Navegando por Palavras-chave "medicina baseada em evidências"
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- ItemAcesso aberto (Open Access)Efetividade das intervenções psicossociais no tratamento dos transtornos alimentares: overview das revisões sistemáticas Cochrane(Universidade Federal de São Paulo (UNIFESP), 2013-09-25) Costa, Marcelle Barrueco [UNIFESP]; Melnik, Tamara [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Background:.The Overviews of Systematic Reviews (SRs) are devoloped by The Cochrane Collaboration in order to compile the results of multiple SRs for specific clinical condition. There are 5 SRs of psychosocial interventions for one or more Eating Disorders (EDs) published in The Cochrane Library up to now. Due to the high rate of relapse, chronicity and the possibility of migration of a type of Eating Disorder to another, a single document that presents the scientific evidence on psychosocial interventions can facilitate the decision making in health. Objective: To conduct an Overview of Cochrane Systematic Reviews on the effectiveness of psychosocial interventions in treatment of EDs. Methods: We performed a critical evaluation of all Cochrane Systematic Reviews (CSRs) published in The Cochrane Library about psychosocial interventions for EDs. The AMSTAR instrument with 11 items was used for evaluate the quality of included SRs. Results: Five CSRs were included (90 studies, 5487 participants), as shown in the Table 1. The main outcome analyzed was symptomatic remission. The categories of EDs were analyzed separately (Anorexia Nervosa (AN); Bulimia Nervosa (BN); Binge Eating (BED); (EDs). All 5 CSRs were assessed as high quality according to the AMSTAR. Conclusions: Current evidences suggest that for AN, Family Therapy may be effective for younger patients; For BN and BED, Cognitive Behavior Therapy is effective and your combination with antidepressants too, despite likely side effects; For BED, self-help may be effective as first step and less for BN also. However, are required further studies with larger samples, which analyses treatments according to ages, chronicity of disease, psychiatric comorbidities (especially anxiety and depression) and subtypes of EDs. Furthermore, preventive and promotional strategies are needed as well as the dissemination of knowledge on EDs for health professionals in general.
- ItemSomente MetadadadosIsotretinoína oral para acne(Universidade Federal de São Paulo (UNIFESP), 2015-02-25) Costa, Caroline Sousa [UNIFESP]; Riera, Rachel Riera [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Objectives: To assess the efficacy and safety of oral isotretinoin for acne vulgaris. Methods: Systematic review of the literature, conducted at Programa de Pós-Graduação em Saúde Baseada em Evidências, Universidade Federal de São Paulo (UNIFESP), and Brazilian Cochrane Centre. Search Methods: until September 30th 2014, we conducted searches in the following electronic databases: ?Cochrane Skin Group Specialised Register?; ?Cochrane Central Register of Controlled Trials (CENTRAL)?, The Cochrane Library, Issue 8, 2014; MEDLINE via OVID (since 1946); EMBASE via OVID (since 1974); PsycINFO via OVID (since 1806); LILACS (since 1982). In the databases MEDLINE and EMBASE, we conducted an additional specific search strategy for adverse effects. We also searched ongoing trials in the clinical trials register database. We conducted handsearches in the reference lists of relevant studies and in issues of the scientific journals ?Journal of Investigative Dermatology?, ?Archives of Dermatology?, and ?British Medical Dermatology?, in conference proceedings since 1975 until September 30th 2014. We contacted the pharmaceutical industry and field specialists to identify ongoing trials. Inclusion Criteria: Randomized Controlled Trials (RCTs) comparing oral isotretinoin with itself, placebo or any other active systemic treatment or topical, in patients with the clinical diagnosis of acne vulgaris; non-randomized clinical trials, cohort and case?control studies on serious adverse effects, depression or inflammatory intestinal disease due to oral isotretinoin use for acne. Data collection: Two authors, CSC and EB, independently selected the studies, assessed the methodological quality and extracted the data. A third author, RR, resolved divergences during the process. We contacted by electronic mail authors of included studies for additional information. We collected data of all adverse effects reported in the clinical trials. Results: We included 25 RCTs with parallel design involving 3.247 patients. All studies presented high or unclear risk of bias. The included RCTs compared oral isotretinoin with itself (in alternative dose schedules in comparison with the standard, in different pharmaceutical formulations from the original and in combination with topical agents), placebo and other six therapeutic active options against acne. For all comparisons, the quality of the body of evidence was considered low or very low along throughout different outcomes. Regarding the comparison with oral antibiotics associated to topical agent, the main comparison in the review, the inadequate data reports and the heterogeneity regarding the primary efficacy outcome measurement prevented pooling the results of the three RCTs restricted to severe to moderate acne in the meta-analysis. Based in only one of the RCTs (n = 49), oral isotretinoin was not significantly superior to oral tetracycline associated with topical adapalene regarding the percentage of patients who reached a full cleaning (or 100% of improvement) of inflammatory lesions after 24 weeks of use (RR (risk ratio) 4.17, (95% CI (confidence interval) 0.50 to 34.66) and those who kept no inflammatory lesions on the following 2 months after the end of the treatment (RR 11.44, 95% CI 0.67 to 196.30). Only one serious adverse effect was detected in the analysis of all 25 included RCTs: Stevens-Johnson syndrome in 1 patient that received oral isotretinoin in one of the three RTCs that assessed the main comparison. In the safety primary outcome meta-analysis for the main comparison, from the three RCTs (n = 403), oral isotretinoin was equal to oral antibiotics combined with topical drugs regarding the risk of developing a severe adverse effect (RD (risk difference) 0.00, 95% CI -0.01 to 0.02). With respect to the secondary outcomes of the main comparison: 1- oral isotretinoin was superior (RR 1.22, IC 95% 1.09 a 1.38) to systemic antibiotic associated with topical medications in one RCT (n = 266) and similar (RR 1.08, IC 95%, 0.97 a 1.20) to that association in another RCT (n = 85), regarding the improvement in acne severity assessed by the global physician? assessment at the end on the treatment; 2 ? based on the results from one RCT (n = 49), there was no difference between oral isotretinoin and oral antibiotics associated with topical agents regarding the mean scores obtained on the ?Dermatology Life Quality Index? (DLQI) after the end of 24 weeks of treatment (MD (mean difference) -0.12 score; 95% CI -0.83 to 0.60); 3 ? based on a meta-analysis of extracted data from two RCTs (n = 351), less serious adverse effects were more frequent due to oral isotretinoin (RR 1.69, 95% CI 1.42 to 2.00); 4 ? a meta-analysis from data of three RCTs (n = 403) did not show differences between oral isotretinoin and the combination of a systemic antibiotics with topical agents regarding the global rates of drop-outs (RR 0.68, 95% CI 0.43 to 1.06). Comparing different dosage schedules in one included RCT (n = 60), the daily use of oral isotretinoin in low or conventional dose, significantly reduced more the mean counts of inflammatory lesions after 24 weeks of treatment when compared to the intermittent schedule (MD 3.72 lesions; 95% CI 2.13 to 5.31) and (MD 3.87 lesions; CI 95% 2.31 to 5.43), respectively. The qualitative analysis of four non-randomized prospective studies (n = 643), resulted of additional search focused in severe and rare adverse effects, showed that there is no increase in risk of depression caused by the acne treatment with oral isotretinoin in comparison with other drug therapies. Oral isotretinoin decreased the depression incidence in comparison with topical medications in a nonrandomized clinical trial (n = 78). Three retrospective study (n = 58.163), all cross-over study designs, presented conflicting results regarding the higher risk of depressive outcomes with the use of oral isotretinoin for acne, if compared to therapy with other drugs. We considered the body of evidence from non-randomized studies, prospective and retrospectives, as very low quality. Still in the additional search for non-randomized studies, we did not find direct evidence (regarding the studied population) regarding the use of oral isotretinoin in acne vulgaris and the occurrence of inflammatory bowel disease. Conclusion: Due to considerable limitations of applicability and quality of evidence, it was not possible to draw a precise and definite conclusion regarding the superior efficacy of oral isotretinoin in relation to the association of oral antibiotics with topical medications in moderate to severe acne. The risk of severe adverse effects seem to be no different within interventions, but the less serious adverse effects significantly happen more within patients treated with oral isotretinoin. Regarding the different oral isotretinoin dose schedules, daily administration in low or standard dose seems to be more efficacious than the intermittent use; however, the low quality of the evidence makes it unlikely to draw a conclusion without uncertainties. The association of oral isotretinoin with severe depressive outcomes, when compared to other acne treatments, remains still little clear and unlikely, based in a body of evidence with serious limitations of design and quality.
- ItemSomente MetadadadosJulgamentos de valor no processo de incorporação de tecnologias de saúde no Brasil(Universidade Federal de São Paulo (UNIFESP), 2014-11-26) Santoro Neto, Luiz [UNIFESP]; Ferraz, Marcos Bosi Ferraz [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Introduction: Treating the shortage of health resources ethically and rationally seems to be the best way to face the dilemmas related to health technology assessment. Many aspects influence this process, including ethical, economic and social issues, which should serve as a basis for setting priorities in health and for the development of decision analysis. Objectives: To evaluate the value judgment on critical decisions involving the allocation of resources and the use of technologies in the Brazilian Health System, through the vision of health professionals and managers, and, by this appraisal, estimating implications that have potential influence on the health policies in the country. Methods: Cross-sectional exploratory study applied online, through a decision-making questionnaire for incorporation of health technologies, endowed with four scenarios that simulate real situations of resource allocation in an environment of severe budget constraints, which was completely answered by 193 managers and professionals from various health sectors. The scenarios presented trade-offs such as patient age, disease prevalence, reduction/extinction of current health programs, creation of taxes, and choices between prevention and treatment. The variations found in the responses were measured by Chi-square test. Results: The survey had a response rate of 27.3%. Of these, almost half were medical doctors, 90% had at least one post-graduation, and there was an equal distribution between men and women, as well as among those working in the public and private system. There was a diverse sample of respondents with participation of all proposed segments. Of the four presented scenarios, Scenarios 1, 2 and 3 involved some form of incorporation. In Scenario 1, 78% of respondents opted for decisions that nothing, or very little, affected the budget. In Scenario 2, 68% of respondents also opted for decisions that nothing, or very little, affected the budget. In Scenario 3, we find the highest trend for the incorporation among the studied scenarios, with 58% of respondents choosing XI for one of the options that involved incorporation. In Scenario 4, when comparing the results between treatment and prevention programs, the latter was prioritized for resource allocation, with 65% of responses. Conclusion: This study suggests that Brazilian health professionals and managers are significantly influenced by economic and budgetary issues when deciding about the allocation of resources for health technologies assessment in the country. In search of a paradigm for decision-making, most professionals and managers generally prioritized to save resources, instead of incorporating the technologies. Among the segments, the pharmaceutical industry showed the greater tendency for technological incorporation. We hope that this and other studies are able to collaborate in the establishment and strengthening of health policies that ensure economic feasibility for an effective incorporation of progressive technologies, avoiding an undesirable technological gap, because of the severe budget constraint of Brazilian health.
- ItemSomente MetadadadosNíveis de evidência da cirurgia de joelho em periódicos nacionais São Paulo 2014(Universidade Federal de São Paulo (UNIFESP), 2014-06-25) Rosario, Davi Araujo Veiga [UNIFESP]; Franciozi, Carlos Eduardo da Silveira Franciozi [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)O conceito da Medicina Baseada em Evidências (MBE) foi introduzido em 1991 e desde então vem despertando o interesse da comunidade científica.1 Os conceitos da MBE começaram a aparecer nos principais congressos e simpósios a partir de 2003. Diferentemente da medicina tradicional, esse novo ramo não é embasado na intuição, experiência clínica não sistemática e raciocínio fisiopatológico como base fundamental para adotar conduta clínica. Medicina baseada em evidências exige novas habilidades do profissional, que inclui o conhecimento da pesquisa na literatura, suas ferramentas e a avaliação da evidência clínica. Houve um aumento na publicação de artigos que orientam os médicos sobre como acessar, avaliar e interpretar a literatura médica.3,4 Esse senso crítico se torna obrigatório, em virtude do grande número de publicações e frequentes armadilhas metodológicas, que podem induzir o leitor a conclusões equivocadas e potencialmente danosas para prática clinica e cirúrgica.5,6 A literatura ortopédica brasileira seguiu a linha das publicações internacionais em busca de melhores níveis de evidência nas publicações e a qualidade metodológica dos artigos passou a ser analisada com critérios mais rigorosos.4 Entretanto, até o momento, a literatura nacional carece de estudos críticos dos níveis de evidência em ortopedia. Objetivo: O estudo trata-se de uma revisão com o objetivo de selecionar os estudos relacionados à cirurgia do joelho publicados de 2000 a 2011 na literatura ortopédica nacional por meio da Acta Ortopédica Brasileira(AOB) e da Revista Brasileira de Ortopedia (RBO) e classificá-los de acordo com os níveis de evidência. Estes dois periódicos foram escolhidos por estarem inseridos no âmbito nacional e estarem indexados, via Scielo, como uma base de dados bibliográfica internacional. Variáveis secundárias a serem observadas: a quantidade de estudos publicados por ano, a região em que foram desenvolvidos e o principal tema abordado no estudo.