Eficácia do tratamento cirúrgico no tórax instável: revisão sistemática e metanálise

Pós-graduação em Bases Gerais da Cirurgia - FMB

Diagnóstico, tratamento e seguimento do carcinoma medular de tireoide: recomendações do Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia

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

Geochronological constraints on the age of a Permo-Triassic impact event: U-Pb and Ar-40/Ar-39 results for the 40 km Araguainha structure of central Brazil

Impact cratering has been a fundamental geological process in Earth history with major ramifications for the biosphere. The complexity of shocked and melted rocks within impact structures presents difficulties for accurate and precise radiogenic isotope age determination, hampering the assessment of the effects of an individual event in the geological record. We demonstrate the utility of a multi-chronometer approach in our study of samples from the 40 km diameter Araguainha impact structure of central Brazil. Samples of uplifted basement granite display abundant evidence of shock deformation, but U/Pb ages of shocked zircons and the Ar-40/Ar-39 ages of feldspar from the granite largely preserve the igneous crystallization and cooling history. Mixed results are obtained from in situ Ar-40/Ar-39 spot analyses of shocked igneous biotites in the granite, with deformation along kink-bands resulting in highly localized, partial resetting in these grains. Likewise, spot analyses of perlitic glass from pseudotachylitic breccia samples reflect a combination of argon inheritance from wall rock material, the age of the glass itself, and post-impact devitrification. The timing of crater formation is better assessed using samples of impact-generated melt rock where isotopic resetting is associated with textural evidence of melting and in situ crystallization. Granular aggregates of neocrystallized zircon form a cluster of ten U-Pb ages that yield a "Concordia" age of 247.8 +/- 3.8 Ma. The possibility of Pb loss from this population suggests that this is a minimum age for the impact event. The best evidence for the age of the impact comes from the U-Th-Pb dating of neocrystallized monazite and Ar-40/Ar-39 step heating of three separate populations of post-impact, inclusion-rich quartz grains that are derived from the infill of miarolitic cavities. The Pb-206/U-238 age of 254.5 +/- 3.2 Ma (2 sigma error) and Pb-208/Th-232 age of 255.2 +/- 4.8 Ma (2 sigma error) of monazite, together with the inverse, 18 point isochron age of 254 +/- 10 Ma (MSWD = 0.52) for the inclusion-rich quartz grains yield a weighted mean age of 254.7 +/- 2.5 Ma (0.99%, 2 sigma error) for the impact event. The age of the Araguainha crater overlaps with the timing of the Permo-Triassic boundary, within error, but the calculated energy released by the Araguainha impact is insufficient to be a direct cause of the global mass extinction. However, the regional effects of the Araguainha impact event in the Parana-Karoo Basin may have been substantial. (C) 2012 Elsevier Ltd. All rights reserved.

Depositional age, provenance and metamorphic age of metasedimentary rocks from southern Madagascar

Southern Madagascar is the core of a >1 million km(2) Gondwanan metasedimentary belt that forms much of the southern East African Orogen of eastern Africa, Madagascar, southern India and Sri Lanka. Here the Vohibory Series yielded U-Pb isotopic data from detrital zircon cores that indicate that it was deposited in the latest Tonian to late Cryogenian (between -900 and 640 Ma). The deposition of the Graphite and Androyen Series protoliths is poorly constrained to between the late Palaeoproterozoic and the Cambrian (similar to 1830-530 Ma). The Vohibory Series protoliths were sourced from very restricted-aged sources with a maximum age range between 910 and 760 Ma. The Androyen and Graphite Series protoliths were sourced from Palaeoproterozoic rocks ranging in age between 2300 and 1800 Ma. The best evidence of the timing of metamorphism in the Vohibory Series is a weighted mean Pb-206/U-238 age of 642 +/- 8 Ma from 3 analyses of zircon from sample M03-01. A considerably younger Pb-206/U-238 metamorphic age of 531 +/- 7 Ma is produced from 10 analyses of zircon from sample M03-28 in the Androyen Series. This similar to 110 Ma difference in age is correlated with the early East African Orogeny affecting the west of Madagascar along with its type area in East Africa, whereas the Cambrian Malagasy Orogeny affected the east of Madagascar and southern India during the final suturing of the Mozambique Ocean. (C) 2011 International Association for Gondwana Research. Published by Elsevier B.V. All rights reserved.

Guidelines for the management of traumatic dental injuries. III. Primary teeth

Trauma to the primary dentition present special problems and the management is often different as compared with permanent teeth. An appropriate emergency treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this third article out of three, the IADT Guidelines for the management of traumatic injuries in the primary dentition, are presented.

Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth

Avulsion of permanent teeth is the most serious of all dental injuries. The prognosis depends on the measures taken at the place of accident or the time immediately after the avulsion. Replantation is the treatment of choice, but cannot always be carried out immediately. An appropriate emergency management and treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this second article of three, the IADT Guidelines for management of avulsed permanent teeth are presented.

Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth

Crown fractures and luxations occur most frequently of all dental injuries. An appropriate treatment plan after an injury is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence, based on literature research and professional opinion. In this first article of three, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS.

The implementation of new surgical techniques offers chances but carries risks. Usually, several years pass before a critical appraisal and a balanced opinion of a new treatment method are available and rely on the evidence from the literature and expert's opinion. The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications. This paper represents a common effort of the Vascular Domain of EACTS together with several surgeons with particular expertise in aortic surgery, and summarizes the current knowledge and the state of the art about the FET technique. The majority of the information about the FET technique has been extracted from 97 focused publications already available in the PubMed database (cohort studies, case reports, reviews, small series, meta-analyses and best evidence topics) published in English.

Land Inheritance Rules: Theory and Cross-Cultural Analysis

This paper develops a general theory of land inheritance rules. We distinguish between two classes of rules: those that allow a testator discretion in disposing of his land (like a best-qualified rule), and those that constrain his choice (like primogeniture). The primary benefit of the latter is to prevent rent seeking by heirs, but the cost is that testators cannot make use of information about the relative abilities of his heirs to manage the land. We also account for the impact of scale economies in land use. We conclude by offering some empirical tests of the model using a cross-cultural sample of societies.

Identification of diabetic retinopathy genes through a genome-wide association study among Mexican-Americans from Starr County, Texas

To identify genetic susceptibility loci for severe diabetic retinopathy, 286 Mexican-Americans with type 2 diabetes from Starr County, Texas completed detailed physical and ophthalmologic examinations including fundus photography for diabetic retinopathy grading. 103 individuals with moderate-to-severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy were defined as cases for this study. DNA samples extracted from study subjects were genotyped using the Affymetrix GeneChip® Human Mapping 100K Set, which includes 116,204 single nucleotide polymorphisms (SNPs) across the whole genome. Single-marker allelic tests and 2- to 8-SNP sliding-window Haplotype Trend Regression implemented in HelixTreeTM were first performed with these direct genotypes to identify genes/regions contributing to the risk of severe diabetic retinopathy. An additional 1,885,781 HapMap Phase II SNPs were imputed from the direct genotypes to expand the genomic coverage for a more detailed exploration of genetic susceptibility to diabetic retinopathy. The average estimated allelic dosage and imputed genotypes with the highest posterior probabilities were subsequently analyzed for associations using logistic regression and Fisher's Exact allelic tests, respectively. To move beyond these SNP-based approaches, 104,572 directly genotyped and 333,375 well-imputed SNPs were used to construct genetic distance matrices based on 262 retinopathy candidate genes and their 112 related biological pathways. Multivariate distance matrix regression was then used to test hypotheses with genes and pathways as the units of inference in the context of susceptibility to diabetic retinopathy. This study provides a framework for genome-wide association analyses, and implicated several genes involved in the regulation of oxidative stress, inflammatory processes, histidine metabolism, and pancreatic cancer pathways associated with severe diabetic retinopathy. Many of these loci have not previously been implicated in either diabetic retinopathy or diabetes. In summary, CDC73, IL12RB2, and SULF1 had the best evidence as candidates to influence diabetic retinopathy, possibly through novel biological mechanisms related to VEGF-mediated signaling pathway or inflammatory processes. While this study uncovered some genes for diabetic retinopathy, a comprehensive picture of the genetic architecture of diabetic retinopathy has not yet been achieved. Once fully understood, the genetics and biology of diabetic retinopathy will contribute to better strategies for diagnosis, treatment and prevention of this disease.^

Effective interventions for lowering HbA1C in African Americans with type 2 diabetes: A review

This synthesis of the literature provides descriptive analysis and outlines current self-management interventions for African Americans with type 2 diabetes. Specifically, this study describes and explores the design of those studies whose interventions have been shown to lower HbA1C levels in this population by at least 0.5% points, an improvement that provides approximately 10% reduction in long term complications from this disease.^ Results. In total, 37 articles were reviewed and 17 articles met inclusion criteria for analysis. Analysis of each study's methodology and results was performed and selected studies with interventions that resulted in improvements in HbA1C outcomes equal to 0.5% or greater for both group 1 and 2 were summarized by intervention type in table format. Descriptive analysis, outlining the number and characteristics of proximal and distal mediating components addressed in Group 1 studies, was performed in order to determine whether mediating components may have had some relation to effectiveness of intervention on outcome HbA1C. Descriptive analysis revealed that no particular design is substantially more effective than another among Behavioral studies although, there may be an advantage in using culturally sensitive, group interventions that address greater numbers of distal mediating components. Among Process studies, structured approaches (i.e. algorithm care and scheduled follow up), as well as utilization of specialty and group care are represented as effective for African American populations. ^ Conclusions. It may be summarized that by targeting behavior and addressing provider delivery (i.e. algorithm use, group care, home care, and provider follow up) in this population, a greater yield in outcome improvements may be accomplished. However, many gaps exist in a review process that stratifies results and focuses on identifying group specific intervention successes and failures. Further research in different populations will aid researchers and practitioners in discovering the best evidence, and identifying models that could be utilized in practice to achieve the best diabetes management for at risk groups.^

The success of worksite nutrition and physical activity interventions with environmental modifications A systematic review

Background: As obesity increases among U.S. workers, employers are implementing programs to increase physical activity and improve diets. Although programs to address individual determinants of obesity have been evaluated, less is known about the effects of workplace programs that change environmental factors, because most reviews have not isolated environmental programs; the one that did was published in 2005. ^ Objective: To update the 2005 review to determine the effectiveness of workplace environmental interventions. ^ Methods: The Medline database was searched for published English language reports (2003-2011) of randomized controlled (RCTs) or quasi-experimental trials (NRCTs) that evaluated strategies to modify physical activity opportunities or food services, targeting employees at least 18 years, not including retirees and that provided data for at least one physical activity, dietary, or health risk indicator. Three coders independently extracted study characteristics and scored the quality of study methods. Program effectiveness was determined using the 2005 review's best evidence approach. ^ Results: Seven studies represented in nine reports met eligibility criteria; three focused on diet and the remainder targeted diet and physical activity interventions. All but one study received a high quality score for internal validity. The evidence for the effectiveness of workplace environmental interventions was at best, inconclusive for diet and physical activity and limited for health risk indicators. The outcome constructs were inconsistent across the studies. ^ Conclusions: Limitations in the methods of the 2005 review made it challenging to draw conclusions about findings for this review that include: variation in outcome measures, reliance on distal measures without proximal behavior change measures, no distinction between changes at the workplace versus outside the workplace, and inappropriate analyses of cluster designs that biased findings toward statistical significance. The best evidence approach relied on vote-counting, using statistical significance alone rather than effect size and confidence intervals. Future research should address these limitations and use more rigorous methods; systematic reviews should use methods of meta-analysis to summarize study findings. These recommendations will help employers to better understand how environmental modifications in the workplace can support their efforts to combat the effects of obesity among employees.^

Patient-centered medical home technology effects on hypertension and diabetes control

Background: Hypertension and Diabetes is a public health and economic concern in the United States. The utilization of medical home concepts increases the receipt of preventive services, however, do they also increase adherence to treatments? This study examined the effect of patient-centered medical home technologies such as the electronic health record, clinical support system, and web-based care management in improving health outcomes related to hypertension and diabetes. Methods: A systematic review of the literature used a best evidence synthesis approach to address the general question " Do patient-centered medical home technologies have an effect of diabetes and hypertension treatment?" This was followed by an evaluation of specific examples of the technologies utilized such as computer-assisted recommendations and web-based care management provided by the patient's electronic health record. Ebsco host, Ovid host, and Google Scholar were the databases used to conduct the literature search. Results: The initial search identified over 25 studies based on content and quality that implemented technology interventions to improve communication between provider and patient. After further assessing the articles for risk of bias and study design, 13 randomized controlled studies were chosen. All of the studies chosen were conducted in various primary care settings in both private practices and hospitals between the years 2000 and 2007. The sample sizes of the studies ranged from 42 to 2924 participants. The mean age for all of the studies ranged from 56 to 71 years. The percent women in the studies ranged from one to 78 percent. Over one-third of the studies did not provide the racial composition of the participants. For the seven studies that did provide information about the ethnic composition, 64% of the intervention participants were White. All of the studies utilized some type of web-based or computer-based communication to manage hypertension or diabetes care. Findings on outcomes were mixed, with nine out of 13 studies showing no significant effect on outcomes examined, and four of the studies showing significant and positive impact on health outcomes related to hypertension or diabetes Conclusion: Although the technologies improved patient and provider satisfaction, the outcomes measures such as blood pressure control and glucose control were inconclusive. Further research is needed with diverse ethnic and SES population to investigate the role of patient-centered technologies on hypertension and diabetes control. Also, further research is needed to investigate the effects of innovative medical home technologies that can be used by both patients and providers to increase quality of communication concerning adherence to treatments.^

Engaging stakeholders in community-level obesity prevention programming: Evaluation of the Fit Family Challenge

Introduction: Both a systems approach to change and a focus on multi-sector interventions ensures obesity prevention programming within the community is equitable, sustainable, and cost-effective. An authentic community engagement approach is required to implement interventions guided by best-evidence research and practice. Although there are examples illustrating the benefits of community engagement, there is no standardized method to implement it. The San Antonio Sports Foundation (SA Sports), a non-profit community-based organization, implements a variety of free events and programs promoting active life styles. One such program is the Fit Family Challenge which is a summer-long program implemented at the school level targeted at families. ^ Aims: This thesis was a culmination of the experience from the student collaborating with SA Sports as part of a practicum opportunity. Using secondary data collected by the Fit Family Challenge during the 2011 year, the goals of this thesis were: to assess individual changes; evaluate short-term impact; and describe the community engagement process. ^ Methods: SA Sports collected quantitative and qualitative data during the implementation and evaluation of the FFC program. SA Sports allowed the used of de-identified data to be analyzed to study the aims of this thesis. ^ Results: The program was able to provide families with the knowledge, information, and opportunity to exercise as a family and cook healthier meals. School district coordinators were generally satisfied and illustrated the benefits of a community partnership. An authentic community engagement was present highlighting the importance of communication, collaboration and the sustainability of such partnerships in the community. ^ Conclusion: The success of an obesity program should focus on triggers that initiate behavioral change rather than physiological changes. The evaluation was guided by a community engagement approach, which illustrated the development of new partnerships and the strengthening of other collaborations. Ultimately, the engagement approach empowered the community to identify their own problems and build collaboration, rather than tackling obesity prevention alone. ^

La Biblioteca Médica Nacional de Cuba tiene la primicia : Curso Cochrane Library, aprendizaje con estrategias para obtener las mejores evidencias en salud

La Biblioteca Médica Nacional de Cuba ha puesto en marcha un programa de alfabetización informacional para adiestrar a sus usuarios y fomentar en ellos las habilidades necesarias para el uso de bases de datos, así como para fomentar el uso de estrategias de búsquedas bien diseñadas y validadas por los bibliotecarios especialistas en información. En el presente trabajo se describen contenidos y habilidades que se fomentan en el curso "Cochrane Library: La Medicina Basada en Evidencias", cuyo objetivo es que el usuario domine esta base de datos y el concepto de medicina basada en evidencias para la toma de mejores decisiones en la atención médica. Durante el curso se introduce además el Modelo Big 6, como guía del pensamiento para resolver problemas de información que facilite la búsqueda y la organización de la información médica basada en evidencias. Igualmente, se capacita al estudiante para que diseñe productos informativos, como boletines electrónicos, que le permitan tanto presentar los resultados de búsquedas de información como promover información para el cuidado de la salud en el futuro