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1.
Medicina (B Aires) ; 79(4): 241-250, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-31487242

RESUMO

Type 2 diabetes is a chronic, progressive disease with increasing prevalence and still late diagnostic. This leads to an increase in the incidence of chronic complications, with signifi cantly increasing health costs. There is also a delay in the onset of insulin therapy in patients with type 2 diabetes for causes related to both patients and physicians. Despite advances in treatment, a low proportion of patients achieve adequate glycemic control. The high hypoglycemia prevalence, consequence of insulin, has led to the development of a new generation long-acting basal insulins to achieve a more stable and prolonged action profile, reducing the variability and risk of hypoglycemia. The EDITION program evaluated the efficacy and safety of glargine U300 compared to glargine U100 in patients with type 1 and 2 diabetes at different stages of the disease. Gla-300 is a new formulation of insulin glargine which has a more stable and prolonged pharmacokinetic and pharmacodynamic profile. Gla-300 demonstrated efficacy and tolerability comparable to glargine U100, with a significant decrease in the risk of hypoglycemia, at night and in 24 hours, providing greater flexibility in the injection schedule, with a window of 6 hours. No increase in weight was observed compared to glargine U100. Bright study (2018) compared glargine U300 vs. degludec U100, demonstrating greater benefit in relation to the risk of hypoglycemia with Gla-300 during titration period. Gla-300 is a last-generation basal insulin, available to improve metabolic control, with a lower risk of hypoglycemia.


Assuntos
Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/administração & dosagem , Insulina Glargina/administração & dosagem , Insulina Glargina/farmacocinética , Medicina Baseada em Evidências , Humanos , Hipoglicemiantes/efeitos adversos , Hipoglicemiantes/farmacocinética , Insulina Glargina/efeitos adversos
4.
J Laryngol Otol ; 133(8): 640-649, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31366414

RESUMO

OBJECTIVE: To review the literature regarding screening for vestibular schwannoma in the context of demographic changes leading to increasing numbers of elderly patients presenting with asymmetric auditory symptoms. METHODS: A systematic review of the literature was performed, with narrative synthesis and statistical analysis of data where appropriate. RESULTS: Vestibular schwannomas diagnosed in patients aged over 70 years exhibit slower growth patterns and tend to be of smaller size compared to those tumours in younger age groups. This fact, combined with reduced life expectancy, renders the probability of these tumours in the elderly requiring active treatment with surgery or stereotactic radiotherapy to be extremely low. Vestibular schwannomas in the elderly are much more likely to be managed by serial monitoring with magnetic resonance imaging. The weighted yield of magnetic resonance imaging in the diagnosis of vestibular schwannoma in all age groups is 1.18 per cent, with almost 85 scans required to diagnose 1 tumour. CONCLUSION: An evidence-based approach to the investigation of asymmetric hearing loss and tinnitus in the elderly patient can be used to formulate guidelines for the rational use of magnetic resonance imaging in this population.


Assuntos
Envelhecimento/fisiologia , Perda Auditiva/etiologia , Neuroma Acústico/diagnóstico por imagem , Zumbido/etiologia , Idoso , Medicina Baseada em Evidências , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Vigilância da População
5.
Stud Health Technol Inform ; 264: 188-192, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31437911

RESUMO

PICO (Population/problem, Intervention, Comparison, and Outcome) is widely adopted for formulating clinical questions to retrieve evidence from the literature. It plays a crucial role in Evidence-Based Medicine (EBM). This paper contributes a scalable deep learning method to extract PICO statements from RCT articles. It was trained on a small set of richly annotated PubMed abstracts using an LSTM-CRF model. By initializing our model with pretrained parameters from a large related corpus, we improved the model performance significantly with a minimal feature set. Our method has advantages in minimizing the need for laborious feature handcrafting and in avoiding the need for large shared annotated data by reusing related corpora in pretraining with a deep neural network.


Assuntos
Medicina Baseada em Evidências , Redes Neurais (Computação) , PubMed , Ensaios Clínicos Controlados Aleatórios como Assunto
6.
Arq Gastroenterol ; 56(2): 202-208, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31460587

RESUMO

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal diseases. GERD generates significant impairment in patients' quality of life and it is associated to relevant medical resources utilization. A better understanding of GERD pathophysiology in the past five decades has favored the evolution of therapeutic strategies from non-drug interventions and antacids to more efficacious and safer alternatives. OBJECTIVE: To summarize data about the historical evolution of GERD management in Brazil, focusing on medical therapy and addressing evidence on efficacy and safety of drug classes currently recommended. METHODS: A narrative review was conducted by systematizing information about discoveries on GERD pathophysiology. We also addressed efficacy and safety of medications currently used to reduce symptoms and improve endoscopic healing of esophageal lesions. A structured search on Pubmed was performed to identify systematic reviews and meta-analysis investigating GERD outcomes positively impacted by proton pump inhibitors (PPIs), the first choice of pharmacotherapy for the disease. RESULTS: The chronological development of therapeutic measures for GERD in Brazil evolved from lifestyle interventions with relative poor effect on symptoms related to esophageal acid exposure, particularly heartburn, to effective and safe pharmacological interventions such as histamine H2-receptor antagonists and PPIs. In the present days, some drug classes play a minor role in disease management, namely prokinetics and antacids, due to their reduced efficacy and relevant safety concerns (particularly with prokinetics). The main challenge for prescribers and researchers seems to be finding long-acting acid suppressants strategies able to ameliorate patients' symptoms and quality of life, thereafter, reducing medical resource consumption. The dual delayed-release PPI dexlansoprazole seems to respond for some of the limitations other PPIs have. CONCLUSION: Recognizing the historical evolution of GERD management can help care providers to better understand therapeutic options for their patients, as well as focus on unmet needs that deserve further attention. PPIs are still the first choice therapy, with good evidence in favor of their efficacy, despite some safety concerns. However, as with any medical intervention, it is recommended to prescribe PPIs for patients with clear indication, using adequate dosing and monitoring for adverse events.


Assuntos
Terapia Comportamental/métodos , Medicina Baseada em Evidências , Refluxo Gastroesofágico/terapia , Estilo de Vida , Antiácidos/uso terapêutico , Antieméticos/uso terapêutico , Antagonistas dos Receptores Histamínicos H2/uso terapêutico , Humanos , Inibidores da Bomba de Prótons/uso terapêutico
7.
Lancet ; 394(10196): 360, 2019 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-31379322
8.
Stud Health Technol Inform ; 264: 734-738, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438021

RESUMO

Clinical practice guidelines (CPGs) are indispensable in the practice of evidence-based medicine. However, the cost of effective CPG dissemination strategies is prohibitive and not cost-effective. Therefore, scalable strategies using available technology are needed. We describe a formal model-driven approach to design a gamified e-learning system for clinical guidelines. We employ gamification to increase user motivation and engagement in the training of guideline content. Our approach involves the use of models for different aspects of the system, an entity model for the clinical domain, a workflow model for the clinical processes and a game model to manage the training sessions. A game engine instantiates a training session by coupling the workflow and entity models to automatically generate questions based on the data in the model instances. Our approach is flexible and adaptive as it allows for easy updates of the guidelines, integration with different device interfaces and representation of any guideline.


Assuntos
Instrução por Computador , Assistência à Saúde , Medicina Baseada em Evidências , Guias como Assunto , Aprendizagem , Motivação
11.
Women Birth ; 32(5): 460-465, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31303540

RESUMO

BACKGROUND: Approaches to health promotion that are collaborative, support strengths inherent in Aboriginal and Torres Strait Islander culture, and demonstrate respect and understanding for individual communities, have achieved the most positive outcomes to date. AIM: To illustrate how the implementation and evaluation of a safe infant sleep health promotion strategy was facilitated by embedding recognised best practice principles for the conduct of research with Aboriginal and Torres Strait Islander peoples and communities. METHODS: The Pepi-Pod® Program was introduced across rural, remote and metropolitan locations in Queensland between 2013 and 2017. This case study discusses the partnership between the Pepi-Pod® Program and one community-controlled maternal and child health service that employed an Aboriginal Health Worker led model of maternal and child health care for remote regions of Queensland. FINDINGS: Best practice principles were embedded within the program design and adaptation, and in the approach to community consultation prior to program implementation. Collaborative partnerships based on trust, which established stakeholder expectations through transparent communication processes, together with effective engagement in achieving program goals, led to the implementation of this evidence-based health promotion initiative as intended. Consideration for locally relevant and culturally competent program delivery was key to success. The integrity of the program was maintained and embedded into ongoing service delivery. CONCLUSIONS: Through adherence to best practice principles for research with Aboriginal and Torres Strait Islander communities, implementation and evaluation of health promotion programs can be conducted in mutually acceptable, feasible and sustainable ways that develop capacity within participating health services.


Assuntos
Pesquisa Participativa Baseada na Comunidade/métodos , Assistência à Saúde Culturalmente Competente , Medicina Baseada em Evidências , Promoção da Saúde/métodos , Serviços de Saúde Materno-Infantil , Grupo com Ancestrais Oceânicos , Austrália , Pesquisa Participativa Baseada na Comunidade/ética , Feminino , Serviços de Saúde do Indígena , Humanos , Lactente , Queensland
13.
Codas ; 31(3): e20180243, 2019 Jun 27.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31271584

RESUMO

PURPOSE: to verify the applications of AAT in health by performing a systematic review of the literature. RESEARCH STRATEGY: a survey was carried out in four databases with the descriptors: animal assisted therapy, horse assisted therapy, speech therapy. SELECTION CRITERIA: article published between 2010 and 2018, in Portuguese or English, free electronic access and that mentioned the characteristics of the intervention program. DATA ANALYSIS: criteria: casuistry, area of knowledge, program characteristic, type of research, year and language of publication, nationality, periodical and impact factor. RESULTS: 43 articles published in 30 journals, 16 with impact factor, were reviewed. Clinical studies prevailed (93.02%), 37.20% were from Medicine, the population studied had different diagnoses and ages, 55.81% with adults / elderly. AAT was used preferentially for physical rehabilitation (67.44%) and the main mediator was the dog, mentioned in 72.09% of the articles. Eight (n = 8) programs with a focus on communication intervention were described. CONCLUSION: There is scientific evidence on the use of AAT published in the period studied, in Brazil and in the world. The programs were used by different health and education professionals. The AAT goals were specific to the profile of the participants, and consistent with the characteristics of the mediator animal and the site.


Assuntos
Terapia Assistida por Animais/métodos , Animais , Cães , Medicina Baseada em Evidências , Cavalos , Humanos
15.
Am Surg ; 85(6): 645-653, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31267907

RESUMO

The purpose of this meta-analysis was to determine the value of quantitative dynamic contrast-enhanced (DCE) MRI (DCE-MRI) in evaluating the response of breast cancer to neoadjuvant chemotherapy (NAC). PubMed, Embase, and Cochrane Library databases (from building to July 31, 2018) were searched to collect articles about the therapeutic evaluation of NAC using the quantitative DCE-MRI in patients with breast cancer. The sensitivities and specificities of quantitative DCE-MRI in the evaluation of NAC for breast cancer were extracted from the articles. Meta-DiSc1.4 was applied to evaluate the efficacy of the sensitivity and specificity; forest figure and summary receiver operating characteristics (SROC) were created. A total of 356 articles were enrolled in this study, including 739 cases in total, in which 218 cases were effective and the other 521 cases were ineffective to NAC, considering the pathological results as the gold standard. The sensitivity and specificity in the included 14 articles of quantitative DCE-MRI (Ktrans, Kep, and ve) in comprehensively evaluating NAC for breast cancer were 84 per cent (95% confidence interval (CI): 78-88%) and 83 per cent (95% CI: 79-86%), respectively. The area under SROC was 0.899 (95% CI: 0.867-0.943). The sensitivity and specificity in the three articles of Ktrans evaluating NAC for breast cancer were 84.1 per cent (95% CI: 71.0-92.1%) and 81.3 per cent (95% CI: 70.5%-88.5%), respectively. The area under SROC was 0.899 (95% CI: 0.834-0.962). Our study confirmed that the quantitative DCE-MRI is able to monitor NAC treatment for breast cancer because of its high sensitivity and specificity. However, there is a high degree of heterogeneity in published studies, highlighting the lack of standardization in the field.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/tratamento farmacológico , Meios de Contraste , Imagem por Ressonância Magnética/métodos , Terapia Neoadjuvante/métodos , Intensificação de Imagem Radiográfica/métodos , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Área Sob a Curva , Neoplasias da Mama/mortalidade , Estudos de Avaliação como Assunto , Medicina Baseada em Evidências , Feminino , Humanos , Pessoa de Meia-Idade , Curva ROC , Medição de Risco , Sensibilidade e Especificidade , Análise de Sobrevida , Resultado do Tratamento
18.
Gastroenterology ; 157(2): 320-348, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31320109

RESUMO

BACKGROUND & AIMS: We aim to provide guidance for medical treatment of luminal Crohn's disease in children. METHODS: We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them. RESULTS: The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation. CONCLUSIONS: Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.


Assuntos
Doença de Crohn/tratamento farmacológico , Medicina Baseada em Evidências/normas , Gastroenterologia/normas , Fármacos Gastrointestinais/uso terapêutico , Sociedades Médicas/normas , Canadá , Criança , Medicina Baseada em Evidências/métodos , Gastroenterologia/métodos , Humanos , Resultado do Tratamento
19.
Br J Anaesth ; 123(3): 325-334, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31327465

RESUMO

BACKGROUND: Ketamine is a phencyclidine intravenous anaesthetic that blocks N-methyl-d-aspartate receptors and HCN channels in the CNS. Lately it has gained acceptance in a low-dose form, with studies showing an analgesic benefit in orthopaedic surgery. Our goal was to critically appraise and synthesise current evidence regarding use of low-dose ketamine in major, painful orthopaedic surgeries. METHODS: We conducted searches in Medline, Embase, Cochrane, and specialty journals for randomised controlled trials (RCTs) that compared low-dose ketamine to placebo. Primary outcomes included total opioid use, time to first opioid, and VAS pain scores. Meta-analyses were undertaken in RevMan software using a random effects model. We rated the quality of the evidence using the GRADE Working Group criteria. RESULTS: We included 20 studies across four subgroups for meta-analysis. The overall quality of the evidence was moderate. Ketamine significantly decreased total opioid use and pain scores (VAS) at 24 and 48 h (Opioid: standardised mean difference [SMD] -0.82 [-1.24, -0.40], p=0.0001, and -0.65 [-1.03,-0.27], p=0.0008; VAS: SMD -0.53 [-0.91, -0.15], p=0.006 and -0.60 [-1.05, -0.16], p=0.008), and delayed the time to first opioid dose (SMD 0.64 [0.01, 1.27], p=0.05). Results for nausea and hallucinations were equivocal, whereas results for chronic pain were inconclusive. The most prominent effects were seen in total joint operations. CONCLUSION: Low-dose ketamine is an effective adjuvant that decreases pain and opioid requirements in painful orthopaedic procedures, especially in the first 24 h after procedure. Future research should focus on arthroscopic procedures and the incidence of chronic pain.


Assuntos
Analgésicos/administração & dosagem , Ketamina/administração & dosagem , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Anestésicos Dissociativos/administração & dosagem , Relação Dose-Resposta a Droga , Esquema de Medicação , Quimioterapia Combinada , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Humanos , Medição da Dor/métodos
20.
Br J Anaesth ; 123(3): 269-287, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31351590

RESUMO

BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER: PROSPERO CRD42018099935.


Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Geral/efeitos adversos , Raquianestesia/efeitos adversos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Anestesia Epidural/mortalidade , Anestesia Geral/mortalidade , Raquianestesia/mortalidade , Artroplastia de Quadril/mortalidade , Artroplastia do Joelho/mortalidade , Medicina Baseada em Evidências/métodos , Humanos , Complicações Pós-Operatórias/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
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