Rationale and design of the national benchmarking and evidence-based national clinical guidelines for chronic heart failure management programs study

OBJECTIVES: The National Benchmarks and Evidence-Based National Clinical Guidelines for Heart Failure Management Programs Study is a national, multicenter study designed to determine the nature, range, and effect of interventions applied by chronic heart failure management programs (CHF-MPs) throughout Australia on patient outcomes. Its primary objective is to use these data to develop national benchmarks and evidence-based clinical guidelines and optimize their cost-effective application by reducing quality and outcome variability. DATA SOURCES/STUDY SETTING: Primary data will be collected from CHF-MP coordinators and CHF patients enrolled in these programs on a national basis. Secondary outcome data will be collected from a national morbidity record and from patients' medical records. STUDY DESIGN: Stage I of the study involves a prospective clinical audit of all CHF-MPs throughout Australia (n = 45) to determine the extent of variability in programs currently. Stage II is a prospective cross-sectional survey design enrolling 1,500 patients (average of 40 patients per program) to firstly determine the typical profile of patients being managed via a CHF-MP in Australia and, secondly, the subsequent morbidity and mortality during the 6-month follow-up. Outcome data will be subject to multivariate analysis to determine the key components of care in this regard. All study data will be then examined in the final stage of the study (III) to develop national benchmarks for the application and auditing of CHF-MPs in Australia. CONCLUSION: Variability in patient outcomes is a product of heterogeneity among CHF-MPs. The development of national benchmarks will minimize such heterogeneity and will provide a greater level of evidence for their cost-effective application.

Economic evaluation of Australian stroke services: a prospective, multicenter study comparing dedicated stroke units with other care modalities

Background and Purpose: Level I evidence from randomized controlled trials demonstrates that the model of hospital care influences stroke outcomes; however, the economic evaluation of such is limited. An economic appraisal of 3 acute stroke care models was facilitated through the Stroke Care Outcomes: Providing Effective Services (SCOPES) study in Melbourne, Australia. The aim was to describe resource use up to 28 weeks poststroke for each model and examine the cost-effectiveness of stroke care units (SCUs). Methods: A prospective, multicenter, cohort study design was used. Costs and outcomes of stroke patients receiving 100% treatment in 1 of 3 inpatient care models (SCUs, mobile service, conventional care) were compared. Health-sector resource use up to 28 weeks was measured in 1999. Outcomes were thorough adherence to a suite of important clinical processes and the number of severe inpatient complications. Results: The sample comprised 395 participants (mean age 73 [SD 14], 77% first-ever strokes, males 53%). When compared with conventional care (n=84), costs for mobile service (n=209) were significantly higher (P=0.024), but borderline for SCU (n=102, P=0.08; $AUD12 251; $AUD15 903; $AUD15 383 respectively). This was primarily explained by the greater use of specialist medical services. The incremental cost-effectiveness of SCUs over conventional care was $AUD9867 per patient achieving thorough adherence to clinical processes and $AUD16 372 per patient with severe complications avoided, based on costs to 28 weeks. Conclusions: Although acute SCU costs are generally higher, they are more cost-effective than either mobile service or conventional care.

Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy

Background: Diagnosis of patellar tendinopathy is based primarily on clinical examination; however, it is commonplace to image the patellar tendon for diagnosis confirmation, with the imaging modalities of choice being magnetic resonance imaging (MRI) and ultrasonography (US). The comparative accuracy of these modalities has not been established.

Hypothesis: Magnetic resonance imaging and US have good (>80%) accuracy and show substantial agreement in confirming clinically diagnosed patellar tendinopathy.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: Magnetic resonance imaging and US (gray scale [GS-US] and color Doppler [CD-US]) features of 30 participants with clinically diagnosed patellar tendinopathy and 33 activity-matched, asymptomatic participants were prospectively compared. Accuracy, sensitivity, specificity, positive and negative predictive values, and the likelihood of positive and negative test results were determined for each technique.

Results: The accuracy of MRI, GS-US, and CD-US was 70%, 83%, and 83%, respectively (P = .04; MRI vs GS-US). The likelihood of positive MRI, GS-US, and CD-US was 3.1, 4.8, and 11.6, respectively. The MRI and GS-US had equivalent specificity (82% vs 82%; P = 1.00); however, the sensitivity of GS-US was greater than MRI (87% vs 57%; P = .01). Sensitivity (70% vs 87%; P = .06) and specificity (94% vs 82%; P = .10) did not differ between CD-US and GS-US.

Conclusions: Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy. GS-US and CD-US may represent the best combination for confirming clinically diagnosed patellar tendinopathy because GS-US had the greatest sensitivity, while a positive CD-US test result indicated a strong likelihood an individual was symptomatic.

The evidence that exercise during growth or adulthood reduces the risk of fragility fractures is weak

There has never been, and will never be, a randomized double-blind placebo-controlled trial demonstrating that exercise in youth, adulthood or old age reduces fragility or osteoporosis-related fractures in old age. The next level of evidence, a randomized, controlled but unblinded study with fractures as an end-point is feasible but has never been done. The basis for the belief that exercise reduces fractures is derived from lower levels of ‘evidence’, namely, retrospective and prospective observation cohort studies and case–control studies. These studies are at best hypothesis generating, never hypothesis testing. They are all subject to many systematic biases and should be interpreted with extreme scepticism. Surrogate measures of anti-fracture efficacy are the next level of evidence, such as the demonstration of a reduction in risk factors for falls, a reduction in falls, a reduction in fractures due to falls, an increase in peak bone size and mass, prevention of bone loss in midlife and restoration of bone mass and structure in old age.

Improving access to evidence-based acute stroke services: development and evaluation of a health systems model to address equity of access issues

Level 1 evidence for management of patients with stroke in a dedicated Stroke Care Unit (SCU) demonstrates improved outcomes by about 20%. It has been estimated that 21% of Australian hospitals provide an SCU and that these SCUs are mainly located in either metropolitan sites and/or in hospitals with more than 300 beds. To address equity issues related to access to SCUs, the National Stroke Foundation and the Australian Government undertook the National Stroke Units Program. One program outcome was the development of a conceptual model of acute stroke service delivery. The development process and initial evaluation of the model are described. Use of the model to increase capacity within the health care system to treat stroke is discussed.

Assessing advanced life support (ALS) competence: Victorian practices

Advanced life support (ALS) assessments are performed to assess nurses’ abilities to recognize cardiac arrest events, and appropriately manage patients according to resuscitation guidelines. Although there is evidence for conducting assessments after initial ALS education, there is little evidence to guide educators about ongoing assessments in terms of methods, format and frequency.

The aim of this study was to determine methods used by educators to assess ALS skills and knowledge for nurses in Victorian intensive care units. This descriptive study used telephone interviews to collect data. Data were analysed using content analysis. Twenty intensive care educators participated in this study. Thirteen educators (65%) were employed in public hospitals, and 7 educators (35%) worked in private hospitals across 12 Level 3 (60%) and 8 Level 2 (40%) intensive care units.

Results showed all educators used scenarios to assess ALS skills, with 12 educators (60%) including an additional theoretical test. There was variability in ALS assessment frequency, assessment timing in relation to initial/ongoing education, person performing the assessment, and the assessor/participant ratio. Nineteen educators (95%) reported ALS skill competency assessments occurred annually; 1 educator (5%) reported assessments occurred every 2 years. Assessments were conducted during a designated month (n = 10), numerous times throughout the year (n = 8), or on nurses’ employment anniversaries (n = 2). All educators reported many nurses avoided undertaking assessments.

Variability in ongoing ALS assessment methods was evident in Victorian intensive care units with some units applying evidence-based practices. Consideration should be given to the purposes and methods of conducting annual ALS assessments to ensure resources and strategies are directed appropriately. To encourage nurses to retain ALS skills and knowledge, regular practices are recommended as an alternative to assessments. However, further research is required to support this notion.

Better access to mental health : mapping the evidence supporting participation in meaningful occupations

Introduction: The purpose of this scoping and mapping project is to assess evidence for the use of focused psychological strategies (FPS) under the Better Access to Mental Health (BAMH) scheme to enable people with mental health problems to increase their functional performance and to participate in meaningful occupations. In particular, it aims to provide an accessible summary of evidence for practitioners who use FPS with their clients.

Methods: Evidence scoping and mapping is a relatively new technique, used to provide an overview of key findings in an area of practice. A five stage process of scoping and mapping was used in this project.

Results: A total of 81 studies which addressed the use of focused psychological strategies to promote functional performance and participation in meaningful occupations were found. Surprisingly, only three were published in occupational therapy journals with one further article being authored by occupational therapists. Three maps are provided showing this evidence by diagnosis, intervention and level of evidence.

Conclusion: Clinicians can say with some confidence that cognitive behavioural therapies are effective functional tools, particularly when working with people with depression or schizophrenia. They can also be confident that good quality evidence exists across a range of diagnoses, although there are many gaps where little to no research has been conducted. Suggestions for further research are provided which take into account the findings of these maps.

Do renal access coordinators make a difference? What is the evidence?

Background
Since the introduction of the renal access coordinator (RAC) role into Australia there have been only anecdotal examples of associated improvements in patient outcome and service delivery and scant published quantitative extant evidence exists.

Aim
To review the literature related to the impact of RACs on dialysis patient outcomes and associated service delivery, gauge the level of evidence available and identify gaps in the literature.

Method
A three stage Joanna Briggs Institute (JBI) systematic review process was used to collect and synthesise data. The review considered studies that explored and measured the RAC role in the adult haemodialysis context. All quantitative study designs were considered. Due to lack of homogeneity a narrative synthesis was undertaken.

Results
Five studies met the inclusion criteria for the review. All studies included multidisciplinary teams with variable emphasis on the RAC role. Four pre post intervention cohort studies measured incident and/or prevalent AVF, AVG and CVC rates in the haemodialysis population and the quality assurance report measured differences in patency rates between AVF and AVG and associated hospital length of stay. All discussed the role of central coordination as a contributor to the success of vascular access care.

Conclusion
The available reports do suggest an association between RACs and improved patient outcomes. These improved patient outcomes were apparent in an increase in incident and prevalent AVFs, and a decrease in the incidence and prevalence of CVCs. Both associations are correlated with a reduction in infection rates, length of hospital stay and healthcare costs
 

Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients (review)

Background : The sedation needs of critically ill patients have been recognized as a core component of critical care and meeting these is vital to assist recovery and ensure humane treatment. There is growing evidence to suggest that sedation requirements are not always optimally managed. Sub-optimal sedation incorporates both under- and over-sedation and has been linked to both short-term (e.g. length of stay) and long-term (e.g. psychological recovery) outcomes. Various strategies have been proposed to improve sedation management and address aspects of assessment as well as delivery of sedation.

Objectives : To assess the effects of protocol-directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit (ICU) patients. We looked at various outcomes and examined the role of bias in order to examine the level of evidence for this intervention.

Search methods : We searched the Cochrane Central Register of Controlled trials (CENTRAL) (2013; Issue 11), MEDLINE (OvidSP) (1990 to November 2013), EMBASE (OvidSP) (1990 to November 2013), CINAHL (BIREME host) (1990 to November 2013), Database of Abstracts of Reviews of Effects (DARE) (1990 to November 2013), LILACS (1990 to November 2013), Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990 to November 2013), and reference lists of articles. We re-ran the search in October 2014. We will deal with any studies of interest when we update the review.

Selection criteria : We included randomized controlled trials (RCTs) conducted in adult ICUs comparing management with and without protocol-directed sedation.

Data collection and analysis : Two authors screened the titles and abstracts and then the full-text reports identified from our electronic search. We assessed seven domains of potential risk of bias for the included studies. We examined the clinical, methodological and statistical heterogeneity and used the random-effects model for meta-analysis where we considered it appropriate. We calculated the mean difference (MD) for duration of mechanical ventilation and risk ratio (RR) for mortality across studies, with 95% confidence intervals (CI).

Main results : We identified two eligible studies with 633 participants. Both included studies compared the use of protocol-directed sedation, specifically protocols delivered by nurses, with usual care. We rated the risk of selection bias due to random sequence generation low for one study and unclear for one study. The risk of selection bias related to allocation concealment was low for both studies. We also assessed detection and attrition bias as low for both studies while we considered performance bias high due to the inability to blind participants and clinicians in both studies. Risk due to other sources of bias, such as potential for contamination between groups and reporting bias, was considered unclear. There was no clear evidence of differences in duration of mechanical ventilation (MD -5.74 hours, 95% CI -62.01 to 50.53, low quality evidence), ICU length of stay (MD -0.62 days, 95% CI -2.97 to 1.73) and hospital length of stay (MD -3.78 days, 95% CI -8.54 to 0.97) between people being managed with protocol-directed sedation versus usual care. Similarly, there was no clear evidence of difference in hospital mortality between the two groups (RR 0.96, 95% CI 0.71 to 1.31, low quality evidence). ICU mortality was only reported in one study preventing pooling of data. There was no clear evidence of difference in the incidence of tracheostomy (RR 0.77, 95% CI 0.31 to 1.89). The studies reported few adverse event outcomes; one study reported self extubation while the other study reported re-intubation; given this difference in outcomes, pooling of data was not possible. There was significant heterogeneity between studies for duration of mechanical ventilation (I2 = 86%, P value = 0.008), ICU length of stay (I2 = 82%, P value = 0.02) and incidence of tracheostomy (I2 = 76%, P value = 0.04), with one study finding a reduction in duration of mechanical ventilation and incidence of tracheostomy and the other study finding no difference.

Authors' conclusions : There is currently insufficient evidence to evaluate the effectiveness of protocol-directed sedation. Results from the two RCTs were conflicting, resulting in the quality of the body of evidence as a whole being assessed as low. Further studies, taking into account contextual and clinician characteristics in different ICU environments, are necessary to inform future practice. Methodological strategies to reduce the risk of bias need to be considered in future studies.

Do surgeons treat their patients like they would treat themselves?

Background - There is substantial unexplained geographical and surgeon-to-surgeon variation in rates of surgery. One would expect surgeons to treat patients and themselves similarly based on best evidence and accounting for patient preferences.

Questions/purposes - (1) Are surgeons more likely to recommend surgery when choosing for a patient than for themselves? (2) Are surgeons less confident in deciding for patients than for themselves?

Methods - Two hundred fifty-four (32%) of 790 Science of Variation Group (SOVG) members reviewed 21 fictional upper extremity cases (eg, distal radius fracture, De Quervain tendinopathy) for which surgery is optional answering two questions: (1) What treatment would you choose/recommend: operative or nonoperative? (2) On a scale from 0 to 10, how confident are you about this decision? Confidence is the degree that one believes that his or her decision is the right one (ie, most appropriate). Participants were orthopaedic, trauma, and plastic surgeons, all with an interest in treating upper extremity conditions. Half of the participants were randomized to choose for themselves if they had this injury or illness. The other half was randomized to make treatment recommendations for a patient of their age and gender. For the choice of operative or nonoperative, the overall recommendation for treatment was expressed as a surgery score per surgeon by dividing the number of cases they would operate on by the total number of cases (n = 21), where 100% is when every surgeon recommended surgery for every case. For confidence, we calculated the mean confidence for all 21 cases per surgeon; overall score ranges from 0 to 10 with a higher score indicating more confidence in the decision for treatment.

Results - Surgeons were more likely to recommend surgery for a patient (44.2% ± 14.0%) than they were to choose surgery for themselves (38.5% ± 15.4%) with a mean difference of 6% (95% confidence interval [CI], 2.1%–9.4%; p = 0.002). Surgeons were more confident in deciding for themselves than they were for a patient of similar age and gender (self: 7.9 ± 1.0, patient: 7.5 ± 1.2, mean difference: 0.35 [CI, 0.075–0.62], p = 0.012).

Conclusions - Surgeons are slightly more likely to recommend surgery for a patient than they are to choose surgery for themselves and they choose for themselves with a little more confidence. Different perspectives, preferences, circumstantial information, and cognitive biases might explain the observed differences. This emphasizes the importance of (1) understanding patients’ preferences and their considerations for treatment; (2) being aware that surgeons and patients might weigh various factors differently; (3) giving patients more autonomy by letting them balance risks and benefits themselves (ie, shared decision-making); and (4) assessing how dispassionate evidence-based decision aids help inform the patient and influences their decisional conflict.

Level of Evidence - Level III, diagnostic study.

Acumulação tecnológica e aprimoramento de performance competitiva: evidências de diferenças e similaridades e médias empresas do setor metal-mecânico no estado do rio de janeiro

The main objective of this dissertation is to examine the implications of technological capacities in the improvement of technical performance indexes, specifically at the company level. These relationships were examined in a small sample of metal-working enterprises in the state of Rio de Janeiro (1960 to 2006). Although diverse studies on technological competences have been carried out in the last twenty years, a gap in empirical studies still exist that correlate the performance of companies in the context of developing countries, especially in Brazil. Aiming to contribute to a reduction of these gaps, this dissertation examines the questions by the light of available models in literature, which opting themselves to using operational indexes of companies. For drawing the accumulation of technological competences in this study, the metric proposal by Figueiredo (2000) shall be used indicating the levels of technological qualification in process, product, and equipment functions. The empirical evidence examined in this dissertation is both qualitative and quantitative in nature and were collected, first hand, through extensive field research involving informal interviews, meetings, direct-site observation and document analysis. In relation to the results, the evidence suggests that: - In terms of technological accumulation, a company reached Level 5 of technological capacity in process and organization of production as well as product and equipment. Three companies obtained Level 4 in the function process function while two others had reached the same technological level in the functions of product and equipment. Two companies had reached Level 3 in the product and equipment functions and one remained this level in the function of process; - In terms of the rate of accumulation of technological capacities, the observed companies had reached Level 4 needs 29 years in process function, 32 years in product function and 29 years in equipment function; - In terms of improvement performance pointers, a company which reached Level 5 of technological capacity improved in 70% of its indicators of performance, while the company that had achieved Level 4 had raised its pointers 60% and the other companies had gotten improved in the order of 40%. It was evidenced that the majority of the pointers of the companies with higher levels of technological capacities had obtained better performance. This dissertation contributes to advancing the strategic management of companies in metal-working segment to understanding internal accumulation of technological capacity and indicators of performance especially in the field of empirical context studied. This information offers management examples of how to improve competitive performance through the accumulation of technological capacities in the process, product and equipment functions.

Co-evolução dos componentes do marco institucional e das trajetórias de acumulação de capacidades tecnológicas no setor de agro-energia (etanol) no Brasil (1970-2009)

Esta dissertação centra-se no exame da evolução dos componentes do marco institucional em associação com as trajetórias de acumulação de capacidades tecnológicas de produção e inovação em setores à base de recursos naturais em economias emergentes. Esse relacionamento é examinado no setor de etanol brasileiro, no período entre 1970 e 2009. O marco institucional é operacionalizado à base das macro-instituições (os regimes complexos constituídos por políticas públicas), meso-instituições (as relações políticas e estruturas burocráticas) e as instituições baseadas em conhecimento (os institutos de pesquisa e as universidades). As trajetórias de acumulação de capacidades tecnológicas são examinadas à base de níveis de inovação. A dissertação baseia-se em um estudo de caso em nível setorial. Além disso, o estudo baseia-se em evidências obtidas a partir de fontes diversas, em nível de indústria, em documentos governamentais e também em evidências secundárias em nível de empresa. Os principais resultados desta dissertação são os seguintes: (1) O setor de etanol atingiu níveis inovadores de capacidade tecnológica nas duas funções analisadas. Numa escala de 1 a 5, o setor adquiriu, durante o 1º período (1970-1989), capacidades tecnológicas industriais (produto e processo) no Nível 3 e, durante o 2º período (1990-2009), o setor de etanol acumulou capacidades tecnológicas industriais no Nível 5. No tocante à acumulação de capacidades tecnológicas na área agrícola (matéria-prima), durante o 1º período, o setor adquiriu capacidades tecnológicas no Nível 4 e apenas no período seguinte atingiu o Nível 5. (2) As instituições desempenharam um papel relevante sobre as trajetórias de acumulação de capacidades tecnológicas no setor de etanol brasileiro. Entre elas destaca-se às atividades de P&D desenvolvidas em instituições baseadas em conhecimento, que acumularam capacidades tecnológicas de produção e inovação, compartilhadas com as empresas. (3) Entretanto, o estudo aponta para algumas vulnerabilidades do setor de etanol brasileiro no que se refere a sua capacidade de sustentar o seu desempenho inovador. Entre elas destaca-se: (1) grande parte das atividades inovadoras em nível de P&D é realizada a base de arranjos externos, com pouco esforço de atividades realizadas a partir das empresas; (2) apesar do enorme esforço governamental para desenvolver o setor, esse está direcionado (locked-in) à trajetória de acumulação de capacidades tecnológicas de etanol de 1ª geração; (3) os componentes do marco institucional incentivaram as atividades de pesquisa em universidades e institutos de pesquisa, em nível de bancada, que resultaram em invenções e projetos experimentais; (4) as condições favoráveis de mercado, a grande disponibilidade de cana-de-açúcar e a flexibilidade de produção de etanol/álcool contribuíram para a acomodação do setor de etanol, ou seja, parece haver uma zona de conforto no setor. Desta forma, as evidências alertam sobre a necessidade de investimentos em atividades inovadoras de P&D dentro das empresas (foco em inovações, riqueza e na diversificação para outros setores). Portanto, os resultados desta dissertação permitem apontar sugestões para gestores governamentais. As novas políticas públicas podem: (1) redirecionar as estratégias de acumulação de capacidades tecnológicas inovadoras, fortemente focadas na sustentação das trajetórias de acumulação de capacidades tecnológicas para produzir etanol de 1ª geração; (2) impulsionar a acumulação de capacidades tecnológicas de produção e inovação na trajetória emergente para produzir etanol de 2ª geração, atualmente em nível experimental e largamente desenvolvida dentro das instituições baseadas em conhecimento, e para diversificar os produtos para novos setores e linhas de negócio. Os resultados desta dissertação também sugerem aos gestores de empresas no setor brasileiro de etanol: (1) reformular as estratégias empresariais com a finalidade de expandir as atividades inovadoras dentro das empresas do setor de etanol, que poderão resultar na criação de inovações em escala industrial; (2) as empresas do setor de etanol deveriam assumir um comportamento proativo com a finalidade de coordenar os esforços de P&D em direção aos problemas e desafios futuros a serem enfrentados pelo setor brasileiro de etanol.

Processo alternativo de catch-up em indústrias intensivas em recursos naturais: uma análise empírica da trajetória tecnológica da indústria de bioetanol de cana-de-açúcar no Brasil

Esta tese diz respeito ao desenvolvimento tecnológico e inovação em indústrias intensivas em recursos naturais no contexto de economias emergentes. A tese explora como a acumulação de capacidades tecnológicas e os mecanismos de aprendizagem influenciaram a trajetória tecnológica na indústria de bioetanol de cana-de-açúcar no Brasil, durante o período de meados da década de 1970 a 2014. Muito se avançou na compreensão do processo de catch-up tecnológico de empresas e indústrias de economias emergentes. Contudo, essas pesquisas geralmente exploram o processo de catch-up tecnológico relacionado às trajetórias tecnológicas já mapeadas pelos líderes mundiais em indústrias de manufatura e transformação. Parte desses estudos ignora que o desenvolvimento de atividades industriais poderia ocorrer em indústrias intensivas em recursos naturais. Além disso, indústrias intensivas em recursos naturais são geralmente encapsuladas como commodities e low-tech, caracterizadas por uma limitada oportunidade de aprendizagem tecnológica e acumulação de capacidades tecnológicas. Entretanto, o processo de industrialização em indústrias intensivas em recursos naturais em regiões como a América Latina ainda é pouco compreendido e são escassas as pesquisas que investigam o processo de catch-up tecnológico em nível de indústria, com raras exceções. Baseando-se em evidências da indústria de bioetanol do Brasil, esta pesquisa explora um processo de catch-up tecnológico que tem recebido pouca atenção na literatura. Esta pesquisa adotou um desenho qualitativo com base em uma estratégia de estudo de caso em nível de indústria, com extensivo trabalho de campo e coleta de evidências empíricas de primeira mão com cobertura de longo prazo em 20 organizações. Esta pesquisa encontrou que: (1) a evolução da trajetória tecnológica da indústria de bioetanol no Brasil caracterizou-se pela abertura de uma direção distinta daquela mapeada por líderes tecnológicos existentes. Esse processo de desvio qualitativo da trajetória tecnológica dominante iniciou durante os primeiros estágios de desenvolvimento tecnológico. Assim, a indústria percorreu uma trajetória de entrada precoce em path-creating; (2) a evolução dessa trajetória tecnológica não se deu de maneira homogenia. Foram encontrados três padrões relativamente distintos de acumulação de capacidades tecnológicas para funções (ou áreas) tecnológicas específicas: feedstock, processos agrícolas e processos industriais. Nas funções de feedstock e processos industriais, houve acumulação de capacidades tecnológicas de liderança mundial, enquanto na função processos agrícolas a acumulação de capacidades tecnológicas não evoluiu além do nível intermediário; (3) essas capacidades foram acumuladas de forma dispersa entre os atores da indústria (empresas produtoras, institutos de pesquisa, universidades, fornecedores, empresas de biotecnologia etc.) e possibilitaram a abertura de oportunidades de exploração de novos negócios, ainda que modestamente aproveitadas; e (4) a sutil heterogeneidade encontrada nos padrões de acumulação de capacidades tecnológicas foi influenciada pela combinação de mecanismos de aprendizagem tecnológica utilizados pela indústria ao longo do tempo. Por fim, constatou-se também que essa trajetória tecnológica contribuiu para gerar implicações significativas e foi também influenciada por fatores outros. Não obstante, esses resultados merecem esforço de investigação mais sistemático, uma vez que foram examinados aqui de forma superficial. Concluiu-se, portanto, que posições tecnológicas relevantes, especialmente por indústrias de economias emergentes, podem ser alcançadas por meio de trajetórias tecnológicas que não se baseiam, necessariamente, em tecnologias dominantes, já exploradas por líderes mundiais, de economias avançadas. Assim, os processos alternativos de catch-up podem ser altamente relevantes para a obtenção de progresso industrial. Ademais, a pesquisa concluiu que as indústrias intensivas em recursos naturais oferecem oportunidades para inovações significativas, e podem ser protagonistas nesse processo de catch-up alternativo, particularmente no contexto de países abundantes em recursos naturais. Assim sendo, esta pesquisa contribui para gerar novas evidências e explicações que nos ajudem a ampliar a noção de alternativas para o desenvolvimento industrial e econômico no contexto de economias emergentes. No debate sobre desenvolvimento industrial e econômico, as trajetórias tecnológicas alternativas, bem como as indústrias intensivas em recursos naturais, deveriam receber uma atenção especial por parte de decisores de políticas públicas e de ações empresariais.

Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies

PURPOSE: To evaluate the efficacy of surgical treatment for esophageal perforation. METHODS: A systematic review of the literature was performed. We conducted a search strategy in the main electronic databases such as PubMed, Embase and Lilacs to identify all case series. RESULTS: Thirty three case series met the inclusion criteria with a total of 1417 participants. The predominant etiology was iatrogenic (54.2%) followed by spontaneous cause (20.4%) and in 66.1% the localization was thoracic. In 65.4% and 33.4% surgical and conservative therapy, respectively, was considered the first choice. There was a statistically significance different with regards mortality rate favoring the surgical group (16.3%) versus conservative treatment (21.2%) (p<0.05). CONCLUSION: Surgical treatment was more effective and safe than conservative treatment concerning mortality rates, although the possibility of bias due to clinical and methodological heterogeneity among the included studies and the level of evidence that cannot be ruled out.

Efeitos do ultra-som terapêutico sobre o crescimento longitudinal do fêmur e da tíbia em ratos

Objectives: To determine the effects of ultrasound therapy on the femur and tibia growth in young rats. Method: Four-week-old male Ratus Norvegicus totaling 115 animals, divided into four groups, were submitted to ultrasound therapy (0.8 MHz, fixed tube head, continuous pulse, for 10 minutes, once a day, ten times) on the medial face of the right knee, with powers of 0.0 W/cm2 (group 31), 0.5 W/cm2 (group G2), 1.0 W/cm2 (group G3), and 1.5 W/cm2 (group G4). Histological slides of the epiphysis, growth plate and metaphysis and the femoral and tibial length measurements were studied in the sixth, thirteenth and twenty-sixth weeks of life. The data were submitted to factorial analysis of variance according to a one-way layout. Results: No statistically significant bone growth alteration was established between any of the three treated groups and the control group. However, alterations in femoral and tibial growth suggesting a decrease in G4 in relation to 02 and G3 were noted. In G4, histopathological alterations, such as cellular necrosis and post-necrosis bone neoformation were found. Conclusion: According to this study, no statistical evidence of bone growth stimulus or inhibition resulting from the application of ultrasound therapy was found when comparing the treated groups with the control group. Histological alterations regarded as pathological were only observed in G4. Also, smaller significant bone growth was found in G4 compared to G2 and G3. Level of Evidence: Level II, cross-sectional study.