Moving beyond transition outcomes: meta-analysis of remission rates in individuals at high clinical risk for psychosis

Recent evidence suggests that transition risks from initial clinical high risk (CHR) status to psychosis are decreasing. The role played by remission in this context is mostly unknown. The present study addresses this issue by means of a meta-analysis including eight relevant studies published up to January 2012 that reported remission rates from an initial CHR status. The primary effect size measure was the longitudinal proportion of remissions compared to non-remission in subjects with a baseline CHR state. Random effect models were employed to address the high heterogeneity across studies included. To assess the robustness of the results, we performed sensitivity analyses by sequentially removing each study and rerunning the analysis. Of 773 subjects who met initial CHR criteria, 73% did not convert to psychosis along a 2-year follow. Of these, about 46% fully remitted from the baseline attenuated psychotic symptoms, as evaluated on the psychometric measures usually employed by prodromal services. The corresponding clinical remission was estimated as high as 35% of the baseline CHR sample. The CHR state is associated with a significant proportion of remitting subjects that can be accounted by the effective treatments received, a lead time bias, a dilution effect, a comorbid effect of other psychiatric diagnoses.

Estimating Diagnostic Test Accuracies for Brachyspira hyodysenteriae Accounting for the Complexities of Population Structure in Food Animals

For swine dysentery, which is caused by Brachyspira hyodysenteriae infection and is an economically important disease in intensive pig production systems worldwide, a perfect or error-free diagnostic test ("gold standard") is not available. In the absence of a gold standard, Bayesian latent class modelling is a well-established methodology for robust diagnostic test evaluation. In contrast to risk factor studies in food animals, where adjustment for within group correlations is both usual and required for good statistical practice, diagnostic test evaluation studies rarely take such clustering aspects into account, which can result in misleading results. The aim of the present study was to estimate test accuracies of a PCR originally designed for use as a confirmatory test, displaying a high diagnostic specificity, and cultural examination for B. hyodysenteriae. This estimation was conducted based on results of 239 samples from 103 herds originating from routine diagnostic sampling. Using Bayesian latent class modelling comprising of a hierarchical beta-binomial approach (which allowed prevalence across individual herds to vary as herd level random effect), robust estimates for the sensitivities of PCR and culture, as well as for the specificity of PCR, were obtained. The estimated diagnostic sensitivity of PCR (95% CI) and culture were 73.2% (62.3; 82.9) and 88.6% (74.9; 99.3), respectively. The estimated specificity of the PCR was 96.2% (90.9; 99.8). For test evaluation studies, a Bayesian latent class approach is well suited for addressing the considerable complexities of population structure in food animals.

Determinants of antithrombotic choice for patent foramen ovale in cryptogenic stroke

Objective: We examined the influence of clinical, radiologic, and echocardiographic characteristics on antithrombotic choice in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), hypothesizing that features suggestive of paradoxical embolism might lead to greater use of anticoagulation. Methods: The Risk of Paradoxical Embolism Study combined 12 databases to create the largest dataset of patients with CS and known PFO status. We used generalized linear mixed models with a random effect of component study to explore whether anticoagulation was preferentially selected based on the following: (1) younger age and absence of vascular risk factors, (2) “high-risk” echocardiographic features, and (3) neuroradiologic findings. Results: A total of 1,132 patients with CS and PFO treated with anticoagulation or antiplatelets were included. Overall, 438 participants (39%) were treated with anticoagulation with a range (by database) of 22% to 54%. Treatment choice was not influenced by age or vascular risk factors. However, neuroradiologic findings (superficial or multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, and septal hypermobility) were predictors of anticoagulation use. Conclusion: Both antithrombotic regimens are widely used for secondary stroke prevention in patients with CS and PFO. Radiologic and echocardiographic features were strongly associated with treatment choice, whereas conventional vascular risk factors were not. Prior observational studies are likely to be biased by confounding by indication.

Aspiration Thrombectomy for Treatment of ST-segment Elevation Myocardial Infarction: a Meta-analysis of 26 Randomized Trials in 11 943 Patients.

INTRODUCTION AND OBJECTIVES There is continued debate about the routine use of aspiration thrombectomy in patients with ST-segment elevation myocardial infarction. Our aim was to evaluate clinical and procedural outcomes of aspiration thrombectomy-assisted primary percutaneous coronary intervention compared with conventional primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. METHODS We performed a meta-analysis of 26 randomized controlled trials with a total of 11 943 patients. Clinical outcomes were extracted up to maximum follow-up and random effect models were used to assess differences in outcomes. RESULTS We observed no difference in the risk of all-cause death (pooled risk ratio = 0.88; 95% confidence interval, 0.74-1.04; P = .124), reinfarction (pooled risk ratio = 0.85; 95% confidence interval, 0.67-1.08; P = .176), target vessel revascularization (pooled risk ratio = 0.86; 95% confidence interval, 0.73-1.00; P = .052), or definite stent thrombosis (pooled risk ratio = 0.76; 95% confidence interval, 0.49-1.16; P = .202) between the 2 groups at a mean weighted follow-up time of 10.4 months. There were significant reductions in failure to reach Thrombolysis In Myocardial Infarction 3 flow (pooled risk ratio = 0.70; 95% confidence interval, 0.60-0.81; P < .001) or myocardial blush grade 3 (pooled risk ratio = 0.76; 95% confidence interval, 0.65-0.89; P = .001), incomplete ST-segment resolution (pooled risk ratio = 0.72; 95% confidence interval, 0.62-0.84; P < .001), and evidence of distal embolization (pooled risk ratio = 0.61; 95% confidence interval, 0.46-0.81; P = .001) with aspiration thrombectomy but estimates were heterogeneous between trials. CONCLUSIONS Among unselected patients with ST-segment elevation myocardial infarction, aspiration thrombectomy-assisted primary percutaneous coronary intervention does not improve clinical outcomes, despite improved epicardial and myocardial parameters of reperfusion. Full English text available from:www.revespcardiol.org/en.

Irrational Beliefs and Psychological Distress: A Meta-Analysis

Background: Since the cognitive revolution of the early 1950s, cognitions have been discussed as central components in the understanding and treatment of mental illnesses. Even though there is an extensive literature on the association between therapy-related cognitions such as irrational beliefs and psychological distress over the past 60 years, there is little meta-analytical knowledge about the nature of this association. Methods: The relationship between irrational beliefs and distress was examined based on a systematic review that included 100 independent samples, gathered in 83 primary studies, using a random-effect model. The overall effects as well as potential moderators were examined: (a) distress measure, (b) irrational belief measure, (c) irrational belief type, (d) method of assessment of distress, (e) nature of irrational beliefs, (f) time lag between irrational beliefs and distress assessment, (g) nature of stressful events, (h) sample characteristics (i.e. age, gender, income, and educational, marital, occupational and clinical status), (i) developer/validator status of the author(s), and (k) publication year and country. Results: Overall, irrational beliefs were positively associated with various types of distress, such as general distress, anxiety, depression, anger, and guilt (omnibus: r = 0.38). The following variables were significant moderators of the relationship between the intensity of irrational beliefs and the level of distress: irrational belief measure and type, stressful event, age, educational and clinical status, and developer/validator status of the author. Conclusions: Irrational beliefs and distress are moderately connected to each other; this relationship remains significant even after controlling for several potential covariates.

Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis.

BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are the backbone of osteoarthritis pain management. We aimed to assess the effectiveness of different preparations and doses of NSAIDs on osteoarthritis pain in a network meta-analysis. METHODS For this network meta-analysis, we considered randomised trials comparing any of the following interventions: NSAIDs, paracetamol, or placebo, for the treatment of osteoarthritis pain. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the reference lists of relevant articles for trials published between Jan 1, 1980, and Feb 24, 2015, with at least 100 patients per group. The prespecified primary and secondary outcomes were pain and physical function, and were extracted in duplicate for up to seven timepoints after the start of treatment. We used an extension of multivariable Bayesian random effects models for mixed multiple treatment comparisons with a random effect at the level of trials. For the primary analysis, a random walk of first order was used to account for multiple follow-up outcome data within a trial. Preparations that used different total daily dose were considered separately in the analysis. To assess a potential dose-response relation, we used preparation-specific covariates assuming linearity on log relative dose. FINDINGS We identified 8973 manuscripts from our search, of which 74 randomised trials with a total of 58 556 patients were included in this analysis. 23 nodes concerning seven different NSAIDs or paracetamol with specific daily dose of administration or placebo were considered. All preparations, irrespective of dose, improved point estimates of pain symptoms when compared with placebo. For six interventions (diclofenac 150 mg/day, etoricoxib 30 mg/day, 60 mg/day, and 90 mg/day, and rofecoxib 25 mg/day and 50 mg/day), the probability that the difference to placebo is at or below a prespecified minimum clinically important effect for pain reduction (effect size [ES] -0·37) was at least 95%. Among maximally approved daily doses, diclofenac 150 mg/day (ES -0·57, 95% credibility interval [CrI] -0·69 to -0·46) and etoricoxib 60 mg/day (ES -0·58, -0·73 to -0·43) had the highest probability to be the best intervention, both with 100% probability to reach the minimum clinically important difference. Treatment effects increased as drug dose increased, but corresponding tests for a linear dose effect were significant only for celecoxib (p=0·030), diclofenac (p=0·031), and naproxen (p=0·026). We found no evidence that treatment effects varied over the duration of treatment. Model fit was good, and between-trial heterogeneity and inconsistency were low in all analyses. All trials were deemed to have a low risk of bias for blinding of patients. Effect estimates did not change in sensitivity analyses with two additional statistical models and accounting for methodological quality criteria in meta-regression analysis. INTERPRETATION On the basis of the available data, we see no role for single-agent paracetamol for the treatment of patients with osteoarthritis irrespective of dose. We provide sound evidence that diclofenac 150 mg/day is the most effective NSAID available at present, in terms of improving both pain and function. Nevertheless, in view of the safety profile of these drugs, physicians need to consider our results together with all known safety information when selecting the preparation and dose for individual patients. FUNDING Swiss National Science Foundation (grant number 405340-104762) and Arco Foundation, Switzerland.

Now You See it, Now You Don't: Why Do Real Estate Agents Withhold Available Houses from Black Customers?

Potential home buyers may initiate contact with a real estate agent by asking to see a particular advertised house. This paper asks whether an agent's response to such a request depends on the race of the potential buyer or on whether the house is located in an integrated neighborhood. We build on previous research about the causes of discrimination in housing by using data from fair housing audits, a matched-pair technique for comparing the treatment of equllay qualified black and white home buyers. However, we shift the focus from differences in the treatment of paired buyers to agent decisions concerning an individual housing unit using a sample of all houses seen during he 1989 Housing Discrimination study. We estimate a random effect, multinomial logit model to explain a real estate agent's joint decisions concerning whether to show each unit to a black auditor and to a white auditor. We find evidence that agents withhold houses in suburban, integrated neighborhoods from all customers (redlining), that agents' decisions to show houses in integrated neighborhoods are not the same for black and white customers (steering), and that the houses agents show are more likely to deviate from the initial request when the customeris black than when the customer is white. These deviations are consistent with the possibility that agents act upon the belief that some types of transactions are relatively unlikely for black customers (statistical discrimination).

Bayesian joint modeling of longitudinal and survival data

The joint modeling of longitudinal and survival data is a new approach to many applications such as HIV, cancer vaccine trials and quality of life studies. There are recent developments of the methodologies with respect to each of the components of the joint model as well as statistical processes that link them together. Among these, second order polynomial random effect models and linear mixed effects models are the most commonly used for the longitudinal trajectory function. In this study, we first relax the parametric constraints for polynomial random effect models by using Dirichlet process priors, then three longitudinal markers rather than only one marker are considered in one joint model. Second, we use a linear mixed effect model for the longitudinal process in a joint model analyzing the three markers. In this research these methods were applied to the Primary Biliary Cirrhosis sequential data, which were collected from a clinical trial of primary biliary cirrhosis (PBC) of the liver. This trial was conducted between 1974 and 1984 at the Mayo Clinic. The effects of three longitudinal markers (1) Total Serum Bilirubin, (2) Serum Albumin and (3) Serum Glutamic-Oxaloacetic transaminase (SGOT) on patients' survival were investigated. Proportion of treatment effect will also be studied using the proposed joint modeling approaches. ^ Based on the results, we conclude that the proposed modeling approaches yield better fit to the data and give less biased parameter estimates for these trajectory functions than previous methods. Model fit is also improved after considering three longitudinal markers instead of one marker only. The results from analysis of proportion of treatment effects from these joint models indicate same conclusion as that from the final model of Fleming and Harrington (1991), which is Bilirubin and Albumin together has stronger impact in predicting patients' survival and as a surrogate endpoints for treatment. ^

Simulation study of joint transition and Weibull survival model with shared parameters

This study investigates a theoretical model where a longitudinal process, that is a stationary Markov-Chain, and a Weibull survival process share a bivariate random effect. Furthermore, a Quality-of-Life adjusted survival is calculated as the weighted sum of survival time. Theoretical values of population mean adjusted survival of the described model are computed numerically. The parameters of the bivariate random effect do significantly affect theoretical values of population mean. Maximum-Likelihood and Bayesian methods are applied on simulated data to estimate the model parameters. Based on the parameter estimates, predicated population mean adjusted survival can then be calculated numerically and compared with the theoretical values. Bayesian method and Maximum-Likelihood method provide parameter estimations and population mean prediction with comparable accuracy; however Bayesian method suffers from poor convergence due to autocorrelation and inter-variable correlation. ^

Impact of hormonal therapy on survival and racial disparities in a large community-based cohort of older men with local/regional prostate cancer

Prostate cancer (CaP) is the most diagnosed non-cutaneous malignancy and the second leading cause of cancer mortality among United States males. Major racial disparities in incidence, survival, as well as treatment persist. The mortality is three times higher among African Americans (AAs) compared with Caucasians. Androgen carcinogenesis has been persistently implicated but results are inconsistent; and hormone manipulation has been the main stay of treatment for metastatic disease, supportive of the androgen carcinogenesis. The survival disadvantage of AAs has been attributed to the differences in socioeconomic factors (SES), tumor stage, and treatment. We hypostasized that HT prolongs survival in CaP and that the racial disparities in survival is influenced by variation in HT and primary therapies as well as SES. To address these overall hypothesis, we first utilized a random-effect meta-analytic design to examine evidence from randomized trials on the efficacy of androgen deprivation therapy in localized and metastatic disease, and assessed, using Cox proportional hazards models, the effectiveness of HT in prolonging survival in a large community-based cohort of older males diagnosed with local/regional CaP. Further we examined the role of HT and primary therapies on the racial disparities in CaP survival. The results indicated that adjuvant HT compared with standard care alone is efficacious in improving overall survival, whereas HT has no significant benefit in the real world experience in increasing the overall survival of older males in the community treated for local/regional disease. Further, racial differences in survival persist and were explained to some extent by the differences in the primary therapies (radical prostatectomy, radiation and watchful waiting) and largely by SES. Therefore, given the increased used of hormonal therapy and the cost-effectiveness today, more RCTs are needed to assess whether or not survival prolongation translates to improved quality of life, and to answer the research question on whether or not the decreased use of radical prostatectomy by AAs is driven by the Clinicians bias or AAs's preference of conservative therapy and to encourage AAs to seek curative therapies, thus narrowing to some degree the persistent mortality disparities between AAs and Caucasians. ^

The determinants of improvements in health outcomes and of cost reduction in hospital inpatient care

This study aims to address two research questions. First, ‘Can we identify factors that are determinants both of improved health outcomes and of reduced costs for hospitalized patients with one of six common diagnoses?’ Second, ‘Can we identify other factors that are determinants of improved health outcomes for such hospitalized patients but which are not associated with costs?’ The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database from 2003 to 2006 was employed in this study. The total study sample consisted of hospitals which had at least 30 patients each year for the given diagnosis: 954 hospitals for acute myocardial infarction (AMI), 1552 hospitals for congestive heart failure (CHF), 1120 hospitals for stroke (STR), 1283 hospitals for gastrointestinal hemorrhage (GIH), 979 hospitals for hip fracture (HIP), and 1716 hospitals for pneumonia (PNE). This study used simultaneous equations models to investigate the determinants of improvement in health outcomes and of cost reduction in hospital inpatient care for these six common diagnoses. In addition, the study used instrumental variables and two-stage least squares random effect model for unbalanced panel data estimation. The study concluded that a few factors were determinants of high quality and low cost. Specifically, high specialty was the determinant of high quality and low costs for CHF patients; small hospital size was the determinant of high quality and low costs for AMI patients. Furthermore, CHF patients who were treated in Midwest, South, and West region hospitals had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. Gastrointestinal hemorrhage and pneumonia patients who were treated in South region hospitals also had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. This study found that six non-cost factors were related to health outcomes for a few diagnoses: hospital volume, percentage emergency room admissions for a given diagnosis, hospital competition, specialty, bed size, and hospital region.^

Statistical issues on studies of mixed longitudinal design

Mixed longitudinal designs are important study designs for many areas of medical research. Mixed longitudinal studies have several advantages over cross-sectional or pure longitudinal studies, including shorter study completion time and ability to separate time and age effects, thus are an attractive choice. Statistical methodology used in general longitudinal studies has been rapidly developing within the last few decades. Common approaches for statistical modeling in studies with mixed longitudinal designs have been the linear mixed-effects model incorporating an age or time effect. The general linear mixed-effects model is considered an appropriate choice to analyze repeated measurements data in longitudinal studies. However, common use of linear mixed-effects model on mixed longitudinal studies often incorporates age as the only random-effect but fails to take into consideration the cohort effect in conducting statistical inferences on age-related trajectories of outcome measurements. We believe special attention should be paid to cohort effects when analyzing data in mixed longitudinal designs with multiple overlapping cohorts. Thus, this has become an important statistical issue to address. ^ This research aims to address statistical issues related to mixed longitudinal studies. The proposed study examined the existing statistical analysis methods for the mixed longitudinal designs and developed an alternative analytic method to incorporate effects from multiple overlapping cohorts as well as from different aged subjects. The proposed study used simulation to evaluate the performance of the proposed analytic method by comparing it with the commonly-used model. Finally, the study applied the proposed analytic method to the data collected by an existing study Project HeartBeat!, which had been evaluated using traditional analytic techniques. Project HeartBeat! is a longitudinal study of cardiovascular disease (CVD) risk factors in childhood and adolescence using a mixed longitudinal design. The proposed model was used to evaluate four blood lipids adjusting for age, gender, race/ethnicity, and endocrine hormones. The result of this dissertation suggest the proposed analytic model could be a more flexible and reliable choice than the traditional model in terms of fitting data to provide more accurate estimates in mixed longitudinal studies. Conceptually, the proposed model described in this study has useful features, including consideration of effects from multiple overlapping cohorts, and is an attractive approach for analyzing data in mixed longitudinal design studies.^

Efeito da suplementação prolongada de grão de soja cru e integral no pré-parto sobre o desempenho produtivo, qualidade oocitária e embrionária, e função imune de vacas leiteiras

Objetivou-se avaliar o efeito da suplementação prolongada de grão de soja cru e integral (GSI) como fonte de ácido graxo Ω6 sobre o desempenho produtivo, perfil metabólico, qualidade oocitária e embrionária e função imune de vacas leiteiras no período de transição e início de lactação. Foram selecionadas 44 vacas da raça Holandesa, multíparas e gestantes, com parto previsto para 90 dias após o início da avaliação e fornecimento das dietas experimentais, porém em razão da ocorrência de enfermidades metabólicas ou infecciosas (3 abortos; 3 deslocamentos de abomaso; 3 enfermidades podais; 4 distocias) 13 animais foram retirados do experimento. As vacas foram distribuídas aleatoriamente em quatro grupos experimentais diferindo entre eles o início do fornecimento de grão de soja cru e integral (GSI) durante o pré-parto. A dieta era baseada na inclusão de 12% de GSI %MS, com aproximadamente 5,1% de extrato etéreo (EE) o início de seu fornecimento foi conforme descrito a seguir: Grupo 0: Animais não receberam dieta contendo GSI no pré-parto; Grupo 30: Início do fornecimento de dieta com GSI nos 30 dias finais da gestação; Grupo 60: Início do fornecimento de dieta com GSI nos 60 dias finais da gestação; Grupo 90: Início do fornecimento de dieta com GSI nos 90 dias finais da gestação. Após o parto, todas as vacas receberam dieta única com 5,1% de EE, baseada na inclusão de 12% de GSI %MS até 90 dias de lactação. Os animais foram arraçoados de acordo com o consumo de matéria seca no dia anterior, de forma a ser mantido porcentual de sobras das dietas, diariamente, entre 5 e 10%. As amostras dos alimentos e sobras foram coletadas diariamente e armazenadas a -20ºC. Semanalmente as amostras coletadas diariamente foram misturadas e foi retirada uma amostra composta referente a um período de uma semana, a fim de mensurar o consumo de matéria seca e nutrientes. Amostras de fezes foram coletadas nos dias -56, -21, 21, 56 e 84 dias em relação ao parto, com o propósito de mensurar a digestibilidade da matéria seca e nutrientes. A produção de leite foi mensurada diariamente e para a composição dos teores de gordura, proteína, lactose e perfil de ácidos graxos amostras foram coletadas semanalmente. As amostras de sangue para análise dos metabólitos sanguíneos foram coletadas semanalmente. Amostras de sangue para mensurar a atividade do sistema imune foram coletadas na semanas -8, -4, -2, -1 em relação ao parto, parto, +1, +2, +4 e +8 semanas no período pós-parto. Nos dias 21, 42, 63 e 84 do período pós-parto foram realizadas aspirações foliculares, com posterior fertilização in vitro dos oócitos. Todas as variáveis mensuradas foram analisadas pelo procedimento PROC MIXED do SAS 9.4 através de regressão polinomial, utilizando efeito fixo de tratamento, semana, interação tratamento*semana e efeito de animal dentro de tratamento como aleatório. Utilizou nível de 5% de significância. Foi observado efeito (P<0,05) linear crescente para CEE no pré-parto. Não foi observado diferenças no CMS e nutrientes no pós-parto. Não houve alteração da digestibilidade nos períodos pré e pós-parto. Não houve alteração no balanço de energia e nitrogênio nos periodos pré e pós-parto. Não foi observado diferença na produção, composição e teor dos componentes totais do leite. No perfil de ácidos graxos do leite houve efeito (P<0,05) linear descrescente para as concentrações de C16:1cis, C18:1 cis, total de C:18 insaturado, total de AG monoinsaturados, insaturados e a relação do total de AGS:AGI. Foi observado efeito linear (P<0,05) crescente para o total de AG aturado e efeito (P<0,05) quadrático para C18:2, CLAcis9-trans11, e total de AGPI. Foi observado efeito linear crescente (P<0,05) para colesterol total, LDL no préparto e linear decrescente (P<0,05) para GGT nos períodos pré e pós-parto. Foi observado efeito quadrático (P<0,05) para HDL no pré-parto e AST no pós-parto. Em relação a atividade do sistema imune foi observado efeito linear (P<0,05) crescente para o percentual de CD3+ ativos no pós-parto, para o percentual de monócitos que produziram espécie reativa de oxigênio (ERO) no pós-parto quando foram estimulados por S.aureus e E.coli e para a intensidade de imunofluorescência de ERO para ganulócitos no pós-parto quando estimulados por S.aureus. Foi observado efeito (P<0,05) quadrático para o percentual de granulócitos, mononucleares, CD8+ ativos no pós-parto e para o percentual de granulócitos que produziram ERO no pós-parto quando estimulados por E.coli. A suplementação prolongada com GSI no pré-parto melhora a atividade do sistema imune, não melhora a qualidade oocitária e embrionária bem como não influencia negativamente os parametros produtivos de vacas leiteiras no período de transição e início de lactação

Comparação entre prótese plástica e metálica na paliação endoscópica da obstrução maligna da via biliar: revisão sistemática e metanálise baseadas em estudos randomizados

INTRODUÇÃO: A prótese biliar endoscópica é aceita em todo o mundo como a primeira escolha de tratamento paliativo na obstrução biliar maligna. Atualmente ainda persistem dois tipos de materiais utilizados em sua confecção: plástico e metal. Consequentemente, muitas dúvidas surgem quanto a qual deles é o mais benéfico para o paciente. Esta revisão reúne as informações disponíveis da mais alta qualidade sobre estes dois tipos de prótese, fornecendo informações em relação à disfunção, complicação, taxas de reintervenção, custos, sobrevida e tempo de permeabilidade; e pretende ajudar a lidar com a prática clínica nos dias de hoje. OBJETIVO: Analisar, através de metanálise, os benefícios de dois tipos de próteses na obstrução biliar maligna inoperável. MÉTODOS: Uma revisão sistemática de ensaios clínicos randomizados (RCT) foi conduzida, com a última atualização em março de 2015, utilizando EMBASE, CINAHL (EBSCO), Medline, Lilacs / Centro (BVS), Scopus, o CAPES (Brasil), e literatura cinzenta. As informações dos estudos selecionados foram extraídas tendo em vista seis desfechos: primariamente disfunção, taxas de reintervenção e complicações; e, secundariamente, custos, sobrevivência e tempo de permeabilidade. Os dados sobre as características dos participantes do RCT, critérios de inclusão e exclusão e tipos de próteses também foram extraídos. Os vieses foram avaliados principalmente através da escala de Jadad. Esta metanálise foi registrada no banco de dados PROSPERO pelo número CRD42014015078. A análise do risco absoluto dos resultados foi realizada utilizando o software RevMan 5, calculando as diferenças de risco (RD) de variáveis dicotômicas e média das diferenças (MD) de variáveis contínuas. Os dados sobre a RD e MD para cada desfecho primário foram calculados utilizando o teste de Mantel-Haenszel e a inconsistência foi avaliada com o teste Qui-quadrado (Chi2) e o método de Higgins (I2). A análise de sensibilidade foi realizada com a retirada de estudos discrepantes e a utilização do efeito aleatório. O teste t de Student foi utilizado para a comparação das médias aritméticas ponderadas, em relação aos desfechos secundários. RESULTADOS: Inicialmente foram identificados 3660 estudos; 3539 foram excluídos por título ou resumo, enquanto 121 estudos foram totalmente avaliados e foram excluídos, principalmente por não comparar próteses metálicas (SEMS) e próteses plásticas (PS), levando a treze RCT selecionados e 1133 indivíduos metanálise. A média de idade foi de 69,5 anos, e o câncer mais comum foi de via biliar (proximal) e pancreático (distal). O diâmetro de SEMS mais utilizado foi de 10 mm (30 Fr) e o diâmetro de PS mais utilizado foi de 10 Fr. Na metanálise, SEMS tiveram menor disfunção global em comparação com PS (21,6% versus 46,8% p < 0,00001) e menos reintervenções (21,6% versus 56,6% p < 0,00001), sem diferença nas complicações (13,7% versus 15,9% p = 0,16). Na análise secundária, a taxa média de sobrevida foi maior no grupo SEMS (182 contra 150 dias - p < 0,0001), com um período maior de permeabilidade (250 contra 124 dias - p < 0,0001) e um custo semelhante por paciente, embora menor no grupo SEMS (4.193,98 contra 4.728,65 Euros - p < 0,0985). CONCLUSÃO: SEMS estão associados com menor disfunção, menores taxas de reintervenção, melhor sobrevida e maior tempo de permeabilidade. Complicações e custos não apresentaram diferença

A magnitude do efeito placebo no síndrome das pernas Irrequietas

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014