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1.
Caries Res ; 53(5): 502-513, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31220835

RESUMO

The aim of this study was to assess the effectiveness of fluoride varnish (FV) in reducing dentine caries at the patient, tooth, and surface levels as well as caries-related hospitalizations in preschoolers. We performed a systematic review of clinical trials of FV, alone or associated with an oral health program, compared with placebo, usual care, or no intervention. Bibliographical search included electronic searches of seven databases, registers of ongoing trials, and meeting abstracts, as well as hand searching. We performed random-effects meta-analyses and calculated confidence and prediction intervals. The search yielded 2,441 records; 20 trials were included in the review and 17 in at least one meta-analysis. Only one study had low risk of bias in all domains. We found no study reporting on caries-related hospitalizations. At the individual level, the pooled relative risk was 0.88 (95% confidence interval [CI] 0.81, 0.95); this means that in a population of preschool children with 50% caries incidence, we need to apply fluoride varnish in 17 children to avoid new caries in one child. At the tooth level, the pooled weighted mean difference was -0.30 (95% CI -0.69, 0.09) and at the surface level -0.77 (95% CI -1.23, -0.31). Considering the prediction intervals, none of the pooled estimates were statistically significant. We conclude that FV showed a modest and uncertain anticaries effect in preschoolers. Cost-effectiveness analyses are needed to assess whether FV should be adopted or abandoned by dental services.

2.
Artigo em Inglês | MEDLINE | ID: mdl-30873290

RESUMO

Background: Periodontitis is a common oral inflammation, which is a risk factor for adverse pregnancy outcomes. Intakes of vitamin D and calcium are inversely associated with occurrence and progression of periodontitis. This study aims to assess the feasibility of a multi-component intervention, including provision of milk powder supplemented with calcium and vitamin D and periodontal therapy (PT), for improving maternal periodontal health and metabolic and inflammatory profiles of low-income Brazilian pregnant women with periodontitis. Methods: The IMPROVE trial is a feasibility randomised controlled trial (RCT) with a 2 × 2 factorial design with a parallel process evaluation. Pregnant women with periodontitis, aged 18-40 years and with < 20 gestational weeks (n = 120) were recruited and randomly allocated into four groups: (1) fortified sachet (vitamin D and calcium) and powdered milk plus PT during pregnancy, (2) placebo sachet and powdered milk plus PT during pregnancy, (3) fortified sachet (vitamin D and calcium) and powdered milk plus PT after delivery and (4) placebo sachet and powdered milk plus PT after delivery. Dentists and participants are blinded to fortification. Acceptability of study design, recruitment strategy, random allocation, data collection procedures, recruitment rate, adherence and attrition rate will be evaluated. Data on serum levels of vitamin D, calcium and inflammatory biomarkers; clinical periodontal measurements; anthropometric measurements; and socio-demographic questionnaires are collected at baseline, third trimester and 6-8 weeks postpartum. Qualitative data are collected using focus group, for analysis of favourable factors and barriers related to study adherence. Discussion: Oral health and mineral/vitamin supplementation are much overlooked in the public prenatal assistance in Brazil and of scarcity of clinical trials addressing these issues in low and middle-income countries,. To fill this gap the present study was designed to assess the feasibility of a RCT on acceptability of a multi-component intervention combining conventional periodontal treatment and consumption of milk fortified with calcium-vitamin D for improving periodontal conditions and maternal metabolic and inflammation status, among Brazilian low-income pregnant women with periodontitis. Thus, we hope that this relatively low-cost and safe multicomponent intervention can help reduce inflammation, improve maternal periodontal health and metabolic profile and consequently prevent negative gestational outcomes. Trial registration: NCT, NCT03148483. Registered on May 11, 2017.

3.
Rev. bras. cancerol ; 65(3)19/09/2019.
Artigo em Português | LILACS | ID: biblio-1047846

RESUMO

Introdução: Os danos cardiovasculares do rastreamento mamográfico não têm sido objeto de estudo ou preocupações, inclusive na área de cardio-oncologia. O resultado é uma importante lacuna na literatura a despeito de evidências da grande magnitude do sobrediagnóstico e do sobretratamento no rastreamento e sua ligação com aumento da mortalidade cardiovascular. Objetivo: Apresentar e discutir as principais evidências a respeito das causas de aumento de mortalidade cardiovascular associadas ao rastreamento. Método: Foram realizadas buscas sistemáticas na literatura, por meio de quatro estratégias de busca em duas bases de dados (MEDLINE e LILACS), para identificar as causas de aumento de mortalidade cardiovascular potencialmente associadas ao sobrediagnóstico e ao sobretratamento. Para cada uma das estratégias de busca, os resultados tiveram seu nível de evidência atribuídos de acordo com a classificação do Oxford Centre for Evidence-Based Medicine. Resultados: Dois grandes grupos de causas de aumento da mortalidade cardiovascular foram identificados: o primeiro ligado diretamente ao diagnóstico de câncer de mama; e o segundo ao tratamento do câncer de mama, incluindo cirurgia e radioterapia adjuvante. O aumento de mortalidade cardiovascular incluiu diversos subgrupos de causas, tais como infarto agudo do miocárdio, tromboembolismo pulmonar, insuficiência cardíaca, arritmias, doença orovalvar e acidente vascular encefálico. Conclusão: Existem evidências consistentes sobre mortalidade cardiovascular associada ao diagnóstico e ao tratamento do câncer de mama em situações clinicamente compatíveis com o rastreamento. É provável também que essa seja uma das causas mais importantes da mortalidade relacionada ao rastreamento, em especial aquelas associadas ao sobretratamento com radioterapia adjuvante.


Introduction: Cardiovascular harms of mammographic screening have not been the subject of study or concern, including in the cardio-oncology area of. The result is an important gap in literature despite the evidence of great magnitude of overdiagnosis and overtreatment in screening and its association with increased cardiovascular mortality. Objective: Present and discuss the main evidence regarding the causes of increased cardiovascular mortality associated with screening. Method: Systematic searches were performed in the literature through four search strategies in two databases (MEDLINE and LILACS), to identify the causes of increased cardiovascular mortality potentially associated with overdiagnosis and overtreatment. For each one of the search strategies, it was used the classification of the Oxford Centre for Evidence-Based Medicine to assign the level of evidence of the results. Results: Two major groups of causes of increased cardiovascular mortality were identified: the first linked directly to the diagnosis of breast cancer; and the second to the treatment of breast cancer, including surgery and adjuvant radiotherapy. The increase of cardiovascular mortality included several subgroups of causes such as acute myocardial infarction, pulmonary thromboembolism, heart failure, arrhythmias, heart valve disease and stroke. Conclusion: There are consistent evidence about cardiovascular mortality associated with breast cancer diagnosis and treatment in conditions clinically compatible with screening. It is also likely to be one of the most important causes of mortality related to screening, especially those associated with overtreatment with adjuvant radiotherapy.


Introducción: El daño cardiovascular causado por el cribado mamográfico no ha sido objeto de estudio ni de preocupación, incluso en el área de la cardio-oncología. El resultado es una brecha importante en la literatura a pesar de la evidencia de la gran magnitud del sobrediagnóstico y el sobretratamiento en cribado. y su asociación con el aumento de la mortalidad cardiovascular. Objetivo: Presentar y discutir los principales pruebas en las causas del aumento de la mortalidad cardiovascular asociados con la tamización. Método: Se realizaron búsquedas sistemáticas en la literatura a través de cuatro estrategias de búsqueda en dos bases de datos (MEDLINE y LILACS), para identificar las causas del aumento de la mortalidad cardiovascular potencialmente asociadas con el sobrediagnóstico y el sobretratamiento. Para cada una de las estrategias de búsqueda, a los resultados se les asignó su nivel de evidencia de acuerdo con la clasificación del Oxford Centre for Evidence-Based Medicine. Resultados: Se identificaron dos grupos principales de causas de aumento de la mortalidad cardiovascular: el primero relacionado directamente con el diagnóstico de cáncer de mama; y el segundo para el tratamiento del cáncer de mama, incluida la cirugía y la radioterapia adyuvante. El aumento de la mortalidad cardiovascular incluyó varios subgrupos de causas como infarto agudo de miocardio, tromboembolismo pulmonar, insuficiencia cardíaca, arritmias, enfermedad orovalvar y accidente cerebrovascular. Conclusión: Existe evidencia consistente de mortalidad cardiovascular asociada con el diagnóstico y tratamiento del cáncer de mama en condiciones clínicamente compatibles con la tamización. También es probable que sea una de las causas más importantes de mortalidad relacionada con la tamización, especialmente aquellas asociadas con el sobretratamiento con radioterapia adyuvante.


Assuntos
Humanos , Neoplasias da Mama/diagnóstico , Doenças Cardiovasculares/mortalidade , Mamografia , Programas de Rastreamento , Radioterapia Adjuvante
4.
Cad Saude Publica ; 34(6): e00046317, 2018 06 25.
Artigo em Inglês, Português | MEDLINE | ID: mdl-29952397

RESUMO

The objective of the current article is to present the main challenges for the implementation of the new recommendations for early detection of breast cancer in Brazil, and to reflect on the barriers and the strategies to overcome them. The implementation of evidence-based guidelines is a global challenge, and traditional strategies based only on disseminating their recommendations have proven insufficient for changing prevailing clinical practice. A major challenge for adherence to the new guidelines for early detection of breast cancer in Brazil is the current pattern in the use of mammographic screening in the country, which very often includes young women and a short interval between tests. Such practice, harmful to the population's health, is reinforced by the logic of defensive medicine and the dissemination of erroneous information that overestimates the benefits of screening and underestimates or even omits its harms. In addition, there is a lack of policies and measures focused on early diagnosis of symptomatic cases. To overcome these barriers, changes in the regulation of care, financing, and implementation of shared decision-making in primary care are essential. Audit and feedback, academic detailing, and the incorporation of decision aids are some of the strategies that can facilitate implementation of the new recommendations.


Assuntos
Neoplasias da Mama/diagnóstico , Detecção Precoce de Câncer/normas , Fidelidade a Diretrizes , Guias como Assunto/normas , Fatores Etários , Brasil , Detecção Precoce de Câncer/tendências , Medicina Baseada em Evidências , Feminino , Fidelidade a Diretrizes/tendências , Humanos , Mamografia/normas , Mamografia/tendências
5.
Cad Saude Publica ; 34(6): e00074817, 2018 06 21.
Artigo em Inglês, Português | MEDLINE | ID: mdl-29947654

RESUMO

Breast cancer is the leading cause of cancer mortality in Brazilian women. The new Brazilian guidelines for early detection of breast cancer were drafted on the basis of systematic literature reviews on the possible harms and benefits of various early detection strategies. This article aims to present the recommendations and update the summary of evidence, discussing the main controversies. Breast cancer screening recommendations (in asymptomatic women) were: (i) strong recommendation against mammogram screening in women under 50 years of age; (ii) weak recommendation for mammogram screening in women 50 to 69 years of age; (iii) weak recommendation against mammogram screening in women 70 to 74 years of age; (iv) strong recommendation against mammogram screening in women 75 years or older; (v) strong recommendation that screening in the recommended age brackets should be every two years as opposed to shorter intervals; (vi) weak recommendation against teaching breast self-examination as screening; (vii) absence of recommendation for or against screening with clinical breast examination; and (viii) strong recommendation against screening with magnetic resonance imaging, ultrasonography, thermography, or tomosynthesis alone or as a complement to mammography. The recommendations for early diagnosis of breast cancer (in women with suspicious signs or symptoms) were: (i) weak recommendation for the implementation of awareness-raising strategies for early diagnosis of breast cancer; (ii) weak recommendation for use of selected signs and symptoms in the current guidelines as the criterion for urgent referral to specialized breast diagnosis services; and (iii) weak recommendation that every breast cancer diagnostic workup after the identification of suspicious signs and symptoms in primary care should be done in the same referral center.


Assuntos
Neoplasias da Mama/diagnóstico , Detecção Precoce de Câncer/normas , Medicina Baseada em Evidências/normas , Fatores Etários , Brasil , Ensaios Clínicos como Assunto , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Mamografia/normas , Fatores de Risco
6.
Cad Saude Publica ; 34(6): e00116317, 2018 06 21.
Artigo em Inglês, Português | MEDLINE | ID: mdl-29947660

RESUMO

Clinical guidelines are traditionally drafted by expert consensus. The benefits of mammographic screening have been questioned in recent years, owing to biases detected in the clinical trials that popularized its widespread use. Meanwhile, growing body of evidence on harms associated with mammographic screening also required a new approach, taking into account the uncertainties on the benefits and a balance between the gains and possible harms from screening. This article discusses the development of the new guidelines for early detection of breast cancer in Brazil, with details on the drafting methods and implications for the new recommendations. The new methodology features systematic literature reviews, assessment of the validity of the evidence, and the balance between each intervention's risks and benefits, ensuring greater transparency, reproducibility, and validity in the drafting process. The new guidelines also include recommendations for cases with suspicious signs and symptoms. The authors provide a detailed discussion of the advantages of the approach as compared to the traditional expert consensus model, as well as the methods' limitations and disadvantages. They also address the implications of various decisions, such as choices on study designs, screening effectiveness outcomes, definition of overdiagnosis, and methods for calculation.


Assuntos
Neoplasias da Mama/diagnóstico , Detecção Precoce de Câncer/normas , Guias de Prática Clínica como Assunto/normas , Brasil , Ensaios Clínicos como Assunto/normas , Medicina Baseada em Evidências/normas , Feminino , Humanos , Mamografia/normas , Reprodutibilidade dos Testes
7.
J Clin Periodontol ; 45(8): 952-958, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29904930

RESUMO

AIM: To estimate the prevalence of self-reported gingival bleeding in a representative sample of 12- to 17-year-old Brazilian adolescents. MATERIALS AND METHODS: Sociodemographic and oral health information were obtained through a self-administered questionnaire of the Study of Cardiovascular Risk Factors in Adolescents. The adolescents answered "yes" or "no" to the question "Do your gums bleed?" RESULTS: 74,589 of the 102,327 eligible adolescents answered the questionnaire and 18.4% (95% CI 17.5-19.3) reported having bleeding gums. The prevalence of self-reported gingival bleeding varied as following: 21.4% (95% CI 20.3-22.6) in girls and 15.3% (95% CI 14.3-16.4) in boys; 20.5% (95% CI 19.2-21.8) in older and 17.5% (95% CI 16.4-18.6) in younger adolescents; 20.6% (95% CI 18.5-22.9) in Black people and 17.1% (95% CI 16.1-18.1) in White people. Regarding mother's level of education, the prevalences were 18.1% (95% CI 16.2-20.3), 17.6% (95% CI 16.4-18.9) and 19.3% (95% CI 17.9-20.9) for high, middle and low levels, respectively. For socioeconomic status, the equivalent figures were 16.4% (95% CI 14.3-18.7), 18.4% (95% CI 17.5-19.4) and 23.0% (95% CI 17.3-29.9). CONCLUSION: Nearly one in five Brazilian adolescents reported having gingival bleeding, which might not be a serious condition, but reflect the disease and the adolescents' perception of oral health status.


Assuntos
Saúde Bucal , Adolescente , Idoso , Brasil , Criança , Feminino , Hemorragia Gengival , Humanos , Masculino , Prevalência , Autorrelato
8.
RGO (Porto Alegre) ; 66(2): 172-176, Apr.-June 2018. graf
Artigo em Inglês | LILACS-Express | ID: biblio-956211

RESUMO

ABSTRACT The aim of this article was to offer an efficient systematic search strategy appropriate for clinicians, professors and dental students, for when they have a question regarding the effectiveness of clinical intervention. We adapted the "6-S System" proposed for Medicine in order to build a search strategy focused on oral health, which is speedy, easy to use and arrives at the appropriate evidence. With a focus on validity and search efficiency, the following searching sequence is proposed: critical abstracts of systematic reviews (SR) of randomized controlled trials (RCTs), SR of RCTs, critical abstracts of RCTs, and RCTs. These can be searched in the Cochrane library; evidence-based journals; websites and blogs; and in Pubmed using the tool Clinical Queries. This strategy can enhance the ability to quickly retrieve evidence that is important to dental education, clinical practice and delivery of oral health care. The adoption of strategies such as the one proposed in this paper is likely to increase evidence based dental practice.


RESUMO O objetivo deste artigo foi apresentar uma estratégia de busca sistemática e eficiente, apropriada para cirurgiões-dentistas, professores e alunos de Odontologia, para ser utilizada quando eles tiverem dúvidas sobre a efetividade de uma intervenção clínica. O sistema proposto para a Medicina, chamado de "Sistema 6-S", foi adaptado para que uma estratégia de busca com foco na Odontologia fosse construída. Essa estratégia é fácil e rápida de usar e alcança a melhor evidência científica disponível. A sequência de busca proposta, com foco na validade da evidência e eficiência da busca, consiste em: resumos críticos de revisões sistemáticas (RS) de ensaios controlados randomizados (ECR), RS de ECR, resumos críticos de ECR e, por último, ECR. A busca por esses artigos pode ser feita na biblioteca Cochrane; em revistas de odontologia baseada em evidência; sites da Internet e blogs; e no Pubmed através da ferramenta "Clinical Queries". Essa estratégia pode aprimorar a habilidade de obter rapidamente evidência importante para informar a prática clínica, a educação em Odontologia e o cuidado em saúde bucal. A adoção de estratégias como a proposta neste artigo pode aumentar a prática da Odontologia Baseada em Evidência.

9.
J Am Dent Assoc ; 149(1): 18-24, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29304907

RESUMO

BACKGROUND: The authors assessed whether dentists' diagnostic inferences differ when test accuracy information is communicated using natural frequencies versus conditional probabilities. METHODS: A parallel, randomized controlled trial with dentists was carried out in Rio de Janeiro, Brazil. The dentists received a question on the probability of a patient having interproximal caries, given a positive bite-wing radiograph. This question was asked using information that was formulated into either natural frequencies or conditional probabilities. RESULTS: Only 14 (13.9%) of the dentists gave the correct answer; 13 in the natural frequencies group, and 1 in the conditional probabilities group (P < .001). There were 7 nearly correct answers in the natural frequencies group and none in the conditional probabilities group (P = .005). CONCLUSIONS: Representing diagnostic test accuracy in natural frequencies substantially helped dentists make diagnostic inferences. Nearly twice as many dentists overestimated the presence of interproximal caries when given information in conditional probabilities. PRACTICAL IMPLICATIONS: Our study findings show information shared using natural frequencies may be more accurately interpreted by dentists than that based on conditional probabilities. Patients will probably receive different standards of care depending on the format in which dentists receive diagnostic test accuracy information.


Assuntos
Cárie Dentária , Odontólogos , Brasil , Humanos , Padrões de Prática Odontológica , Probabilidade
10.
Int J Paediatr Dent ; 28(1): 3-11, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28940755

RESUMO

BACKGROUND: The anticaries effect of supervised toothbrushing, irrespective of the effect of fluoride toothpaste, has not been clearly determined yet. AIM: To assess the effects of supervised toothbrushing on caries incidence in children and adolescents. DESIGN: A systematic review of controlled trials was performed (CRD42014013879). Electronic and hand searches retrieved 2046 records, 112 of which were read in full and independently assessed by two reviewers, who collected data regarding characteristics of participants, interventions, outcomes, length of follow-up and risk of bias. RESULTS: Four trials were included and none of them had low risk of bias. They were all carried out in schools, but there was great variation regarding children's age, fluoride content of the toothpaste, baseline caries levels and the way caries incidence was reported. Among the four trials, two found statistically significant differences favouring supervised toothbrushing, but information about the magnitude and/or the precision of the effect estimate was lacking and in one trial clustering effect was not taken into consideration. No meta-analysis was performed due to the clinical heterogeneity among the included studies and differences in the reporting of data. CONCLUSIONS: There is no conclusive evidence regarding the effectiveness of supervised toothbrushing on caries incidence.


Assuntos
Cárie Dentária/epidemiologia , Escovação Dentária , Adolescente , Criança , Humanos , Incidência
11.
Cad. Saúde Pública (Online) ; 34(6): e00046317, 2018. graf
Artigo em Português | LILACS-Express | ID: biblio-952398

RESUMO

O objetivo do presente artigo é apresentar os principais desafios à implementação das novas recomendações para a detecção precoce do câncer de mama no Brasil, bem como refletir sobre as barreiras e estratégias para a sua superação. A implementação de diretrizes baseadas em evidências é um desafio em todo o mundo, e estratégias tradicionais baseadas apenas na disseminação de seu texto são comprovadamente insuficientes para gerar mudanças na prática clínica vigente. Um grande desafio à adesão às novas diretrizes para a detecção precoce do câncer de mama no Brasil é o atual padrão de uso do rastreamento mamográfico no país, que acaba incluindo muito frequentemente mulheres jovens e intervalo curto entre os exames. Essa prática danosa à saúde da população é reforçada pela lógica da medicina defensiva e pela difusão de informações equivocadas, que superestimam os benefícios do rastreamento e subestimam ou mesmo omitem seus riscos. Além disso, há carência de políticas e ações voltadas para o diagnóstico precoce de casos sintomáticos. Para superar essas barreiras, mudanças relacionadas à regulação da assistência, financiamento e a implantação do processo de decisão compartilhada na atenção primária são essenciais. Auditoria-feedback, detalhamento acadêmico e incorporação de ferramentas de suporte à decisão são algumas das estratégias que podem facilitar o processo de implementação das novas recomendações.


El objetivo del presente artículo es presentar los principales desafíos para la implementación de las nuevas recomendaciones en la detección precoz del cáncer de mama en Brasil, así como reflexionar sobre las barreras y estrategias para su superación. La implementación de directrices, basadas en evidencias, es un desafío en todo el mundo, y las estrategias tradicionales basadas sólo en la propagación de las mismas son comprobadamente insuficientes para generar cambios en la práctica clínica vigente. Un gran desafío para la adhesión a las nuevas directrices para la detección precoz del cáncer de mama en Brasil es el actual patrón de uso del rastreo mamográfico en el país, que incluye a menudo a mujeres jóvenes e intervalo corto entre los exámenes. Esta práctica perjudicial para la salud de la población es reforzada por la lógica de la medicina defensiva y por la difusión de información equivocada, que sobrestiman los beneficios del rastreo y subestiman o incluso omiten sus riesgos. Asimismo, existe una carencia de políticas y acciones dirigidas al diagnóstico precoz de casos sintomáticos. Para superar estas barreras, son imprescindibles cambios relacionados con la regulación de la asistencia, financiación y la implantación del proceso de decisión compartida en la atención primaria. Algunas de las estrategias que pueden facilitar el proceso de implementación de las nuevas recomendaciones son: auditoría con retroalimentación, detalle académico e incorporación de herramientas de apoyo a la decisión son algunas de las estrategias que pueden facilitar el proceso de implementación de las nuevas recomendaciones.


The objective of the current article is to present the main challenges for the implementation of the new recommendations for early detection of breast cancer in Brazil, and to reflect on the barriers and the strategies to overcome them. The implementation of evidence-based guidelines is a global challenge, and traditional strategies based only on disseminating their recommendations have proven insufficient for changing prevailing clinical practice. A major challenge for adherence to the new guidelines for early detection of breast cancer in Brazil is the current pattern in the use of mammographic screening in the country, which very often includes young women and a short interval between tests. Such practice, harmful to the population's health, is reinforced by the logic of defensive medicine and the dissemination of erroneous information that overestimates the benefits of screening and underestimates or even omits its harms. In addition, there is a lack of policies and measures focused on early diagnosis of symptomatic cases. To overcome these barriers, changes in the regulation of care, financing, and implementation of shared decision-making in primary care are essential. Audit and feedback, academic detailing, and the incorporation of decision aids are some of the strategies that can facilitate implementation of the new recommendations.

12.
Cad. Saúde Pública (Online) ; 34(6): e00116317, 2018. tab
Artigo em Português | LILACS-Express | ID: biblio-952408

RESUMO

Tradicionalmente, diretrizes clínicas são elaboradas a partir do consenso de opiniões de especialistas. Nos últimos anos, a magnitude dos benefícios do rastreamento mamográfico vem sendo questionada em função dos vieses detectados nos ensaios clínicos que popularizaram a disseminação dessa prática. Paralelamente, o crescente corpo de evidências sobre danos associados ao rastreamento mamográfico também demandava uma nova abordagem que considerasse as incertezas sobre os benefícios e um balanço entre ganhos e possíveis danos. O presente artigo tem por objetivo apresentar o processo de elaboração das novas diretrizes para detecção precoce do câncer de mama no Brasil, detalhando os métodos utilizados, bem como suas implicações para as novas recomendações. A nova abordagem metodológica apresenta como pilares a realização de revisões sistemáticas da literatura, a avaliação da validade das evidências e o balanço entre riscos e benefícios de cada intervenção, garantindo maior transparência, reprodutibilidade e validade no processo de elaboração. Outra inovação das novas diretrizes é a presença de recomendações dirigidas a casos com sinais e sintomas suspeitos. As vantagens da abordagem adotada frente ao modelo tradicional de consenso de especialistas são discutidas com detalhes, bem como os limites e desvantagens dos métodos utilizados. Também são discutidas as implicações de diversas decisões, como escolhas sobre desenhos de estudo, desfechos sobre efetividade do rastreamento, além da definição de sobrediagnóstico e forma de cálculo.


Tradicionalmente, las directrices clínicas se elaboran a partir del consenso de opiniones de especialistas. En los últimos años, la magnitud de los beneficios del rastreo mamográfico ha sido cuestionada, debido a los sesgos detectados en los ensayos clínicos que popularizaron la propagación de esta práctica. Paralelamente, el creciente cuerpo de evidencias sobre daños asociados al rastreo mamográfico también demandaba un nuevo enfoque que considerase las incertidumbres sobre los beneficios y un balance entre ventajas y posibles daños. Este artículo tiene como objetivo presentar el proceso de elaboración de las nuevas directrices para la detección precoz del cáncer de mama en Brasil, detallando los métodos utilizados, así como sus implicaciones para las nuevas recomendaciones. El nuevo enfoque metodológico presenta como pilares la realización de revisiones sistemáticas de la literatura, la evaluación de la validez de las evidencias y el balance entre riesgos y beneficios de cada intervención, garantizando una mayor transparencia, reproductibilidad y validez en el proceso de elaboración. Otra innovación de las nuevas diretrices es la presencia de recomendaciones dirigidas a casos con signos y síntomas sospechosos. Las ventajas del enfoque adoptado, frente al modelo tradicional de consenso por parte de los especialistas, se discute en detalle, así como los límites y desventajas de los métodos utilizados. Asimismo, se discuten las implicaciones de diversas decisiones, como las decisiones en relación con diseños de estudio, resultados sobre efectividad del rastreo, así como la definición de sobrediagnóstico y forma de cálculo.


Clinical guidelines are traditionally drafted by expert consensus. The benefits of mammographic screening have been questioned in recent years, owing to biases detected in the clinical trials that popularized its widespread use. Meanwhile, growing body of evidence on harms associated with mammographic screening also required a new approach, taking into account the uncertainties on the benefits and a balance between the gains and possible harms from screening. This article discusses the development of the new guidelines for early detection of breast cancer in Brazil, with details on the drafting methods and implications for the new recommendations. The new methodology features systematic literature reviews, assessment of the validity of the evidence, and the balance between each intervention's risks and benefits, ensuring greater transparency, reproducibility, and validity in the drafting process. The new guidelines also include recommendations for cases with suspicious signs and symptoms. The authors provide a detailed discussion of the advantages of the approach as compared to the traditional expert consensus model, as well as the methods' limitations and disadvantages. They also address the implications of various decisions, such as choices on study designs, screening effectiveness outcomes, definition of overdiagnosis, and methods for calculation.

13.
Cad. Saúde Pública (Online) ; 34(6): e00074817, 2018. tab
Artigo em Português | LILACS, BIGG | ID: biblio-952407

RESUMO

Resumo: O câncer de mama é a principal causa de morte por câncer em mulheres no Brasil. As novas diretrizes para detecção precoce no Brasil foram elaboradas com base em revisões sistemáticas da literatura sobre riscos e possíveis benefícios de diversas estratégias de detecção precoce. O objetivo do presente artigo é apresentar as recomendações e atualizar a síntese de evidências, discutindo as principais controvérsias existentes. As recomendações para o rastreamento do câncer de mama (mulheres assintomáticas) foram: (i) recomendação contrária forte ao rastreamento com mamografia em mulheres com menos de 50 anos; (ii) recomendação favorável fraca ao rastreamento com mamografia em mulheres com idades entre 50 e 69 anos; (iii) recomendação contrária fraca ao rastreamento com mamografia em mulheres com idades entre 70 e 74 anos; (iv) recomendação contrária forte ao rastreamento com mamografia em mulheres com 75 anos ou mais; (v) recomendação favorável forte de que o rastreamento nas faixas etárias recomendadas seja bienal, quando comparada às periodicidades menores do que a bienal; (vi) recomendação contrária fraca ao ensino do autoexame das mamas para rastreamento; (vii) ausência de recomendação favorável ou contrária ao rastreamento com exame clínico das mamas; e (viii) recomendação contrária forte ao rastreamento com ressonância nuclear magnética, ultrassonografia, termografia ou tomossíntese, seja isoladamente, seja como complemento à mamografia. As recomendações para o diagnóstico precoce do câncer de mama (mulheres com sinais ou sintomas suspeitos) foram: (i) recomendação favorável fraca à implementação de estratégias de conscientização para o diagnóstico precoce do câncer de mama; (ii) recomendação favorável fraca ao uso de sinais e sintomas selecionados nas presentes diretrizes como critério de referência urgente para serviços de diagnóstico mamário; e (iii) recomendação favorável fraca de que toda a avaliação diagnóstica do câncer de mama, após a identificação de sinais e sintomas suspeitos na atenção primária, seja feita em um mesmo centro de referência.


Resumen: El cáncer de mama es la principal causa de muerte por cáncer en mujeres en Brasil. Las nuevas directrices para la detección precoz en Brasil fueron elaboradas basándose en revisiones sistemáticas de la literatura sobre riesgos y posibles beneficios de diversas estrategias de detección precoz. El objetivo del presente artículo es presentar las recomendaciones y actualizar la síntesis de evidencias, discutiendo las principales controversias existentes. Las recomendaciones para el tamizaje del cáncer de mama (mujeres asintomáticas) fueron: (i) fuerte recomendación contraria al tamizaje con mamografía en mujeres con menos de 50 años; (ii) baja recomendación favorable al tamizaje con mamografía en mujeres con edades entre 50 y 69 años; (iii) baja recomendación contraria al tamizaje con mamografía en mujeres con edades entre 70 y 74 años; (iv) fuerte recomendación contraria al tamizaje con mamografía en mujeres con 75 años o más; (v) fuerte recomendación favorable de que el tamizaje en las franjas etarias recomendadas sea bienal, cuando se compara con periodicidades menores a la bienal; (vi) baja recomendación contraria a la enseñanza del autoexamen de las mamas para tamizaje; (vii) ausencia de recomendación favorable o contraria al tamizaje con examen clínico de las mamas; y (viii) fuerte recomendación contraria al tamizaje con resonancia magnética nuclear, ultrasonografía, termografía o tomosíntesis, bien sea aisladamente, bien sea como complemento a la mamografía. Las recomendaciones para el diagnóstico precoz del cáncer de mama (mujeres con señales o síntomas sospechosos): (i) baja recomendación favorable a la implementación de estrategias de concienciación para el diagnóstico precoz del cáncer de mama; (ii) baja recomendación favorable al uso de señales y síntomas seleccionados en las presentes directrices como criterio de referencia urgente para servicios de diagnóstico mamario; y (iii) baja recomendación favorable de que toda la evaluación diagnóstica del cáncer de mama, tras la identificación de señales y síntomas sospechosos en la atención primaria, sea realizada en un mismo centro de referencia.


Abstract: Breast cancer is the leading cause of cancer mortality in Brazilian women. The new Brazilian guidelines for early detection of breast cancer were drafted on the basis of systematic literature reviews on the possible harms and benefits of various early detection strategies. This article aims to present the recommendations and update the summary of evidence, discussing the main controversies. Breast cancer screening recommendations (in asymptomatic women) were: (i) strong recommendation against mammogram screening in women under 50 years of age; (ii) weak recommendation for mammogram screening in women 50 to 69 years of age; (iii) weak recommendation against mammogram screening in women 70 to 74 years of age; (iv) strong recommendation against mammogram screening in women 75 years or older; (v) strong recommendation that screening in the recommended age brackets should be every two years as opposed to shorter intervals; (vi) weak recommendation against teaching breast self-examination as screening; (vii) absence of recommendation for or against screening with clinical breast examination; and (viii) strong recommendation against screening with magnetic resonance imaging, ultrasonography, thermography, or tomosynthesis alone or as a complement to mammography. The recommendations for early diagnosis of breast cancer (in women with suspicious signs or symptoms) were: (i) weak recommendation for the implementation of awareness-raising strategies for early diagnosis of breast cancer; (ii) weak recommendation for use of selected signs and symptoms in the current guidelines as the criterion for urgent referral to specialized breast diagnosis services; and (iii) weak recommendation that every breast cancer diagnostic workup after the identification of suspicious signs and symptoms in primary care should be done in the same referral center.


Assuntos
Humanos , Neoplasias da Mama/prevenção & controle , Mamografia/métodos , Programas de Rastreamento , Detecção Precoce de Câncer , Brasil
14.
Cad Saude Publica ; 33(4): e00145815, 2017 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-28538791

RESUMO

This study assessed the consistency of self-reports of risk behavior (overall and within four specific domains: alcohol use, tobacco use, drug use, and sexual activity) in two editions of the Brazilian National School Based Survey of Adolescent Health (PeNSE): 2009 and 2012. The overall proportion of cases with at least one inconsistent response in the two editions was 11.7% (2.7% on the alcohol items, 2.1% for drug use, 4.3% for cigarette use, 3% for sexual activity) and 22.7% (12.8% on alcohol items, 2.5% for drug use, 4.3% for cigarette use, 4.1% for sexual activity), respectively. Such inconsistency was more prevalent among males, delayed students, those who reported having experimented with drugs, and those who did not have a cellphone. Because inconsistent responses were more prevalent among the students who claimed to have engaged in risky activities, removing inconsistent responders affected the estimated prevalence of all risk behaviors in both editions of the survey. This study supports the importance of performing consistency checks of self-report surveys, following the growing body of literature on this topic.


Assuntos
Consumo de Bebidas Alcoólicas , Assunção de Riscos , Autorrevelação , Autoavaliação , Comportamento Sexual/estatística & dados numéricos , Estudantes/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adolescente , Comportamento do Adolescente , Saúde do Adolescente , Brasil/epidemiologia , Criança , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Fatores de Risco , Fatores Sexuais , Inquéritos e Questionários
15.
Soc Sci Med ; 181: 17-23, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28364577

RESUMO

This study integrates insights from evolutionary psychology and social epidemiology to present a novel approach to contextual effects on health-risk behaviors (unprotected sex, drunkenness episodes, drugs and tobacco experimentation) among adolescents. Using data from the 2012 Brazilian National Survey of Adolescent Health (PeNSE), we first analyzed the effects of self-reported violent victimization on health-risk behaviors of 47,371 adolescents aged 10-19 nested in the 26 Brazilian state capitals and the Federal District. We then explored whether the magnitude of these associations was correlated with cues of environmental harshness and unpredictability (youth external mortality and income inequality) and mating competition (sex ratio) from the city level. Results indicated that self-reported violent victimization is associated with an increased chance of engagement in health-risk behaviors in all Brazilian state capitals, for both males and females, but the magnitude of these associations varies in relation to broader environmental factors, such as the cities' age-specific mortality rates, and specifically for females, income inequality and sex ratio. In addition to introducing a novel theoretical and empirical approach to contextual effects on adolescent health-risk behaviors, our findings reinforce the need to consider synergies between people's life experiences and the conditions where they live, when studying health-risk behaviors in adolescence.


Assuntos
Comportamentos de Risco à Saúde , Renda/estatística & dados numéricos , Mortalidade , Razão de Masculinidade , Adolescente , Comportamento do Adolescente/psicologia , Imagem Corporal/psicologia , Brasil/epidemiologia , Bullying , Criança , Vítimas de Crime/psicologia , Vítimas de Crime/estatística & dados numéricos , Feminino , Humanos , Masculino , Autorrelato , Apoio Social , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Inquéritos e Questionários
16.
Cad. saúde pública ; 33(4): e00145815, 2017. tab
Artigo em Inglês | LILACS | ID: biblio-839687

RESUMO

Abstract: This study assessed the consistency of self-reports of risk behavior (overall and within four specific domains: alcohol use, tobacco use, drug use, and sexual activity) in two editions of the Brazilian National School Based Survey of Adolescent Health (PeNSE): 2009 and 2012. The overall proportion of cases with at least one inconsistent response in the two editions was 11.7% (2.7% on the alcohol items, 2.1% for drug use, 4.3% for cigarette use, 3% for sexual activity) and 22.7% (12.8% on alcohol items, 2.5% for drug use, 4.3% for cigarette use, 4.1% for sexual activity), respectively. Such inconsistency was more prevalent among males, delayed students, those who reported having experimented with drugs, and those who did not have a cellphone. Because inconsistent responses were more prevalent among the students who claimed to have engaged in risky activities, removing inconsistent responders affected the estimated prevalence of all risk behaviors in both editions of the survey. This study supports the importance of performing consistency checks of self-report surveys, following the growing body of literature on this topic.


Resumo: O presente estudo avaliou as inconsistências no autorrelato de comportamentos de risco (geral e em quatro domínios específicos: uso de álcool, tabaco, drogas e atividade sexual) em duas edições da Pesquisa Nacional de Saúde do Adolescente (PeNSE): 2009 e 2012. Nas duas edições, a proporção de casos com ao menos uma resposta inconsistente foi de 11,7% (2,7% nos itens sobre consumo de álcool, 2,1% para uso de drogas, 4,3% para uso de tabaco, 3% para atividade sexual) e 22,7% (12,8% nos itens sobre consumo de álcool, 2,5% para uso de drogas, 4,3% para uso de tabaco, 4,1% para atividade sexual), respectivamente. Tal inconsistência foi mais prevalente entre participantes do sexo masculino, estudantes com atraso escolar, participantes que relataram ter experimentado drogas e participantes que não possuíam telefone celular. Dado que as inconsistências foram mais prevalentes entre os estudantes que declararam ter se engajado nos comportamentos de risco, remover os casos com inconsistência afetou as estimativas de prevalência destes comportamentos em ambas as edições da pesquisa. Este estudo ressalta a importância de testes para a checagem da consistência dos dados autorrelato em pesquisas, acompanhando a crescente literatura na área.


Resumen: Este estudio evaluó las inconsistencias en las conductas de riesgo de auto-reporte (general y cuatro áreas específicas: el alcohol, el tabaco, las drogas y la actividad sexual) en dos ediciones de la Encuesta Nacional de Salud del Adolescente (PeNSE): 2009 y 2012. En dos ediciones, la proporción de casos con al menos una respuesta inconsistente fue 11,7% (2,7% en alcohol, 2,1% en drogas, 4,3% en tabaco, 3% en actividad sexual) y 22,7% (12,8% en alcohol, 2,5% en drogas, 4,3% en tabaco, 4,1% en actividad sexual), respectivamente. Tal inconsistencia era más frecuente entre los participantes masculinos, los alumnos con retraso escolar, los participantes que reportaron haber consumido drogas y participantes probado que no tenían teléfono celular. Dado que las inconsistencias fueron más prevalentes entre los estudiantes que reportaron haber participado en comportamientos de riesgo, eliminar los casos de inconsistencia afectó a las estimaciones de la prevalencia de estas conductas en las dos ediciones de la encuesta. Este estudio pone de relieve la importancia de las pruebas para comprobar la coherencia de los datos de auto-informe sobre la investigación, a raíz de la creciente literatura en la zona.


Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , Consumo de Bebidas Alcoólicas , Assunção de Riscos , Autorrevelação , Autoavaliação , Comportamento Sexual/estatística & dados numéricos , Estudantes/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Comportamento do Adolescente , Saúde do Adolescente , Brasil/epidemiologia , Reprodutibilidade dos Testes , Fatores de Risco , Fatores Sexuais , Inquéritos e Questionários
17.
Cien Saude Colet ; 21(12): 3691-3702, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27925110

RESUMO

Our aim was to assess differences between men and women in the likelihood of exposure to traffic as drivers of cars and motorcycles, and in the risk of dying from a car or a motorcycle crash, in order to verify the extent to which Darwin's Sexual Selection Theory could have predicted the findings and can help to interpret them. Study population was composed of men and women aged 18 to 60 years residents in the state of Rio de Janeiro between 2004 and 2010, and in the state of Rio Grande do Sul between 2001 and 2010. We built frequency distribution tables and drew bar charts in order to check whether there were differences between the sexes and interactions of sex with age. More men exposed themselves to and died in traffic than women, especially the young. Society should have an especially vigilant attitude towards men on the wheel due to their increased innate tendency to exposure to risk. Darwin's sexual selection theory can be an important ally when postulating hypotheses and interpreting epidemiological findings aiming at improving public policies to reduce the excessive number of traffic deaths, especially in societies where machismo is strong or the stimulus to masculinity is exaggerated.


Assuntos
Acidentes de Trânsito/mortalidade , Condução de Veículo/estatística & dados numéricos , Motocicletas/estatística & dados numéricos , Assunção de Riscos , Acidentes de Trânsito/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Brasil/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção Genética , Fatores Sexuais , Adulto Jovem
18.
Ciênc. saúde coletiva ; 21(12): 3691-3702, 2016. tab, graf
Artigo em Inglês | LILACS | ID: biblio-828509

RESUMO

Abstract Our aim was to assess differences between men and women in the likelihood of exposure to traffic as drivers of cars and motorcycles, and in the risk of dying from a car or a motorcycle crash, in order to verify the extent to which Darwin's Sexual Selection Theory could have predicted the findings and can help to interpret them. Study population was composed of men and women aged 18 to 60 years residents in the state of Rio de Janeiro between 2004 and 2010, and in the state of Rio Grande do Sul between 2001 and 2010. We built frequency distribution tables and drew bar charts in order to check whether there were differences between the sexes and interactions of sex with age. More men exposed themselves to and died in traffic than women, especially the young. Society should have an especially vigilant attitude towards men on the wheel due to their increased innate tendency to exposure to risk. Darwin's sexual selection theory can be an important ally when postulating hypotheses and interpreting epidemiological findings aiming at improving public policies to reduce the excessive number of traffic deaths, especially in societies where machismo is strong or the stimulus to masculinity is exaggerated.


Resumo Objetivamos averiguar diferenças entre homens e mulheres na exposição ao trânsito como motorista de carro e de moto e no risco de morrer por batida desses veículos, para verificar até que ponto a teoria da seleção sexual de Darwin pode predizer os achados e ajudar a interpretá-los. A população de estudo foi composta por homens e mulheres de 18 a 60 anos residentes no Estado do Rio de Janeiro, entre 2004 e 2010, e no Estado do Rio Grande do Sul, entre 2001 e 2010. Elaboramos tabelas de frequência e gráficos de barras para verificar se havia diferenças entre os sexos e interação de sexo com idade. Homens se expuseram e morreram mais no trânsito do que mulheres, especialmente os jovens. A sociedade deveria ter uma atitude especialmente vigilante com homens ao volante devido à tendência inata deles de maior exposição ao risco. A teoria da seleção sexual de Darwin pode ser uma potente aliada na postulação de hipóteses que busquem aperfeiçoar políticas públicas para reduzir a quantidade exagerada de mortes no trânsito, especialmente em sociedades onde o machismo for forte ou o estímulo à masculinidade exagerado.


Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Acidentes de Trânsito/mortalidade , Condução de Veículo/estatística & dados numéricos , Motocicletas/estatística & dados numéricos , Assunção de Riscos , Acidentes de Trânsito/estatística & dados numéricos , Fatores Etários , Brasil/epidemiologia , Seleção Genética , Fatores Sexuais
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