early intervention, developmental screening, and developmental screening tests. There were ten texts on the subject under study. Original articles, reviews, and thesis were analyzed, as well as the reference lists of publications on the topic. Data synthesis: Studies on monitoring of child development in Brazil showed major failures from pediatrician formation to clinical practice. Conclusions: It is urgent to offer continued medical education to pediatricians in order to update their knowledge about child development monitoring, especially due to the increasing numbers of preterm infants.

Mild cognitive impairment (part 2): Biological markers for diagnosis and prediction of dementia in Alzheimer's disease

To present a critical review of publications reporting on the rationale and clinical implications of the use of biomarkers for the early diagnosis of Alzheimer's disease (AD). Methods: We conducted a systematic search of the PubMed and Web of Science electronic databases, limited to articles published in English between 1999 and 2012, and based on the following terms: mild cognitive impairment, Alzheimer's disease OR dementia, biomarkers. We retrieved 1,130 articles, of which 175 were reviews. Overall, 955 original articles were eligible. Results: The following points were considered relevant for the present review: a) rationale for biomarkers research in AD and mild cognitive impairment (MCI); b) usefulness of distinct biomarkers for the diagnosis and prediction of AD; c) the role of multimodality biomarkers for the diagnosis and prediction of AD; d) the role of biomarkers in clinical trials of patients with AD and MCI; and e) current limitations to the widespread use of biomarkers in research and clinical settings. Conclusion: Different biomarkers are useful for the early diagnosis and prediction of AD in at-risk subjects. Nonetheless, important methodological limitations need to be overcome for widespread use of biomarkers in research and clinical settings. © 2013 Associação Brasileira de Psiquiatria.

Fatores sociais e esquisofrenia: investigando possíveis associações

Pós-graduação em Saúde Coletiva - FMB

Craniocervical posture and craniofacial morphology

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

Use of sample size calculation in scientific research in Brazilian Physical Education journals

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

A produção científica sobre diagnóstico de enfermagem NANDA no Brasil: revisão integrativa da literatura-UNESP – Botucatu

Concern about the identity of nursing professionals has existed since Florence Nightingale. The exercise of the nursing profession must be based on scientific principles so that the actual health problems of a given community can be assessed and actions targeted at improving the population’s quality of life can be designed from such assessments. This problem assessment is referred to as Nursing Diagnosis. NANDA defines diagnosis as “a clinical judgment about individual, family or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which nurses are accountable”. The present study aimed at investigating the scientific production on Nursing Diagnosis (NANDA). This is an literature review. For data collection, an instrument that addressed the following items was used: identification of original articles and evaluation of their objectives, methodological characteristics, results and conclusion. In the present review, 15 articles that met the inclusion criteria were analyzed. They were all authored by nurses. Four articles addressed obstetrics, puerperium and neonatology, and the diagnosis of an unsatisfactory breastfeeding process was observed in 100% of cases. As regards chronic diseases, four articles were found, and two exclusively addressed diabetes, with a main diagnosis of an ineffective control of the therapeutic regimen. Three articles addressed the elderly, and the main diagnosis found was hindered mobility in more than 90% of cases. As regards, sexually transmitted diseases, one article was found with three diagnoses with 100% for disturbed sleep patterns, infection risk and ineffective protection. As to patients with sequelae, two articles were identified, and the diagnoses found were hindered physical mobility, with 100%; self-care deficit for... (Complete abstract click electronic access below)

Repercussões cardiovasculares em crianças com distúrbios respiratórios obstrutivos do sono: revisão de literatura

Objective: To review the cardiovascular consequences of obstructive sleep-disordered breathing in children Data source: Medline and Ovid data base. Study selection: pediatric articles (original articles and case report) that investigated the obstructive sleep-disordered breathing in children Data synthesis: The obstructive sleep-disordered breathing can lead to serious cardiovascular consequences such as pulmonary hypertension, pulmonary edema and anatomic and functional abnormalities Conclusions: The knowledge of cardiovascular repercussions allows in better management of pediatric patients and may result in positive consequences for treatment and follow up of these patients.

Visual disturbance following sclerotherapy for varicose veins, reticular veins and telangiectasias: a systematic literature review

The objective of the study was to review the literature reporting visual disturbance (VD) following sclerotherapy for varicose veins. Underlying mechanisms will be discussed. A literature search of the databases Medline and Google Scholar was performed. Original articles including randomized trials, case series and case reports reporting VD in humans following sclerotherapy for varicose veins were included. Additional references were also obtained if they had been referenced in related publications. The search yielded 4948 results of which 25 reports were found to meet the inclusion criteria. In larger series with at least 500 included patients the prevalence of VD following sclerotherapy ranges from 0.09% to 2%. In most reports foam sclerotherapy was associated with VD (19); exclusive use of liquid sclerosant was reported in two cases, some reports included foam and liquid sclerosant (4). There were no persistent visual disorders reported. VD occurred with polidocanol and sodium tetradecyl sulphate in different concentrations (0.25-3%). Various forms of foam preparation including various ways of foam production and the liquid - air ratio (1 or 2 parts of liquid mixed with 3, 4 or 5 parts of air) were reported in association with the occurrence of VD. VDs following sclerotherapy for varicose veins are rare and all reported events were transient. Bubble embolism or any kind of embolism seems unlikely to be the only underlying mechanism. A systemic inflammatory response following sclerotherapy has been suggested. Further research to clarify the mechanism of action of sclerosants is required.

Androgen deprivation therapy for the treatment of prostate cancer: consider both benefits and risks

CONTEXT: Androgen deprivation therapy (ADT) is increasingly used for the treatment of prostate cancer (PCa), even in clinical settings in which there is no evidence-based proof of prolonged overall survival (OS). ADT, however, may be associated with numerous side effects, including an increased therapy-related cardiovascular mortality. OBJECTIVE: To discuss different clinical settings in which ADT is currently used and to critically weigh the benefits of ADT against its possible side effects. EVIDENCE ACQUISITION: A MEDLINE search was conducted to identify original articles and review articles addressing the efficacy and side effects of ADT for the treatment of PCa. Keywords consisted of prostate cancer, hormonal therapy, adverse effects, radical prostatectomy, and radiotherapy. The articles with the highest level of evidence for the various examined end points were identified with the consensus of all authors and were reviewed. EVIDENCE SYNTHESIS: Even short-term use of ADT may lead to numerous side effects, such as osteoporosis, obesity, sarcopenia, lipid alterations, insulin resistance, and increased risk for diabetes and cardiovascular morbidity. Despite these side effects, ADT is commonly used in various clinical settings in which a clear effect on improved OS has not been shown. CONCLUSIONS: ADT is associated with an increased risk of multiple side effects that may reduce quality of life and/or OS. Consequently, these issues should be discussed in detail with patients and their families before initiation of ADT. ADT should be used with knowledge of its potential long-term side effects and with possible lifestyle interventions, especially in settings with the highest risk-benefit ratio, to alleviate comorbidities.