On the Measurement of Change in Medical Research

Measuring of change is essential in medical research. However, these measurements may have different goals and, traditionally, the ability to measure change has focused on sensitivity in a statistical sense, whereas little attention has been directed to the appropriate interpretation and analysis of change indicators. The present report examines some of the most important issues involved in measuring change with pre and post-test data when ordinal scales are used, and the conceptual problems pertaining to the use of these scales are also discussed. It can be said that there is still no agreement about the most adequate strategy for assessing health status change in a group of subjects, what caused the introduction of many indicators, most of which variations of the ES (Effect size: the mean of change scores divided by the standard deviation of the baseline scores) concept. The adequate interpretation of change scores in these cases demands a high degree of knowledge about what these changes mean to specific sub-groups of patients, as well as detailed information on their situation at baseline, such as score distributions. Researchers should strive for interpretations that take into account what "change" means for different patients

Análise de sensibilidade para um confundidor não mensurado utilizando planilha eletrônica

Em estudos que avaliam o efeito de uma dada variável de exposição e um determinado desfecho de interesse, uma situação de confusão pode ser caracterizada pela falsa aparência de que a variável de exposição produz o desfecho de interesse quando, de fato, o efeito observado se deve a um fator de confundimento que está presente. Entretanto, é pouco freqüente a utilização de técnicas quantitativas para determinar a influência potencial de confundidores não mensurados. A análise de sensibilidade é uma técnica estatística que permite uma medida quantitativa do impacto de uma variável confundidora não mensurada na associação de interesse que está sendo avaliada. O objetivo do artigo foi viabilizar a aplicação, por meio de planilha eletrônica, de dois métodos de análise de sensibilidade disponíveis na literatura, desenvolvidos por Rosenbaum e Greenland. Dessa forma, é possível facilitar ao pesquisador a incorporação desse ferramental quantitativo ao conjunto de procedimentos que já são comuns na etapa de validação dos resultados.In studies assessing the effects of a given exposure variable and a specific outcome of interest, confusion may arise from the mistaken impression that the exposure variable is producing the outcome of interest, when in fact the observed effect is due to an existing confounder. However, quantitative techniques are rarely used to determine the potential influence of unmeasured confounders. Sensitivity analysis is a statistical technique that allows to quantitatively measuring the impact of an unmeasured confounding variable on the association of interest that is being assessed. The purpose of this study was to make it feasible to apply two sensitivity analysis methods available in the literature, developed by Rosenbaum and Greenland, using an electronic spreadsheet. Thus, it can be easier for researchers to include this quantitative tool in the set of procedures that have been commonly used in the stage of result validation

Renda e inserção profissional dos médicos brasileiros após instituição do Sistema Único de Saúde

OBJECTIVE: To analyze trends relating to physicians' vocational integration and income composition from the Pesquisas Nacionais por Amostra de Domicílio (PNAD - National Household Sampling Surveys). METHODS: PNAD microdata from 1988, 1993, 1998 and 2003 were analyzed in relation to demographic, social and occupational parameters. In the exploratory analysis, trends relating to physicians' employment and income were considered. Statistical associations were evaluated by means of the chi-square test. RESULTS: Regarding the demographic profile, a trend of increasing presence of women and of professionals over 55 years of age was observed, with a continuing high proportion of whites. Regarding occupation and income, there was an increase in entrepreneurialism among physicians and maintenance of high income, in relative terms, especially among those who combined the occupations of employee and employer. CONCLUSIONS: The possibility of examining individualized characteristics of occupation and income, along with physicians' many professional ties, which albeit in a limited manner can be done through PNAD, contributes towards deepening the comprehension of the patterns and changes in Brazilian physicians' integration in the labor market since the implementation of the Sistema Único de Saúde (SUS - National Health System).OBJETIVO: Analizar las tendencias de inserción en el trabajo y composición de renta de los médicos a partir de la Pesquisas Nacionais por Amostra de Domicílio (PNAD - Pesquisas Nacionales por Muestra de Domicilio). MÉTODOS: Los microdatos de las PNAD de 1988, 1993, 1998 y 2003 fueron analizados según parámetros demográficos, sociales y ocupacionales. En el análisis exploratorio fueron consideradas las tendencias relacionadas con el empleo y renta de los médicos. Las asociaciones estadísticas fueron evaluadas por la prueba de chi-cuadrado. RESULTADOS: En cuanto al perfil demográfico se observó una tendencia de ampliación de la presencia de mujeres y de profesionales con más de 55 años, además de la preservación de la alta proporción de blancos. Con relación a la ocupación y a la renta, se evidenció un aumento del empresariamiento médico y el mantenimiento de elevados rendimientos, en términos relativos, especialmente para aquellos que mezclaban ocupaciones de empleado con empleador. CONCLUSIONES: La posibilidad del examen de características individualizadas de ocupación y renta y los múltiples vínculos de los médicos, disponibles en las PNAD, aún que limitadas, contribuye a la profundización de la comprensión de los patrones y cambios de la inserción de los médicos brasileros en el mercado de trabajo en el período post-implementación del Sistema Único de Salud.OBJETIVO: Analisar as tendências de inserção no trabalho e composição de renda dos médicos a partir das Pesquisas Nacionais por Amostra de Domicílio (PNAD). MÉTODOS: Os microdados das PNAD de 1988, 1993, 1998 e 2003 foram analisados segundo parâmetros demográficos, sociais e ocupacionais. Na análise exploratória foram consideradas as tendências relacionadas com o emprego e renda dos médicos. As associações estatísticas foram avaliadas pelo teste qui-quadrado. RESULTADOS: Quanto ao perfil demográfico observou-se uma tendência de ampliação da presença de mulheres e de profissionais com mais de 55 anos, além da preservação da alta proporção de brancos. Com relação à ocupação e à renda, observou-se um aumento do empresariamento médico e a manutenção de elevados rendimentos, em termos relativos, especialmente para aqueles que mesclavam ocupações de empregado e empregador. CONCLUSÕES: A possibilidade do exame de características individualizadas de ocupação e renda e dos múltiplos vínculos dos médicos, disponíveis nas PNAD, ainda que limitadas, contribui para o aprofundamento da compreensão dos padrões e mudanças da inserção dos médicos brasileiros no mercado de trabalho no período pós-implementação do Sistema Único de Saúde

Acesso a medicamentos de uso contínuo entre idosos, Brasil

OBJETIVO Analisar a prevalência e fatores associados com o acesso a medicamentos de uso contínuo e formas de sua obtenção.MÉTODOS Foram obtidos dados da Pesquisa Nacional por Amostras em Domicílio de 2008. A amostra foi composta por 27.333 indivíduos com idade acima de 60 anos que reportaram utilizar medicamentos de uso contínuo. Foram utilizados modelos de regressão logística multinomial binário e múltipla para análise dos dados.RESULTADOS Tiveram acesso a todos os medicamentos 86,0% dos idosos, dos quais 50,7% os obtiveram por compra. Aqueles que os obtiveram do sistema público de saúde eram mais jovens (60-64 anos), não tinham plano de saúde e pertenciam a grupos com menor renda. Dos idosos que usam medicamentos de uso contínuo, 14,0% não receberam nenhum dos medicamentos; para aqueles com mais de quatro doenças crônicas esse valor chegou a 22,0%; aqueles com maior número de morbidades crônicas tiveram maior risco de não conseguir todos os medicamentos.CONCLUSÕES Alguns grupos de idosos apresentam risco aumentado de não obter todos os medicamentos necessários e de comprar todos os medicamentos. Esses resultados podem orientar programas e planos de acesso a medicamentos no Brasil.OBJECTIVE To determine the prevalence and associated access factors for all continued-use prescription drugs and the ways in which they can be obtained.METHODS Data was obtained from the 2008 Household National Survey. The sample comprised 27,333 individuals above 60 years who reported that they used continued-use prescription drugs. A descriptive analysis and binary and multiple multinomial logistic regressions were performed.RESULTS 86.0% of the older adults had access to all the medication they needed, and among them, 50.7% purchased said medication. Those who obtained medication from the public health system were younger (60-64 years), did not have health insurance plans, and belonged to the lower income groups. It is remarkable that 14.0% of the subjects still had no access to any continued-use medication, and for those with more than four chronic diseases, this amount reached 22.0%. Those with a greater number of chronic diseases ran a higher risk of not having access to all the medication they needed.CONCLUSIONS There are some groups of older adults with an increased risk of not obtaining all the medication they need and of purchasing it. The results of this study are expected to contribute to guide programs and plans for access to medication in Brazil

Caregivers’ Sense of Coherence and Untreated Dental Caries in Children and Adolescents: A Cross-Sectional Study

Objective: To associate caregivers\u27 sense of coherence (SOC) and untreated caries with oral health status in children covered by a dental public health system. Material and Methods: A convenience sample of caregivers/children in Angra dos Reis, Brazil, was surveyed. Caregivers\u27 SOC was evaluated using the 13-question version questionnaire. For both caregivers/children, sociodemographic information was acquired and caries experience was evaluated by DMFT/dmft and PUFA/pufa index. Statistical associations between children\u27s untreated carious teeth and interest variables from the caregivers were evaluated by binary logistic regression assessed by generalized linear modeling. Results: A total of 233 pairs of caregivers-children were included. Children\u27s untreated permanent and primary carious teeth represented 34.8% and 62.2% of the caries experience, respectively and at least one PUFA/pufa scored tooth was detected in 22.7% of them. Caregivers\u27 DMFT was 13.5±7.0, while 33.6% scored on PUFA. A total of 62.1% of them presented untreated carious lesions. Results from the univariate model, correlating children\u27s untreated caries and caregivers\u27 attributes showed a statistical significance for SOC values (p<0.015), untreated decayed teeth (p<0.035), self-perception of oral health (p<0.022) and oral impact on daily performance (p<0.010). The multivariate logistic first model kept the statistical significance only for the caregiver\u27s untreated decayed teeth. Conclusion: Caregivers\u27 SOC and untreated carious teeth could be used as indicators of dental treatment needs in their offspring

Survey of Knowledge, Attitudes and Practices of Brazilian Dentists Regarding Silver Diamine Fluoride

Objective: Current acceptability, barriers to use, and clinical/teaching practices of Silver Diamine Fluoride (SDF) among Brazilian dentists were investigated. Material and Methods: A Google forms questionnaire was sent to dentists (n=10,500) to collect information about the use of SDF and the dentists' workplace, experience, specialty, and city of practice. A logistic regression model was performed. Results: From 409 respondents, 13.2% used SDF. Working at universities increased the use of SDF by 2.29 times (p=0.018) compared to private offices. Each training year, the chance of SDF usage increased by 3%  (p=0.008). Pediatric dentists are more likely to use SDF (OR=6.76, p<0.001). There is no association between SDF usage and the city of practice. The majority (75.9%) indicated SDF for noncompliant patients. Dentists (75.9%) reported the exclusive use in deciduous teeth, while 24.1% also use in permanent teeth. The main barrier for non-users was a lack of knowledge (58.3%), while for users, tooth staining (90.7%) and parental acceptance (64.8%) were the complaints. Conclusion: The Silver Diamine Fluoride is not a common product used by the dentists from RJ. Its clinical applicability should be further disseminated; thus, lack of scientific knowledge would cease to be a problem in the use of SDF to arrest caries lesions

Caregivers’ Sense of Coherence and Untreated Dental Caries in Children and Adolescents: A Cross-Sectional Study

Objective: To associate caregivers' sense of coherence (SOC) and untreated caries with oral health status in children covered by a dental public health system. Material and Methods: A convenience sample of caregivers/children in Angra dos Reis, Brazil, was surveyed. Caregivers' SOC was evaluated using the 13-question version questionnaire. For both caregivers/children, sociodemographic information was acquired and caries experience was evaluated by DMFT/dmft and PUFA/pufa index. Statistical associations between children's untreated carious teeth and interest variables from the caregivers were evaluated by binary logistic regression assessed by generalized linear modeling. Results: A total of 233 pairs of caregivers-children were included. Children's untreated permanent and primary carious teeth represented 34.8% and 62.2% of the caries experience, respectively and at least one PUFA/pufa scored tooth was detected in 22.7% of them. Caregivers' DMFT was 13.5±7.0, while 33.6% scored on PUFA. A total of 62.1% of them presented untreated carious lesions. Results from the univariate model, correlating children's untreated caries and caregivers' attributes showed a statistical significance for SOC values (p<0.015), untreated decayed teeth (p<0.035), self-perception of oral health (p<0.022) and oral impact on daily performance (p<0.010). The multivariate logistic first model kept the statistical significance only for the caregiver's untreated decayed teeth. Conclusion: Caregivers' SOC and untreated carious teeth could be used as indicators of dental treatment needs in their offspring

Diabetes influences liver stiffness in chronic hepatitis C patients with and without virological cure: A longitudinal study

OBJECTIVES: The aim was to prospectively assess the variation in liver stiffness (LS) and the associated factors for LS progression in a cohort of naïve, non-responder (NR), and sustained virological response (SVR) chronic hepatitis C (CHC) patients. METHODS: This was a longitudinal study on CHC patients prospectively followed with serial elastography (Fibroscan®). The LS progression rate was determined, and the associated factors for progression were assessed using multiple linear regression analysis. RESULTS: A total of 406 patients were followed up for 44 (35-53) months [naïve (29%), NR (24%), and SVR (47%)]. At the end of the follow-up period, the SVR group had a significant decrease in LS [11.8 (9.2)&nbsp;vs.&nbsp;8.8 (8.4) kPa (p&lt;0.001)], the NR group had a significant increase in LS [6.6 (5.2)&nbsp;vs.&nbsp;7.1 (4.5) kPa (p=0.069)], and the naïve group had no change in LS [6.3 (3.0)&nbsp;vs.&nbsp;6.0 (3.8) kPa (p=0.22)]. The related factors for LS progression were lack of SVR (p=0.002) and diabetes (p=0.05). In the non-diabetic SVR group, a negative rate of progression (-0.047 kPa/month) was observed, whereas in the diabetic SVR group, a positive rate of progression (+0.037 kPa/month) was observed. The highest rate of progression was observed in NR with diabetes at the rate of +0.044 kPa/month. CONCLUSION: LS in diabetes patients progresses despite SVR, suggesting the need for a close follow-up of this group post-treatment considering the risk of progression of liver disease even after SVR

Perfil audiométrico segundo exposição de pilotos civis ao ruído

OBJECTIVE To evaluate the audiometric profile of civilian pilots according to the noise exposure level. METHODS This observational cross-sectional study evaluated 3,130 male civilian pilots aged between 17 and 59 years. These pilots were subjected to audiometric examinations for obtaining or revalidating the functional capacity certificate in 2011. The degree of hearing loss was classified as normal, suspected noise-induced hearing loss, and no suspected hearing loss with other associated complications. Pure-tone air-conduction audiometry was performed using supra-aural headphones and acoustic stimulus of the pure-tone type, containing tone thresholds of frequencies between 250 Hz and 6,000 Hz. The independent variables were professional categories, length of service, hours of flight, and right or left ear. The dependent variable was pilots with suspected noise-induced hearing loss. The noise exposure level was considered low/medium or high, and the latter involved periods >; 5,000 flight hours and >; 10 years of flight service. RESULTS A total of 29.3% pilots had suspected noise-induced hearing loss, which was bilateral in 12.8% and predominant in the left ear (23.7%). The number of pilots with suspected hearing loss increased as the noise exposure level increased. CONCLUSIONS Hearing loss in civilian pilots may be associated with noise exposure during the period of service and hours of flight.OBJETIVO Analisar o perfil audiométrico de pilotos civis segundo grau de exposição ao ruído. MÉTODOS Trata-se de um estudo observacional, transversal, com 3.130 pilotos civis do sexo masculino de 17 a 59 anos submetidos a exames audiométricos iniciais ou de revalidação de Certificado de Capacidade Física em 2011. Os sujeitos foram categorizados segundo perda auditiva como: normais, sugestivos de perda auditiva induzida por ruído, e outros fatores associados e não sugestivos. A audiometria tonal liminar utilizada foi por via aérea, com a utilização de fones supra-aurais, por meio do estímulo acústico do tipo tom puro, contendo os limiares tonais das frequências de 250 a 6.000 Hz. As variáveis independentes foram as categorias dos pilotos, tempo de serviço, horas de voo e orelha direita ou esquerda. A variável dependente corresponde aos casos sugestivos de perda auditiva induzida por ruído. O grau de exposição foi considerado baixo/médio ou alto, sendo este último com horas de voo maiores que 5.000 e tempo de serviço maior que 10 anos. RESULTADOS Foram observados 29,3% casos sugestivos de perda auditiva induzida por ruído, 12,8% bilaterais com predomínio do lado esquerdo (23,7%). Com o aumento do grau de exposição ao ruído, o número de casos sugestivos de perda auditiva também aumentou. CONCLUSÕES A perda auditiva nos pilotos civis pode estar associada à exposição ao ruído ao longo do tempo de serviço e das horas de voo