Cluster randomized clinical trial to evaluate the effectiveness of a diagnosis recognition and treatment guide for depressive disorders in primary care

Objetivo: Avaliação da efetividade de um instrumento de reconhecimento diagnóstico e de orientação terapêutica para transtornos depressivos em atenção primária. Método: Ensaio clínico controlado com randomização por cluster de oito médicos clínicos das Unidades Básicas de Saúde (UBS) de Marília, estado de São Paulo, Brasil. Os médicos clínicos foram randomizados para tratarem os pacientes do modo habitual ou para experimentarem um guia de tratamento para pacientes diagnosticados com depressão, de acordo com os critérios do DSM-IV e com pontuação de 8 a 22 pontos na escala HAM-D de gravidade de depressão. Entre os pacientes encaminhados para avaliação por uma psiquiatra foram recrutados 30 pacientes para cada médico clínico. Os pacientes foram atendidos pelo médico clínico por dezesseis semanas, com três atendimentos de apoio no primeiro mês, e, mensalmente, do segundo ao quarto mês. Medidas de desfecho: Reconhecimento diagnóstico com início de tratamento para o paciente com transtorno depressivo pelo médico clínico, e remissão clínica para o paciente após dezesseis semanas de acompanhamento. Resultados: As taxas de perdas foram de 23 /114 (20.2%) e 13/120 (10.8%) respectivamente no grupo de tratamento habitual e de intervenção (p = .153). No 4º mês, a taxa de remissão clínica para o paciente foi de 65/114 (57.0%) no grupo de tratamento habitual e 84/120 (70.0%) no grupo de intervenção experimental (p = .004). A taxa de início de tratamento no grupo experimental (119/120 (99.2%)) foi maior do que no de tratamento habitual (100/114 (87.7%), mas a diferença não foi estatisticamente significativa (p = .154). Conclusões: O uso de um instrumento de orientação diagnóstica e terapêutica permitiu aos médicos clínicos de atenção primária, a aplicação de intervenção terapêutica adequada resultando na remissão clínica dos pacientes diagnosticados com depressão, no entanto sem alterar as taxas de reconhecimento diagnóstico e início de intervenção terapêutica.Objective: To evaluate the effectiveness of a diagnosis recognition and treatment guide for treating depressive disorders in a primary care setting. Methods: Cluster randomized controlled clinical trial with eight primary care clinicians being the unit of randomization to either use usual care or an experimental treatment guide for treating patients diagnosed with depression according to DSM-IV criteria and with a HAM-D depression severity scale between 8 and 22. For each clinician 30 patients referred to a psychiatrist were recruited to participate. Patients were seen by the clinician at weeks 2, 4, 8, 12 and 16 following their initial visit. Main outcome measures were appropriate treatment of depressive disorder by the clinician and clinical remission after sixteen weeks of follow-up. Results: Patients withdrawal rates were 19/114 (16.7%) and 9/120 (7.5%) in the usual care and intervention arm, respectively (p = .122). At four months the clinical remission rate was 65/114 (57.0%) in the usual care arm and 84/120 (70.0%) in the intervention arm (p=.004). The appropriate treatment rate was higher in the intervention arm (119/120 (99.2%)) than in the usual care arm (100/114 (87.7%)), but the difference was not statistically significant (p=.154). Conclusion: The use of a diagnosis recognition and treatment guide for depression by primary care clinicians improves patient clinical remission rates. However this study did not show that the use of a guide changes the diagnosis recognition and appropriate treatment rates

Statins for aortic valve stenosis

Background Aortic valve stenosis is the most common type of valvular heart disease in the USA and Europe. Aortic valve stenosis is considered similar to atherosclerotic disease. Some studies have evaluated statins for aortic valve stenosis. Objectives To evaluate the effectiveness and safety of statins in aortic valve stenosis. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS ‐ IBECS, Web of Science and CINAHL Plus. These databases were searched from their inception to 24 November 2015. We also searched trials in registers for ongoing trials. We used no language restrictions. Selection criteria Randomised controlled clinical trials (RCTs) comparing statins alone or in association with other systemic drugs to reduce cholesterol levels versus placebo or usual care. Data collection and analysis Primary outcomes were severity of aortic valve stenosis (evaluated by echocardiographic criteria: mean pressure gradient, valve area and aortic jet velocity), freedom from valve replacement and death from cardiovascular cause. Secondary outcomes were hospitalisation for any reason, overall mortality, adverse events and patient quality of life. Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The GRADE methodology was employed to assess the quality of result findings and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 to create a 'Summary of findings' table. Main results We included four RCTs with 2360 participants comparing statins (1185 participants) with placebo (1175 participants). We found low‐quality evidence for our primary outcome of severity of aortic valve stenosis, evaluated by mean pressure gradient (mean difference (MD) ‐0.54, 95% confidence interval (CI) ‐1.88 to 0.80; participants = 1935; studies = 2), valve area (MD ‐0.07, 95% CI ‐0.28 to 0.14; participants = 127; studies = 2), and aortic jet velocity (MD ‐0.06, 95% CI ‐0.26 to 0.14; participants = 155; study = 1). Moderate‐quality evidence showed no effect on freedom from valve replacement with statins (risk ratio (RR) 0.93, 95% CI 0.81 to 1.06; participants = 2360; studies = 4), and no effect on muscle pain as an adverse event (RR 0.91, 95% CI 0.75 to 1.09; participants = 2204; studies = 3; moderate‐quality evidence). Low‐ and very low‐quality evidence showed uncertainty around the effect of statins on death from cardiovascular cause (RR 0.80, 95% CI 0.56 to 1.15; participants = 2297; studies = 3; low‐quality evidence) and hospitalisation for any reason (RR 0.84, 95% CI 0.39 to 1.84; participants = 155; study = 1; very low‐quality evidence). None of the four included studies reported on overall mortality and patient quality of life. Authors' conclusions Result findings showed uncertainty surrounding the effect of statins for aortic valve stenosis.The quality of evidence from the reported outcomes ranged from moderate to very low. These results give support to European and USA guidelines (2012 and 2014, respectively) that so far there is no clinical treatment option for aortic valve stenosis.Brazilian Cochrane Centre, Federal University of Sao Paulo and Marilia Medical, BrazilDepartment of Education in Health Sciences,Marilia Medical School, Marilia, BrazilDepartment of Psychiatry and Evidence BasedHealth Actions, Marilia Medical School, Marilia, BrazilInstitute of Health Informatics, University College London, London, UK.Brazilian Cochrane Centre, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, BrazilBrazilian Cochrane Centre, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo 598, BR-04039001 Sao Paulo, BrazilBrazilian Cochrane Centre, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo 598, BR-04039001 Sao Paulo, BrazilWeb of Scienc

Estatinas para a progressão da estenose da valva aórtica e a melhor evidência para tomar decisões em saúde

In the Western world, calcified aortic valve stenosis is the most common form of valvular heart disease, affecting up to 3% of adults over the age of 75 years. It is a gradually progressive disease, characterized by a long asymptomatic phase that may last for several decades, followed by a short symptomatic phase associated with severe restriction of the valve orifice. Investigations on treatments for aortic valve stenosis are still in progress. Thus, it is believed that calcification of aortic valve stenosis is similar to the process of atherosclerosis that occurs in coronary artery disease. Recent studies have suggested that cholesterol lowering through the use of station may have a salutary effect on the progression of aortic valve stenosis.Fac Med Marilia Famema, Sao Paulo, BrazilUniv Fed Sao Paulo Escola Paulista Med Unifesp EP, Hosp Sao Paulo, Dept Emergency Serv, Sao Paulo, BrazilUniv Fed Sao Paulo Escola Paulista Med Unifesp EP, Hosp Sao Paulo, Emergency Intens Care Unit, Sao Paulo, BrazilBrazilian Cochrane Ctr, Sao Paulo, BrazilUniv Fed Sao Paulo Escola Paulista Med Unifesp EP, Hosp Sao Paulo, Dept Emergency Serv, Sao Paulo, BrazilUniv Fed Sao Paulo Escola Paulista Med Unifesp EP, Hosp Sao Paulo, Emergency Intens Care Unit, Sao Paulo, BrazilWeb of Scienc

Effort-reward imbalance and overcommitment at work in medicine and nursing faculty in a public institution

Occupational stress studies with effort-reward imbalance at work in medical and nursing faculty have not been described in literature. Objectives: 1) To estimate the effort-reward imbalance and the overcommitment at work in medical and nursing faculty. 2) To verify if there is an association of those variables according to faculty groups. Method: A cross-sectional study was achieved with 232 professors of a public institution in São Paulo State from April to November in 2009. Applied instruments: a sociodemographic and occupational questionnaire and an effort-reward imbalance at work questionnaire (Effort-Reward Imbalance ”“ ERI). The chi-square test was used to verify the association of variables between faculty groups. Results: Prevalence of effort-reward imbalance was 31.3% in nursing faculty, 14.1% in medical faculty and 17.7% in overall sample, with significant difference between faculty (p = 0.006). Prevalence of overcommitment at work was similar in nursing and medical faculty as well as in overall sample (45.8%, 39.7% and 40.9% respectively), without any significant difference between faculty (p = 0.738) . Conclusions: The effort-reward imbalance in nursing faculty was 2.2 times higher compared to medical faculty. Both faculty groups presented a high prevalence of overcommitment at work, which denotes remarkable personal characteristics of better controlling needs and difficulty in relaxing after work in those professions. Further studies may contribute to preventive and interventional measures related to occupational stress in medical and nursing faculty.   Keywords: Burnout. Occupational stress. Epidemiology. Medical Faculty. Nursing Faculty

Medicina baseada em evidências: instrumento para educação médica permanente entre psiquiatras?

INTRODUÇÃO: O médico atualizado pode oferecer o melhor cuidado ao paciente e evitar consequências negativas que a defasagem científica pode acarretar. OBJETIVOS: Identificar os meios de atualização utilizados pelos psiquiatras brasileiros; avaliar seus conhecimentos sobre Medicina Baseada em Evidências (MBE) e sua utilização na educação permanente. MÉTODO: Estudo transversal realizado no XXIV Congresso Brasileiro de Psiquiatria. Os participantes (n = 188) responderam um questionário anônimo autoaplicado, com 28 perguntas sobre características sociodemográficas, fontes e periodicidade de atualização, e conhecimentos sobre MBE. RESULTADOS: Para atualização de conhecimentos, 98,3% utilizavam os congressos brasileiros; 97,9% as revistas nacionais; 93,9% os livros-texto; 89,9% as revistas das indústrias farmacêuticas; 63,5% os consensos brasileiros; 63,3% a base de dados Medline; 56,7% as revistas internacionais; e 35% a Biblioteca Cochrane. Os fatores estatisticamente significativos associados com bom conhecimento sobre MBE foram estar graduados há menos de dez anos (p < 0,001), usar o Medline (p < 0,009) e a Biblioteca Cochrane (p < 0,03) como fonte de busca de literatura médica. CONCLUSÕES: Os psiquiatras fazem pouco uso da melhor fonte de evidência para educação médica permanente e continuada, havendo, assim, menor benefício aos pacientes na tomada de decisão clínica

O conhecimento dos estudantes da faculdade de medicina de Marília (Famema) sobre responsabilidade profissional e segredo médico

INTRODUÇÃO: O CFM INstituiu o Código de Ética Médica (CEM), cuja violação implica sanções, impondo aos profissionais a ele submetidos seu conhecimento e aplicação, por meio de conduta permeada pelos prima facie ducties. Conhecer o assunto torna-se condição básica para sua observação. Daí a importância deste ensino desde os primeiros anos do curso médico, fornecendo ao estudante capacidade de análise ética na prática profissional futura. OBJETIVOS: Avaliar o grau de conhecimento sobre as disposições do CEM relativas a "responsabilidade profissional" e "segredo médico" entre estudantes de Medicina da Famema e verificar se há evolução desse conhecimento durante a graduação. MÉTODO: Estudo realizado em dez meses, com 479 estudantes do primeiro ao sexto ano, regularmente matriculados. Aplicado questionário anônimo, com duas partes: uma com dados sociodemográficos e outra composta por 11 cenários clínicos, envolvendo questões eticamente conflituosas. RESULTADOS: 395 estudantes responderam o questionário (82,46% da amostra inicial). Ao se comparar a média total de acertos entre as turmas nos cenários, encontrou-se o valor de p = 0,7148, sem significância estatística. CONCLUSÕES: Não há diferença estatisticamente significativa no grau de conhecimento sobre ética entre as séries. Sugere-se a introdução efetiva do assunto na graduação do curso médico, com metodologia de ensino adequada

Statins for aortic valve stenosis

ABSTRACT BACKGROUND: Aortic valve stenosis is the most common type of valvular heart disease in the USA and Europe. Aortic valve stenosis is considered similar to atherosclerotic disease. Some studies have evaluated statins for aortic valve stenosis. OBJECTIVES: To evaluate the effectiveness and safety of statins in aortic valve stenosis. METHODS: Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS - IBECS, Web of Science and CINAHL Plus. These databases were searched from their inception to 24 November 2015. We also searched trials in registers for ongoing trials. We used no language restrictions. Selection criteria: Randomized controlled clinical trials (RCTs) comparing statins alone or in association with other systemic drugs to reduce cholesterol levels versus placebo or usual care. Data collection and analysis: Primary outcomes were severity of aortic valve stenosis (evaluated by echocardiographic criteria: mean pressure gradient, valve area and aortic jet velocity), freedom from valve replacement and death from cardiovascular cause. Secondary outcomes were hospitalization for any reason, overall mortality, adverse events and patient quality of life. Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The GRADE methodology was employed to assess the quality of result findings and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 to create a 'Summary of findings' table. MAIN RESULTS: We included four RCTs with 2360 participants comparing statins (1185 participants) with placebo (1175 participants). We found low-quality evidence for our primary outcome of severity of aortic valve stenosis, evaluated by mean pressure gradient (mean difference (MD) -0.54, 95% confidence interval (CI) -1.88 to 0.80; participants = 1935; studies = 2), valve area (MD -0.07, 95% CI -0.28 to 0.14; participants = 127; studies = 2), and aortic jet velocity (MD -0.06, 95% CI -0.26 to 0.14; participants = 155; study = 1). Moderate-quality evidence showed no effect on freedom from valve replacement with statins (risk ratio (RR) 0.93, 95% CI 0.81 to 1.06; participants = 2360; studies = 4), and no effect on muscle pain as an adverse event (RR 0.91, 95% CI 0.75 to 1.09; participants = 2204; studies = 3; moderate-quality evidence). Low- and very low-quality evidence showed uncertainty around the effect of statins on death from cardiovascular cause (RR 0.80, 95% CI 0.56 to 1.15; participants = 2297; studies = 3; low-quality evidence) and hospitalization for any reason (RR 0.84, 95% CI 0.39 to 1.84; participants = 155; study = 1; very low-quality evidence). None of the four included studies reported on overall mortality and patient quality of life. AUTHORS CONCLUSIONS: Result findings showed uncertainty surrounding the effect of statins for aortic valve stenosis. The quality of evidence from the reported outcomes ranged from moderate to very low. These results give support to European and USA guidelines (2012 and 2014, respectively) that so far there is no clinical treatment option for aortic valve stenosis