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Routine HIV Screening in France: Clinical Impact and Cost-Effectiveness

Yazdanpanah, Yazdan; Sloan, Caroline E.; Charlois-Ou, Cécile; Le Vu, Stéphane; Semaille, Caroline; Costagliola, Dominique; Pillonel, Josiane; Poullié, Anne-Isabelle; Scemama, Olivier; Deuffic-Burban, Sylvie; Paltiel, A. David; Losina, Elena; Walensky,
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: In France, roughly 40,000 HIV-infected persons are unaware of their HIV infection. Although previous studies have evaluated the cost-effectiveness of routine HIV screening in the United States, differences in both the epidemiology of infection and HIV testing behaviors warrant a setting-specific analysis for France. Methods/Principal Findings: We estimated the life expectancy (LE), cost and cost-effectiveness of alternative HIV screening strategies in the French general population and high-risk sub-populations using a computer model of HIV detection and treatment, coupled with French national clinical and economic data. We compared risk-factor-based HIV testing (“current practice”) to universal routine, voluntary HIV screening in adults aged 18–69. Screening frequencies ranged from once to annually. Input data included mean age (42 years), undiagnosed HIV prevalence (0.10%), annual HIV incidence (0.01%), test acceptance (79%), linkage to care (75%) and cost/test (€43). We performed sensitivity analyses on HIV prevalence and incidence, cost estimates, and the transmission benefits of ART. “Current practice” produced LEs of 242.82 quality-adjusted life months (QALM) among HIV-infected persons and 268.77 QALM in the general population. Adding a one-time HIV screen increased LE by 0.01 QALM in the general population and increased costs by €50/person...

Comparative Effectiveness Research: An Empirical Study of Trials Registered in ClinicalTrials.gov

Murthy, Srinivas; Bourgeois, Florence Tanya; Mandl, Kenneth David
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: The $1.1 billion investment in comparative effectiveness research will reshape the evidence-base supporting decisions about treatment effectiveness, safety, and cost. Defining the current prevalence and characteristics of comparative effectiveness (CE) research will enable future assessments of the impact of this program. Methods: We conducted an observational study of clinical trials addressing priority research topics defined by the Institute of Medicine and conducted in the US between 2007 and 2010. Trials were identified in ClinicalTrials.gov. Main outcome measures were the prevalence of comparative effectiveness research, nature of comparators selected, funding sources, and impact of these factors on results. Results: 231 (22.3%; 95% CI 19.8%–24.9%) studies were CE studies and 804 (77.7%; 95% CI, 75.1%–80.2%) were non-CE studies, with 379 (36.6%; 95% CI, 33.7%–39.6%) employing a placebo control and 425 (41.1%; 95% CI, 38.1%–44.1%) no control. The most common treatments examined in CE studies were drug interventions (37.2%), behavioral interventions (28.6%), and procedures (15.6%). Study findings were favorable for the experimental treatment in 34.8% of CE studies and greater than twice as many (78.6%) non-CE studies (P<0.001). CE studies were more likely to receive government funding (P = 0.003) and less likely to receive industry funding (P = 0.01)...

The Effect of Systematic Clinical Interventions with Cigarette Smokers on Quit Status and the Rates of Smoking-Related Primary Care Office Visits

Land, Thomas G.; Warner, Donna; Li, Wenjun; Rigotti, Nancy Ann; Levy, Douglas Edward; Schilling, Thad Ferguson
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: The United States Public Health Service (USPHS) Guideline for Treating Tobacco Use and Dependence includes ten key recommendations regarding the identification and the treatment of tobacco users seen in all health care settings. To our knowledge, the impact of system-wide brief interventions with cigarette smokers on smoking prevalence and health care utilization has not been examined using patient population-based data. Methods and Findings Data on clinical interventions with cigarette smokers were examined for primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA) sites. An operational definition of “systems change” was developed. It included thresholds for intervention frequency and sustainability. Twelve sites met the criteria. Five did not. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, p<.01). On average, the likelihood of quitting increased by 2.6% (p<0.05, 95% CI: 0.1%–4.6%) per occurrence of brief intervention. For patients with a recent history of current smoking whose home site experienced systems change, the likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis after systems change occurred (p<0.05...

Informed Consent and Placebo Effects: A Content Analysis of Information Leaflets to Identify What Clinical Trial Participants Are Told about Placebos

Bishop, Felicity L.; Adams, Alison E. M.; Lewith, George T.; Kaptchuk, Ted Jack
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: Placebo groups are used in randomised clinical trials (RCTs) to control for placebo effects, which can be large. Participants in trials can misunderstand written information particularly regarding technical aspects of trial design such as randomisation; the adequacy of written information about placebos has not been explored. We aimed to identify what participants in major RCTs in the UK are told about placebos and their effects. Methods and Findings: We conducted a content analysis of 45 Participant Information Leaflets (PILs) using quantitative and qualitative methodologies. PILs were obtained from trials on a major registry of current UK clinical trials (the UKCRN database). Eligible leaflets were received from 44 non-commercial trials but only 1 commercial trial. The main limitation is the low response rate (13.5%), but characteristics of included trials were broadly representative of all non-commercial trials on the database. 84% of PILs were for trials with 50∶50 randomisation ratios yet in almost every comparison the target treatments were prioritized over the placebos. Placebos were referred to significantly less frequently than target treatments (7 vs. 27 mentions, p<001) and were significantly less likely than target treatments to be described as triggering either beneficial effects (1 vs. 45...

Different Physical Activity Subtypes and Risk of Metabolic Syndrome in Middle-Aged and Older Chinese People

Chen, Mu; He, Meian; Min, Xinwen; Pan, An; Zhang, Xiaomin; Yao, Ping; Li, Xiulou; Liu, Yuewei; Yuan, Jing; Chen, Weihong; Zhou, Li; Fang, Weimin; Liang, Yuan; Wang, Youjie; Miao, Xiaoping; Lang, Mingjian; Zhang, Peng; Li, Dongfeng; Guo, Huan; Yang, Handon
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: The prevalence of metabolic syndrome (MetS) is growing rapidly in China. Tai chi and dancing are common types of exercise among middle-aged and elderly Chinese. It remains unclear whether these activities are associated with a lower risk of MetS. Methodology/Principal Findings A total of 15,514 individuals (6,952 men, 8,562 women) aged 50 to 70 years from the Dongfeng-Tongji Cohort in Shiyan, China participated in a cross-sectional study. Physical activity and other lifestyle factors were assessed with semi-structured questionnaires during face-to-face interviews. MetS was defined by the current National Cholesterol Education Program/Adult treatment Panel III criteria for Asian Americans. The prevalence of MetS was 33.2% in the study population. In the multivariable-adjusted logistic regression analyses, total physical activity levels were monotonically associated with a lower odds of MetS [OR 0.75 comparing extreme quintiles, 95% confidence interval (CI) 0.66–0.86, P<0.001]. Compared with non-exercisers in a specific exercise type, jogging (OR 0.82, 95% CI 0.68–1.00, P = 0.046), tai chi (OR 0.72, 95% CI 0.60–0.88, P<0.001), and dancing (OR 0.56, 95% CI 0.47–0.67, P<0.001) were associated with significantly lower odds of MetS. Furthermore...

Effectiveness of Patient Adherence Groups as a Model of Care for Stable Patients on Antiretroviral Therapy in Khayelitsha, Cape Town, South Africa

Luque-Fernandez, Miguel Angel; Van Cutsem, Gilles; Goemaere, Eric; Hilderbrand, Katherine; Schomaker, Michael; Mantangana, Nompumelelo; Mathee, Shaheed; Dubula, Vuyiseka; Ford, Nathan; Boulle, Andrew; Hernan, Miguel Angel
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: Innovative models of care are required to cope with the ever-increasing number of patients on antiretroviral therapy in the most affected countries. This study, in Khayelitsha, South Africa, evaluates the effectiveness of a group-based model of care run predominantly by non-clinical staff in retaining patients in care and maintaining adherence. Methods and Findings: Participation in “adherence clubs” was offered to adults who had been on ART for at least 18 months, had a current CD4 count >200 cells/ml and were virologically suppressed. Embedded in an ongoing cohort study, we compared loss to care and virologic rebound in patients receiving the intervention with patients attending routine nurse-led care from November 2007 to February 2011. We used inverse probability weighting to estimate the intention-to-treat effect of adherence club participation, adjusted for measured baseline and time-varying confounders. The principal outcome was the combination of death or loss to follow-up. The secondary outcome was virologic rebound in patients who were virologically suppressed at study entry. Of 2829 patients on ART for >18 months with a CD4 count above 200 cells/µl, 502 accepted club participation. At the end of the study...

Myeloid Clusters Are Associated with a Pro-Metastatic Environment and Poor Prognosis in Smoking-Related Early Stage Non-Small Cell Lung Cancer

Zhang, Wang; Pal, Sumanta K.; Liu, Xueli; Yang, Chunmei; Allahabadi, Sachin; Bhanji, Shaira; Figlin, Robert A.; Yu, Hua; Reckamp, Karen L.
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: This study aimed to understand the role of myeloid cell clusters in uninvolved regional lymph nodes from early stage non-small cell lung cancer patients. Methods: Uninvolved regional lymph node sections from 67 patients with stage I–III resected non-small cell lung cancer were immunostained to detect myeloid clusters, STAT3 activity and occult metastasis. Anthracosis intensity, myeloid cluster infiltration associated with anthracosis and pSTAT3 level were scored and correlated with patient survival. Multivariate Cox regression analysis was performed with prognostic variables. Human macrophages were used for in vitro nicotine treatment. Results: (CD68^+) myeloid clusters associated with anthracosis and with an immunosuppressive and metastasis-promoting phenotype and elevated overall STAT3 activity were observed in uninvolved lymph nodes. In patients with a smoking history, myeloid cluster score significantly correlated with anthracosis intensity and pSTAT3 level (P<0.01). Nicotine activated STAT3 in macrophages in long-term culture. (CD68^+) myeloid clusters correlated and colocalized with occult metastasis. Myeloid cluster score was an independent prognostic factor (P = 0.049) and was associated with survival by Kaplan-Maier estimate in patients with a history of smoking (P = 0.055). The combination of myeloid cluster score with either lymph node stage or pSTAT3 level defined two populations with a significant difference in survival (P = 0.024 and P = 0.004...

Risk Profiles and Antithrombotic Treatment of Patients Newly Diagnosed with Atrial Fibrillation at Risk of Stroke: Perspectives from the International, Observational, Prospective GARFIELD Registry

Kakkar, Ajay K.; Mueller, Iris; Bassand, Jean-Pierre; Fitzmaurice, David A.; Goldhaber, Samuel Zachary; Goto, Shinya; Haas, Sylvia; Hacke, Werner; Lip, Gregory Y. H.; Mantovani, Lorenzo G.; Turpie, Alexander G. G.; van Eickels, Martin; Misselwitz, Frank;
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: Limited data are available on the characteristics, clinical management, and outcomes of patients with atrial fibrillation at risk of stroke, from a worldwide perspective. The aim of this study was to describe the baseline characteristics and initial therapeutic management of patients with non-valvular atrial fibrillation across the spectrum of sites at which these patients are treated. Methods and Findings: The Global Anticoagulant Registry in the FIELD (GARFIELD) is an observational study of patients newly diagnosed with non-valvular atrial fibrillation. Enrollment into Cohort 1 (of 5) took place between December 2009 and October 2011 at 540 sites in 19 countries in Europe, Asia-Pacific, Central/South America, and Canada. Investigator sites are representative of the distribution of atrial fibrillation care settings in each country. Cohort 1 comprised 10,614 adults (≥18 years) diagnosed with non-valvular atrial fibrillation within the previous 6 weeks, with ≥1 investigator-defined stroke risk factor (not limited to those in existing risk-stratification schemes), and regardless of therapy. Data collected at baseline included demographics, medical history, care setting, nature of atrial fibrillation, and treatments initiated at diagnosis. The mean (SD) age of the population was 70.2 (11.2) years; 43.2% were women. Mean±SD CHADS2 score was 1.9±1.2...

Clinical Impact and Cost-Effectiveness of Expanded Voluntary HIV Testing in India

Venkatesh, Kartik K.; Becker, Jessica E.; Kumarasamy, Nagalingeswaran; Nakamura, Yoriko M.; Mayer, Kenneth H.; Losina, Elena; Swaminathan, Soumya; Flanigan, Timothy P.; Walensky, Rochelle P.; Freedberg, Kenneth A.
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: Despite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear. Methods: We used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population (“national population”), i.e. base case (HIV prevalence 0.29%; incidence 0.032/100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/µl. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for “cost-effective” was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for “very cost-effective” was <1x the annual per capita GDP ($1...

Consumption of Dairy Products and Colorectal Cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC)

Murphy, Neil; Norat, Teresa; Ferrari, Pietro; Jenab, Mazda; Bueno-de-Mesquita, Bas; Skeie, Guri; Olsen, Anja; Tjønneland, Anne; Dahm, Christina C.; Overvad, Kim; Boutron-Ruault, Marie Christine; Clavel-Chapelon, Françoise; Nailler, Laura; Kaaks, Rudolf;
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
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Background: Prospective studies have consistently reported lower colorectal cancer risks associated with higher intakes of total dairy products, total milk and dietary calcium. However, less is known about whether the inverse associations vary for individual dairy products with differing fat contents. Materials and Methods In the European Prospective Investigation into Cancer and Nutrition (EPIC), we investigated the associations between intakes of total milk and milk subtypes (whole-fat, semi-skimmed and skimmed), yoghurt, cheese, and dietary calcium with colorectal cancer risk amongst 477,122 men and women. Dietary questionnaires were administered at baseline. Multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models, adjusted for relevant confounding variables. Results: During the mean 11 years of follow-up, 4,513 incident cases of colorectal cancer occurred. After multivariable adjustments, total milk consumption was inversely associated with colorectal cancer risk (HR per 200 g/day 0.93, 95% CI: 0.89–0.98). Similar inverse associations were observed for whole-fat (HR per 200 g/day 0.90, 95% CI: 0.82–0.99) and skimmed milk (HR per 200 g/day 0.90, 95% CI: 0.79–1.02) in the multivariable models. Inverse associations were observed for cheese and yoghurt in the categorical models; although in the linear models...

Modified Mediterranean Diet Score and Cardiovascular Risk in a North American Working Population

Yang, Justin; Farioli, Andrea; Korre, Maria; Kales, Stefanos N.
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
Português
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Introduction: Greater adherence to a Mediterranean diet is linked to lower risk for cardiovascular morbidity/mortality in studies of Mediterranean cohorts, older subjects, and/or those with existing health conditions. No studies have examined the effects of this dietary pattern in younger working populations in the United States. We investigated the effects of Mediterranean diet adherence on cardiovascular disease (CVD) biomarkers, metabolic syndrome and body composition in an occupationally active, non-Mediterranean cohort. Methods: A cross-sectional study in a cohort of 780 career male firefighters, ages 18 years or older, from the United States Midwest. No dietary intervention was performed. A modified Mediterranean diet score (mMDS) was developed for assessment of adherence to a Mediterranean dietary pattern from a previously administered life-style questionnaire that examined pre-existing dietary habits. Clinical data from fire department medical examinations were extracted and analyzed. Results: Obese subjects had significantly lower mMDS, and they reported greater fast/take-out food consumption (p<0.001) and intake of sweetened drinks during meals (p = 0.002). After multivariate adjustment, higher mMDS was inversely related to risk of weight gain over the past 5 years (odds ratio [OR]: 0.57...

Cost-Effectiveness of Early Infant HIV Diagnosis of HIV-Exposed Infants and Immediate Antiretroviral Therapy in HIV-Infected Children under 24 Months in Thailand

Collins, Intira Jeannie; Cairns, John; Ngo-Giang-Huong, Nicole; Sirirungsi, Wasna; Leechanachai, Pranee; Le Coeur, Sophie; Samleerat, Tanawan; Kamonpakorn, Nareerat; Mekmullica, Jutarat; Jourdain, Gonzague; Lallemant, Marc
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
Português
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47.12373%
Background: HIV-infected infants have high risk of death in the first two years of life if untreated. WHO guidelines recommend early infant HIV diagnosis (EID) of all HIV-exposed infants and immediate antiretroviral therapy (ART) in HIV-infected children under 24-months. We assessed the cost-effectiveness of this strategy in HIV-exposed non-breastfed children in Thailand. Methods: A decision analytic model of HIV diagnosis and disease progression compared: EID using DNA PCR with immediate ART (Early-Early); or EID with deferred ART based on immune/clinical criteria (Early-Late); vs. clinical/serology based diagnosis and deferred ART (Reference). The model was populated with survival and cost data from a Thai observational cohort and the literature. Incremental cost-effectiveness ratio per life-year gained (LYG) was compared against the Reference strategy. Costs and outcomes were discounted at 3%. Results: Mean discounted life expectancy of HIV-infected children increased from 13.3 years in the Reference strategy to 14.3 in the Early-Late and 17.8 years in Early-Early strategies. The mean discounted lifetime cost was $17,335, $22,583 and $29,108, respectively. The cost-effectiveness ratio of Early-Late and Early-Early strategies was $5...

About the postponement of clinical discharges from an Integrated Continuous Care Unit (UCCI) for non-clinical reasons: nurses perception study; Prorrogações dos internamentos em Unidades de Cuidados Continuados Integrados por motivos não-clínicos : a percepção de profissionais de saúde sobre factores sociais no processo das altas

Monteiro, M. Carolina; Santos, Osvaldo; Costa, Maria do Céu
Fonte: Edições Universitárias Lusófonas Publicador: Edições Universitárias Lusófonas
Tipo: Artigo de Revista Científica
Português
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This study investigates the perception of health professionals in Continuous Care Units (UCCI) regarding the occurrence (or none) of extension of clients’ hospitalization for non-clinical reasons. The group was selected considering their proximity and continuous intervention in supporting the clinical discharges when declared by the physician. This is an exploratory study with a quantitative approach. In methodological terms, a self-completed questionnaire constructed with multiple-choice questions was used. This randomized, convenience sample population included 20 responding nurses. Results show the perceived predominance of family-order factors: 60 % of the nurses referred to poor or totally absent family support of users or its total absence (45 %). Following, perceived factors are economic reasons (29 %), including insufficient income (85 %), institutional reasons (29 %) for lack/absence of social responses (50 %), and very close figures for the limited ability of institutions to receive users coming from the UCCI network (45 %). Major structural reasons (65 %) are poor housing conditions and physical barriers to mobility (55 %). To contribute with appropriate solutions to the emerging scenario, this study should be further developed and applied to all nationwide UCCI to reflect and anticipate intervention strategies in continuous care.; O presente estudo tem por objetivo conhecer a percepção dos profissionais de saúde quanto à existência...

Os sentidos das praticas terapeuticas convencionais e não convencionais no tratamento do cancer; The meaning of conventional and non-conventional therapies in oncological patients

Cristiane Spadacio
Fonte: Biblioteca Digital da Unicamp Publicador: Biblioteca Digital da Unicamp
Tipo: Dissertação de Mestrado Formato: application/pdf
Publicado em 21/02/2008 Português
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Tem havido um crescimento exponencial no uso das Medicinas Alternativas e Complementares (MAC), principalmente em países ocidentais desenvolvidos. A literatura corrente indica que também em países em desenvolvimento e pobres, a medicina não biomédica permanece como um elemento significativo no tratamento. O crescimento do uso das MAC é, também, perceptível no caso de pacientes oncológicos. Este trabalho pretende-se parte de um programa sociológico das MAC no campo da saúde no Brasil, tendo como foco o uso de MAC por pacientes em tratamento do câncer. Dessa forma, esta pesquisa busca compreender os sentidos do uso de MAC por pacientes em tratamento do câncer no Serviço de Oncologia do HC/Unicamp. Para tanto, foi preciso: 1) analisar como os pacientes lidam com o binômio saúde/doença na situação de doença oncológica; 2) identificar as motivações para o uso das MAC no tratamento do câncer e os processos subjacentes à decisão do uso das MAC: sua seleção, interpretação, aquisição da informação sobre essas técnicas, que delimitam os sentidos; e, 3) mapear as redes de sociabilidades que influenciam na decisão pelo tratamento convencional e o não convencional do câncer. Teoricamente, essa pesquisa ancora-se na teoria praxiológica de Pierre Bourdieu...

Adolescent Abstinence and Unprotected Sex in CyberSenga, an Internet-Based HIV Prevention Program: Randomized Clinical Trial of Efficacy

Ybarra, Michele L.; Bull, Sheana S.; Prescott, Tonya L.; Korchmaros, Josephine D.; Bangsberg, David R.; Kiwanuka, Julius P.
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
Português
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Context Cost-effective, scalable programs are urgently needed in countries deeply affected by HIV. Methods: This parallel-group RCT was conducted in four secondary schools in Mbarara, Uganda. Participants were 12 years and older, reported past-year computer or Internet use, and provided informed caregiver permission and youth assent. The intervention, CyberSenga, was a five-hour online healthy sexuality program. Half of the intervention group was further randomized to receive a booster at four-months post-intervention. The control arm received ‘treatment as usual’ (i.e., school-delivered sexuality programming). The main outcome measures were: 1) condom use and 2) abstinence in the past three months at six-months' post-intervention. Secondary outcomes were: 1) condom use and 2) abstinence at three-month's post-intervention; and 6-month outcomes by booster exposure. Analyses were intention to treat. Results: All 416 eligible youth were invited to participate, 88% (n = 366) of whom enrolled. Participants were randomized to the intervention (n = 183) or control (n = 183) arm; 91 intervention participants were further randomized to the booster. No statistically significant results were noted among the main outcomes. Among the secondary outcomes: At three-month follow-up...

Extracting Physician Group Intelligence from Electronic Health Records to Support Evidence Based Medicine

Weber, Griffin M.; Kohane, Isaac S.
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
Português
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Evidence-based medicine employs expert opinion and clinical data to inform clinical decision making. The objective of this study is to determine whether it is possible to complement these sources of evidence with information about physician “group intelligence” that exists in electronic health records. Specifically, we measured laboratory test “repeat intervals”, defined as the amount of time it takes for a physician to repeat a test that was previously ordered for the same patient. Our assumption is that while the result of a test is a direct measure of one marker of a patient's health, the physician's decision to order the test is based on multiple factors including past experience, available treatment options, and information about the patient that might not be coded in the electronic health record. By examining repeat intervals in aggregate over large numbers of patients, we show that it is possible to 1) determine what laboratory test results physicians consider “normal”, 2) identify subpopulations of patients that deviate from the norm, and 3) identify situations where laboratory tests are over-ordered. We used laboratory tests as just one example of how physician group intelligence can be used to support evidence based medicine in a way that is automated and continually updated.

Measuring Coverage in MNCH: Validating Women’s Self-Report of Emergency Cesarean Sections in Ghana and the Dominican Republic

Tunçalp, Özge; Stanton, Cynthia; Castro, Arachu; Adanu, Richard; Heymann, Marilyn; Adu-Bonsaffoh, Kwame; Lattof, Samantha R; Blanc, Ann; Langer, Ana Maria
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
Português
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Background: Cesarean section is the only surgery for which we have nearly global population-based data. However, few surveys provide additional data related to cesarean sections. Given weaknesses in many health information systems, health planners in developing countries will likely rely on nationally representative surveys for the foreseeable future. The objective is to validate self-reported data on the emergency status of cesarean sections among women delivering in teaching hospitals in the capitals of two contrasting countries: Accra, Ghana and Santo Domingo, Dominican Republic (DR). Methods and Findings: This study compares hospital-based data, considered the reference standard, against women’s self-report for two definitions of emergency cesarean section based on the timing of the decision to operate and the timing of the cesarean section relative to onset of labor. Hospital data were abstracted from individual medical records, and hospital discharge interviews were conducted with women who had undergone cesarean section in two hospitals. The study assessed sensitivity, specificity, and positive predictive value of responses to questions regarding emergency versus non-emergency cesarean section and estimated the percent of emergency cesarean sections that would be obtained from a survey...

Changes in Clinical Trials Methodology Over Time: A Systematic Review of Six Decades of Research in Psychopharmacology

Brunoni, André R.; Tadini, Laura; Fregni, Felipe
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
Português
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Background: There have been many changes in clinical trials methodology since the introduction of lithium and the beginning of the modern era of psychopharmacology in 1949. The nature and importance of these changes have not been fully addressed to date. As methodological flaws in trials can lead to false-negative or false-positive results, the objective of our study was to evaluate the impact of methodological changes in psychopharmacology clinical research over the past 60 years. Methodology/Principal Findings: We performed a systematic review from 1949 to 2009 on MEDLINE and Web of Science electronic databases, and a hand search of high impact journals on studies of seven major drugs (chlorpromazine, clozapine, risperidone, lithium, fluoxetine and lamotrigine). All controlled studies published 100 months after the first trial were included. Ninety-one studies met our inclusion criteria. We analyzed the major changes in abstract reporting, study design, participants' assessment and enrollment, methodology and statistical analysis. Our results showed that the methodology of psychiatric clinical trials changed substantially, with quality gains in abstract reporting, results reporting, and statistical methodology. Recent trials use more informed consent...

Peritoneal Dissemination Complicating Morcellation of Uterine Mesenchymal Neoplasms

Seidman, Michael A.; Oduyebo, Titilope; Muto, Michael George; Crum, Christopher Paul; Nucci, Marisa Rose; Quade, Bradley Joseph
Fonte: Public Library of Science Publicador: Public Library of Science
Tipo: Artigo de Revista Científica
Português
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Background: Power morcellation has become a common technique for the minimally invasive resection of uterine leiomyomas. This technique is associated with dissemination of cellular material throughout the peritoneum. When morcellated uterine tumors are unexpectedly found to be leiomyosarcomas or tumors with atypical features (atypical leiomyoma, smooth muscle tumor of uncertain malignant potential), there may be significant clinical consequences. This study was undertaken to determine the frequency and clinical consequence of intraperitoneal dissemination of these neoplasms. Methodology/principal findings: From 2005–2010, 1091 instances of uterine morcellation were identified at BWH. Unexpected diagnoses of leiomyoma variants or atypical and malignant smooth muscle tumors occurred in 1.2% of cases using power morcellation for uterine masses clinically presumed to be “fibroids” over this period, including one endometrial stromal sarcoma (ESS), one cellular leiomyoma (CL), six atypical leiomyomas (AL), three smooth muscle tumor of uncertain malignant potential (STUMPs), and one leiomyosarcoma (LMS). The rate of unexpected sarcoma after the laparoscopic morcellation procedure was 0.09%, 9-fold higher than the rate currently quoted to patients during pre-procedure briefing...

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

Hajjaj, FM; Salek, MS; Basra, MKA; Finlay, AY
Fonte: The Royal Society of Medicine Publicador: The Royal Society of Medicine
Tipo: Artigo de Revista Científica
Publicado em 01/05/2010 Português
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This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.