Apesar de constituírem parte fundamental da prática clínica em psiquiatria e saúde mental, as psicoterapias ainda são pouco investigadas do ponto de vista científico. Este estudo tem o objetivo de examinar as preferências de profissionais da saúde mental em relação às escolas de psicoterapia ao longo da história e investigar a aplicação clínica corrente de uma das abordagens psicoterápicas mais praticadas na atualidade. Tanto quanto sabemos, este é o primeiro estudo a conduzir uma revisão sistemática e metaregressão que examina as prevalências globais de orientações teóricas entre psicoterapeutas ao longo dos últimos 50 anos, e especialmente na ultima década, conforme apresentado no primeiro artigo. A utilização no momento atual de intervenções cognitivo-comportamentais para um amplo espectro de transtornos psiquiátricos e outras condições médicas foi o objeto de estudo do segundo artigo. Por meio de busca computadorizada de artigos da literatura em bancos de dados eletrônicos, conduzimos uma revisão sistemática de pesquisas realizadas com profissionais de saúde que investigaram sobre suas afiliações a escolas psicoterápicas publicadas no período entre 1960 e 2012. Sessenta artigos que apresentavam dados originais com porcentagens específicas de preferências dos terapeutas por uma das 5 escolas de psicoterapia de maior preferência foram incluídos na análise. Posteriormente foi realizada uma segunda revisão sistemática de todos ensaios clínicos randomizados (ECRs) publicados no ano de 2014 que descreviam a comparação de uma intervenção cognitivo-comportamental com outra forma de intervenção psicossocial ou tratamento médico. Trezentos e noventa e quatro ECRs foram identificados e incluídos na análise final. Os dados analisados no primeiro estudo demostram que na ultima década a terapia cognitivo-comportamental (TCC) é o modelo teórico praticado por cerca de 28% dos psicoterapeutas pesquisados, seguido pela abordagem eclética/integrativa praticada por cerca de 23% dos profissionais. A orientação teórica psicanalítica e psicodinâmica foi endossada por 15% dos profissionais de saúde pesquisados. No segundo estudo, dados extraídos de artigos publicados no ano de 2014 revelaram que cerca de 58.000 indivíduos foram submetidos a intervenções cognitivas e comportamentais para tratamento de 22 diferentes diagnósticos médicos e psiquiátricos. Conforme esperado, 20% dos ensaios abordaram tratamentos para transtornos depressivos. Outras condições médicas, como tratamentos para dores e fadiga crônicas, e sintomas colaterais de tratamentos para o câncer, foram tratadas com intervenções cognitivas e comportamentais em 75 estudos, 19% do total. Um em cada 4 estudos foi feito em grupo; 65/394 estudos realizaram intervenções via computador; e quase todos (95% do total) foram realizados em países de alta renda econômica. Há um interesse crescente na utilização do modelo cognitivo-comportamental de psicoterapia por parte dos profissionais de saúde mental. Desde que iniciou sua trajetória, esta abordagem foi a única dentre as 5 estudadas que apresentou aumentos sistemáticos na porcentagem de terapeutas que professavam sua utilização na prática clinica. Um grande número de resultados de ECRs realizados em um único ano, com amostras de estudos conduzidos em todos quadrantes do planeta, relatando sua utilização cada vez mais abrangente para diferentes condições clínicas, demonstra a tendência de consolidação definitiva das terapias cognitivas comportamentais em nosso arsenal terapêutico. / Despite being an essential part of clinical practice in psychiatry and mental health, psychotherapies are still poorly investigated from a scientific point of view. This study aims to examine the endorsements of mental health professionals to psychotherapeutic orientations throughout history and to investigate the current clinical applications of one of the most practiced psychotherapeutic approaches. To our knowledge, this study is the first one to conduct a systematic review and meta-regression examining the prevalence of theoretical orientations amongst psychotherapists worldwide in the last 50 years, particularly in the last decade, as presented in the first article. The current uses of cognitive-behavioral interventions in a wide scope of psychiatric and other medical disorders was the second article focus. From a computerized literature search, we conducted a systematic review of the literature identifying any research conducted with health professional published in the period between January 1960 and December 2012. Sixty papers containing original data about the single preferred orientation of psychotherapists for one of the five most endorsed schools of psychotherapy were included in the final analysis. Then a second systematic review of the literature of all published papers in the year of 2014 describing randomized controlled trials that compared cognitive behavioral therapies with another form of psychosocial intervention or medical treatment was conducted. Three hundred ninety four studies were identified and included in the final analysis. The analysis of the data from the first study shows that in the last decade cognitive-behavioral therapy is the theoretical model practiced by around 28% of the researched psychotherapists, followed by the eclectic/integrative approach preferred by around 23% individuals. The psychoanalytic and psychodynamic theoretical orientation was endorsed by 15% of health professionals. In the second study, extracted data from papers published in the year of 2014 revealed that around 58,000 individuals underwent cognitive and behavioral interventions for the treatment of 22 different medical and psychiatric diagnoses. As expected, treatments for depressive disorders were the focus in 20% of trials. Other medical conditions, as chronic pain and fatigue, and collateral symptoms of cancer treatments, and insomnia, were treated with cognitive behavioral interventions in 75 studies, 19% of total. One in every 4 studies conducted group treatments; 65/394 studies performed computer-assisted psychosocial interventions; and almost all (95% of total) were conducted in high-income economy countries. There is a growing interest by mental health professionals in the cognitivebehavioral model. Since its appearance, this approach was the only one amongst the 5 studied that showed systematic increases in the percentages of therapists’ endorsements. The high number of randomized clinical trials conducted in a single year, with study samples from all planet quadrants, reporting an increasingly widespread use for different clinical conditions, demonstrates a definite consolidation of cognitive behavioral therapies in our therapeutic arsenal.

O curso longitudinal do transtorno bipolar é altamente variável, mas um subconjunto de pacientes parece apresentar uma evolução progressiva associada a alterações cerebrais e comprometimento funcional. Em nosso primeiro artigo, discutimos a teoria da neuroprogressão no transtorno bipolar. Este conceito considera a resposta ao estresse que ocorre nos episódios de humor e déficits no funcionamento e cognição, bem como alterações neuroanatômicas nos estágios tardios da doença. Discutimos também refratariedade ao tratamento que pode ocorrer em alguns casos de transtorno bipolar. Foi executada uma busca na base de dados PubMed para artigos publicados em qualquer idioma até 04 de junho de 2016. Foram encontrados 315 resumos e 87 estudos foram incluídos em nossa revisão. Somos da opinião de que o uso de estratégias farmacológicas específicas e remediação funcional pode ser potencialmente útil em pacientes bipolares em estágios tardios. Novas abordagens analíticas que utilizam dados multimodais têm o potencial para ajudar na identificação de assinaturas de subgrupos de pacientes que irão desenvolver um curso neuroprogressivo. Com base em nossa hipótese de neuroprogressão, decidimos realizar um ensaio clínico randomizado com o antidepressivo tianeptina como tratamento adjuvante para o transtorno bipolar, a fim de melhorar o comprometimento funcional, desfechos clínicos e aumentar os níveis do Brain-Derived Neurothrofic Factor (BDNF). Tianeptina é um fármaco seguro, que atua sobre o sistema glutamatérgico e tem um efeito antidepressivo. Esse estudo teve como objetivo avaliar a eficácia e tolerabilidade da tianeptina como tratamento adjuvante para a depressão bipolar. Foi realizado um ensaio clínico duplo-cego randomizado de manutenção controlado por placebo com tianeptina 37,5 mg/dia. Os participantes (n = 161) tinham uma pontuação na Montgomery Asberg Depression Rating ≥12 no início do ensaio. Após oito semanas de tratamento com tianeptina na fase aberta, aqueles que responderam a tianeptina foram randomizados para o placebo ou tianeptina adjuvante. Os participantes foram recrutados na rede pública de saúde. Tempo para qualquer intervenção foi o desfecho primário do estudo. Mudanças nos sintomas de humor, funcionamento, ritmos biológicos, qualidade de vida, taxas de virada maníaca e níveis séricos de BDNF foram considerados como desfechos secundários. Houve uma diminuição importante nos sintomas depressivos, assim como melhoras no funcionamento, qualidade de vida e pontuações no ritmo biológico durante a fase aberta de tratamento com tianeptina por oito semanas. Durante as 24 semanas do ensaio duplo-cego randomizado e controlado por placebo, não houve diferença em relação ao desfecho primário: tempo para qualquer intervenção. Além disso, não houve diferenças significativas entre os grupos em relação aos sintomas de humor, funcionamento e níveis de BDNF. Tianeptina foi bem tolerada e não foi associada a virada maníaca em comparação com o placebo. Estes achados sugerem que tianeptina é um medicamento seguro e pode ser eficaz no tratamento da depressão bipolar aguda. No entanto, tianeptina não mostrou efeitos benéficos na fase de manutenção. Este é o primeiro ensaio clínico duplo-cego randomizado de manutenção e de longo prazo com antidepressivo no transtorno bipolar. / The longitudinal course of bipolar disorder is highly variable, and a subset of patients seems to present a progressive course associated with brain changes and functional impairment. In our first article, we discussed the theory of neuroprogression in bipolar disorder. This concept considers the systemic stress response that occurs within mood episodes and late-stage deficits in functioning and cognition as well as neuroanatomic changes. We also discuss treatment refractoriness that may take place in some cases of bipolar disorder. We searched PubMed for articles published in any language up to June 4th, 2016. We found 315 abstracts and included 87 studies in our review. We are of the opinion that the use of specific pharmacological strategies and functional remediation may be potentially useful in bipolar patients at late-stages. New analytic approaches using multimodal data hold the potential to help in identifying signatures of subgroups of patients who will develop a neuroprogressive course. Based on our hypothesis of neuroprogression, we decided to perform a randomized clinical trial with tianeptine as adjunctive treatment for bipolar disorder in order to improve functional impairment and increase serum Brain-Derived Neurothrophic Factor BDNF levels. Tianeptine is a safe medication that acts on the glutamatergic system and has an antidepressant effect. The present study aimed at assessing the efficacy and tolerability of tianeptine as an adjunctive treatment for bipolar depression. We performed an enriched maintenance multi-center double-blind randomized controlled trial of tianeptine 37•5mg/day. Participants (n = 161) had a Montgomery Asberg Depression Rating Score ≥12 at trial entry. After eight weeks of open-label tianeptine treatment, those who responded to tianeptine were randomized to adjunctive tianeptine or placebo in addition to usual treatment. Participants were recruited from public health services and through advertisement. Time to any intervention was the primary endpoint of the study. Changes in mood symptoms, functioning, biological rhythms, quality of life, rates of mania switch and serum BDNF assessments were considered as secondary outcomes. There was a robust decrease in depressive symptoms along with improvements in functioning, quality of life and biological rhythms scores during the eight-week open-label tianeptine treatment phase. During the subsequent 24-week double-blind controlled phase, there was no difference regarding the primary outcome: time to intervention. In addition, there were no significant differences between groups in mood symptoms, functioning and BDNF levels. Tianeptine was well tolerated and not associated with mania switch as compared to placebo. These findings suggest that tianeptine is a safe medication and may be effective in the treatment of acute bipolar depression. However, tianeptine did not show beneficial effects in the maintenance phase. This is the first long-term randomized, double-blind maintenance trial of antidepressant augmentation in bipolar disorder.

Objetivo: Avaliar o impacto do tratamento periodontal na concentração sérica de proteína C-reativa (PCR), perfil lipídico e hemoglobina glicada em pacientes cardiopatas participantes de um ensaio clínico randomizado com análise de 12 meses de acompanhamento. Métodos: Trata-se de um ensaio clínico randomizado em hospital terciário com pacientes com doença arterial coronariana (DAC) estável e periodontite crônica grave. Foram realizados exames periodontais (seis sítios por dente em toda a boca) para registro de profundidade de sondagem (PS) e perda de inserção (PI), além de índice de placa visível (IPV) e índice de sangramento gengival (ISG). O grupo teste recebeu tratamento periodontal intensivo, sendo inicialmente realizada uma sessão de raspagem, alisamento e polimento supragengival (RAP) com orientação personalizada de higiene bucal. Em seguida, foram realizadas até quatro sessões de raspagem e alisamento radicular subgengival (RASUB) por quadrante, sob anestesia local. O grupo controle recebeu uma única sessão de RAP e orientação de higiene bucal. Foram coletadas amostras para mensuração dos níveis sistêmicos de PCR de alta sensibilidade, perfil lipídico e hemoglobina glicada. Resultados: 60 pacientes foram analisados após 12 meses, 28 no grupo teste e 32 no grupo controle, com idade média de 59 e 61 anos, respectivamente. Não foram observadas diferenças significativas ao longo do tempo, e entre os grupos nos dois tempos experimentais em relação a PCR. Assim como não foram encontradas diferenças significativas entre perfil lipídico e hemoglobina glicada. Conclusão: O tratamento periodontal não adicionou benefício sobre os níveis de PCR, hemoglobina glicada e perfil lipídico em indivíduos cardíacos crônicos tratados em uma unidade terciária. No entanto, foi observada uma tendência de benefício em pacientes cardíacos com níveis basais controlados de PCR. / Objective: To evaluate the impact of periodontal therapy on serum concentration of CRP, lipid profile and glycated hemoglobin in patients with heart disease participating in a randomized clinical trial with 12 months of follow-up. Methods: A randomized clinical trial in a tertiary hospital with patients with stable coronary artery disease (CAD) and severe chronic periodontitis. Whole mouth periodontal examination (six sites per tooth) was performed and comprised probing depth (PD) and attachment loss, in addition to visible plaque (VPI) and gingival bleeding index (GBI) The test group received intensive periodontal treatment. Initially, supragingival scaling with oral hygiene instruction were performed. In sequence, up to four sessions of subgingival scaling root planing per quadrant, under local anesthesia were performed. The control group had supragingival scaling and oral hygiene instruction. Blood samples were collected to assess the serum levels of high sensitivity CRP, lipid profile and glycated hemoglobin. Results: A total of 60 patients were analyzed after twelve moths, 28 (test group) and 32 (control group), with a mean age of 59 and 61 years. No statistically significant differences were observed along the study between groups in CRP. Also, no statistically significant diferences were detected in glycated hemoblobin and lipid profile. Conclusion: Periodontal treatment did not add benefit on CRP and glycated hemoglobina levels as well as in lipid profile in chronic cardiac individuals treated in a tertiary unit. However, a positive trend was observed in cardiac patients with controlled RCP basal levels.

Objetivos: o objetivo do presente estudo é avaliar a resposta molares e não molares a dois protocolos de atenção periodontal na fase de manutenção periódica preventiva (MPP). Métodos: Sessenta e dois pacientes com periodontite moderada ou avançada (idade média 50.97 ± 9.26 anos, 40 mulheres, 24 fumantes) foram tratados de acordo com um protocolo não-cirúrgico. Finalizada a fase terapêutica, os pacientes iniciaram a fase de MPP e foram randomicamente alocados para receber controle supragengival isolado (SPG) ou combinado ao subgengival (SPG+SBG). Exames periodontais, instruções de higiene bucal e as respectivas intervenções experimentais foram realizados em consultas trimestrais. Resultados: não foram observadas diferenças significativas nas variáveis demográficas, número médio de dentes e distribuição média de dentes não-molares/molares e de sítios livres/proximais entre os dois grupos experimentais. Quando do baseline, os dentes molares apresentaram um maior número de sítios positivos para IPV, ISG, SS e maiores valores médios de PS e PI quando comparados aos não-molares (p<0.001). Ao longo da fase de MPP, foi demonstrado que independente da terapia aplicada, tanto para molares e não molares, a resposta para ambos os grupos dentários não foi diferente. Da mesma forma, a perda dentária entre molares e não molares não diferiu ao longo de 24 meses. Conclusões: Molares apresentam semelhante resposta durante a fase de MPP quando comparados a dentes não molares, independente do protocolo de intervenção clínica aportado. / Aim: The objective of the present study was to evaluate the response of molar teeth and non-molar teeth to two periodontal care protocols in the periodic preventive maintenance phase (PMP). METHODS: Sixty-two patients with moderate or advanced periodontitis (mean age 50.97 ± 9.26 years, 40 women, 24 smokers) were treated according to a non-surgical protocol. After the therapeutic phase, the patients started the PMP and were randomly assigned to receive supragingival (SPG) or combined subgengival (SPG + SBG) control. Periodontal examinations, oral hygiene instructions and the respective experimental interventions were performed in quarterly consultations. Results: There were no significant differences in demographic variables, mean number of teeth and mean distribution of non-molar / molar teeth and free / proximal sites between the two experimental groups. At the baseline, molar teeth had a higher number of positive sites for VPI, GBI, BOP and higher mean values of PPD and CAL when compared to non-molars (p <0.001). Throughout the MPP phase, it was demonstrated that regardless of the applied therapy, for both molars and non-molars, the response for both dental groups was not different. Likewise, tooth loss between molars and non-molars did not differ over 24 months. Conclusions: Molars presented a similar response during the PMP when compared to non-molar teeth, independent of the protocol of clinical intervention provided.

Conclusions. The retractable non-invasive needle seems to have reasonably good capability of blinding patients and is more successful in acupuncture-naive subjects than in experienced ones. The failure to produce similar sensation of stimulation in the sham acupuncture group may be the major reason for incomplete blinding. (Abstract shortened by UMI.) / Design, participants and outcomes. We conducted a randomized controlled trial of 398 acupuncture-naive subjects and 197 acupuncture-experienced subjects who were recruited from the outpatients clinic of a university hospital in China. Acupuncture-naive and experienced subjects were randomized separately to receive the real acupuncture treatment or the placebo acupuncture at acupoint Hegu on the left hand. After the intervention, the percentage of patients who thought they had received real acupuncture was compared between the real and sham acupuncture groups. We defined the degree of blinding as 100% minus the difference in the percentage between the two groups. The score of pain, soreness, numbness, heaviness and distension during the treatment was also compared between the two groups. / Introduction. The newly designed retractable needle which can be used to produce non-invasive placebo or (sham) acupuncture seems promising and has been used in clinical trials. Several studies investigated the credibility of the retractable needle in blinding patients. These studies are generally small and mostly in acupuncture-naive patients and mainly focused on the difference in acupuncture-related sensations rather than the successfulness of blinding. / Objectives. To quantify the degree of blinding of the retractable non-invasive placebo needle in blinding both acupuncture-naive and experienced subjects in clinical trials and to explore possible reasons for incomplete blinding of the sham needle. / Results. In acupuncture-naive subjects, the percentage of those who thought they had received real acupuncture was 70.4% and 42.7% respectively in the real and sham acupuncture groups. The degree of blinding was 72.3% (95% CI: 62.9%, 81.7%). In acupuncture-experienced subjects, the degree of blinding was 58.9 (95% CI: 46.2%, 71.6%). The difference in degree of blinding between acupuncture-naive and experienced subjects was statistically significant (P&lt;0.05). The score of pain, soreness, numbness, heaviness and distension in the real acupuncture group was all statistically significantly higher than that in the sham acupuncture group in both acupuncture-naive and experienced subjects (P&lt;0.001). / Zhang Hongwei. / "February 2005." / Adviser: Jin Ling Tang. / Source: Dissertation Abstracts International, Volume: 67-01, Section: B, page: 0161. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2005. / Includes bibliographical references (p. 93-102). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

Fibromialgia é caracterizada por dor crônica músculo-esquelética difusa, distúrbio do sono, fadiga e humor depressivo ou ansiedade. Cinqüenta e oito mulheres com fibromialgia foram alocadas aleatoriamente e divididas em dois grupos: o primeiro (n=34), tratadas duas vezes por semana com acupuntura perfazendo total de 20 sessões, medicadas com antidepressivos tricíclico e utilizando caminhada, exercícios e relaxamento 2 vezes por semana. O segundo grupo (n=24) recebeu o mesmo tratamento exceto a acupuntura. A avaliação da dor foi realizada através da escala visual analógica (EVA), número de pontos dolorosos (NPD), do índice miálgico (IM) e um questionário SF36 para a qualidade de vida. As avaliações foram feitas antes, após, seis meses, um ano e dois anos depois da primeira avaliação. Foram realizadas por profissionais que desconheciam o grupo ao qual a paciente pertencia. No final das vinte sessões, as pacientes que receberam a acupuntura apresentaram melhora significante nas medidas de dor (EVA, NPD e IM) e em cinco sub-escalas do SF36 em relação ao grupo controle. Após seis meses o grupo de acupuntura apresentou resultado melhor do que o controle em relação ao NPD e ao IM e em uma sub-escala do SF36. Após um ano o grupo de acupuntura mostrou melhora sobre o grupo controle somente em uma sub-escala do SF36. Depois de dois anos do início do tratamento com acupuntura não houve diferença significativa entre os dois grupos em todas as medidas pesquisadas. A associação da acupuntura ao tratamento usual para fibromialgia mostrou-se benéfica para dor e qualidade de vida, mas somente por três meses após o tratamento. / Fibromyalgia is characterized by chronic widespread pain, disturbed sleep, fatigue and psychological distress. The aim of this study was to evaluate the effect of acupuncture as a treatment for this condition. Fifty-eight women diagnosed with fibromyalgia were randomly allocated to two groups. One group received acupuncture (n=34) twice a week for 20 sessions in addition to tricyclic antidepressants and exercises. The control group (n=24) received only tricyclic antidepressants and exercises. Patients rated their pain intensity using a visual analogue scale (VAS). A blinded assessor evaluated the number of fibromyalgia tender points (TePsN) and the pressure pain threshold over the 18 fibromyalgia tender points (PPT18). The same assessor also evaluated quality of life (QoL) using SF-36. These evaluations were done prior to treatments, at the end of the 20 sessions, and again at six months, one year and two years after the first evaluation. At the end of the 20 sessions, patients who had received acupuncture were significantly better than those who had not in all measures of pain (VAS, TePsN, PPT18) and in five subscales of SF-36. After six months, the acupuncture group was significantly better than the control group in some measures of pain (TePsN and PPT18) and in one subscale of SF-36. After one year, the acupuncture group showed significant advantage in only one subscale of SF-36; at two years there were no significant differences between the two groups on all outcome measures. The addition of acupuncture to usual treatment for fibromyalgia is beneficial for pain and quality of life, but only in the first six months.

A hipotermia perioperatória está associada a diferentes complicações, tais como: aumento da incidência de infecção de sítio cirúrgico, arritmias cardíacas, aumento do sangramento no período intraoperatório e desconforto térmico do paciente na sala de recuperação pós-anestésica, entre outras. Na literatura há evidências de que o pré- aquecimento da superfície corporal do paciente antes da indução anestésica é efetivo para a redução da hipotermia, pela diminuição do gradiente de temperatura entre os compartimentos central e periférico do organismo humano. Assim o objetivo do estudo foi avaliar o efeito do pré-aquecimento na manutenção da temperatura corporal de pacientes submetidas a cirurgias ginecológicas eletivas. Trata-se de ensaio clínico controlado randomizado, com a participação de 86 pacientes submetidas a cirurgia ginecológica eletiva, aleatorizadas em dois grupos. Na sala de admissão do Centro Cirúrgico, as participantes do grupo experimental (n=43) foram aquecidas durante 20 minutos com o sistema de ar forçado aquecido (manta térmica para o corpo todo), o equipamento foi ligado na temperatura de 38o C, e as participantes do grupo controle (n=43) foram cobertas com lençol de algodão e cobertor, durante o mesmo tempo. No período intraoperatório, todas as pacientes foram aquecidas com o sistema de ar forçado aquecido (manta térmica para a parte superior do corpo). A temperatura timpânica foi mensurada com termômetro timpânico infravermelho nos períodos pré e intraoperatório. A partir da entrada da paciente na sala de operação, a temperatura e umidade do ar da sala cirúrgica foram mensuradas. As médias da temperatura e umidade do ar da sala cirúrgica, entre os grupos experimental e controle, foram analisadas por meio do teste t- Student. As médias da temperatura corporal, entre os grupos experimental e controle, foram analisadas por meio de modelo linear de regressão de efeitos mistos. Na análise descritiva dos dados relativos às características sociodemográficas e clínicas das pacientes e do procedimento anestésico-cirúrgico, evidenciou-se similaridade entre os grupos experimental e controle. Após o pré-aquecimento, a média da temperatura corporal foi de 38o C no grupo experimental e de 37,8o C no grupo controle, com diferença estatisticamente não significante (p=0,27). No T150 (150 minutos após o início da cirurgia), houve diferença estatisticamente significante entre os grupos (p=0,01). No final da cirurgia, a temperatura média dos grupos estudados foi igual, ou seja, 36,8o C, com diferença estatisticamente não significante (p=0,66). Os resultados da média da temperatura da sala de operação, nos diferentes períodos mensurados, não apresentaram diferença estatisticamente significante entre os grupos estudados. Em relação à umidade do ar da sala de operação, somente no período T120 (120 minutos após o início da cirurgia), os resultados evidenciaram diferença estatisticamente significante entre os grupos (p=0,03). O pré-aquecimento com o sistema de ar forçado aquecido não teve efeito na temperatura corporal de pacientes submetidas a cirurgias ginecológicas eletivas / Perioperative hypothermia is associated with various complications, such as an increased incidence of surgical site infection, cardiac arrhythmias, increased bleeding in the intraoperative period, and thermal discomfort of the patient in the post- anesthetic recovery room, among others. In the literature there is evidence that prewarming the body surface of the patient prior to induction of anesthesia is effective in reducing hypothermia, by lowering the temperature gradient between the central and peripheral compartments of the human organism. Thus, the objective of the present study was to evaluate the effects of prewarming on maintaining the body temperature of patients undergoing elective gynecological surgery. This is a randomized controlled clinical trial involving 86 patients undergoing elective gynecological surgery, randomized into two groups. In the admission room of the Surgical Center, participants in the experimental group (n=43) were warmed for 20 minutes using the forced air heating system (thermal blanket over the whole body), the equipment was turned on at a temperature of 38o C, and the control group (n = 43) were covered with a cotton sheet and blanket for the same period. During the intraoperative period, all patients were warmed using the forced air heating system (thermal blanket for the upper body). The tympanic temperature was measured using an infrared tympanic thermometer in the pre- and intraoperative periods. From the moment of each patient\'s entry into the operating room, the temperature and humidity of the air in the room were measured. The mean temperatures and humidity levels of the operating room, between the experimental and control groups, were analyzed using the Student t-test. The mean body temperatures between the experimental and control groups were analyzed using a linear mixed effects regression model. The descriptive analysis of data on the sociodemographic and clinical characteristics of the patients and the surgical anesthetic procedure demonstrated similarity between the experimental and control groups. After prewarming, the mean body temperature was 38o C in the experimental group and 37.8ºC in the control group, with no statistically significant difference (p = 0.27). At T150 (150 minutes after the start of surgery) there was no statistically significant difference between the groups (p = 0.01). At the end of surgery, the mean temperature of the studied groups was the same, i.e., 36.8o C, with no statistically significant difference between the groups (p = 0.66). The results of the mean operating room temperatures, in the different periods measured, presented no statistically significant differences between groups. In relation to the humidity of the operating room, the results demonstrated a statistically significant difference between groups (p = 0.03) only in the period T120 (120 minutes after the start of surgery). Prewarming with the forced air heating system had no effect on body temperature of patients undergoing elective gynecological surgery

Introdução: As práticas clínicas baseadas em evidências utilizam resultados de estudos bem desenhados e bem conduzidos que, compilados em revisões sistemáticas, auxiliam os profissionais da saúde e orientam-os de modo sintético e atualizado no manejo dos tratamentos. Em um estudo bem conduzido, os dados coletados apresentarão boa qualidade se obtidos a partir de protocolos bem definidos que incluem as orientações para o acompanhamento dos pacientes e ações padronizadas pelos profissionais envolvidos. O monitoramento do estudo permite acompanhar e controlar a execução das ações definidas no protocolo de tal forma que os resultados finais não apresentem vieses de seleção, de desempenho (performance), de detecção, de atrito (attrition) ou de relato. Entre os instrumentos que avaliam a qualidade do relato de ensaios clínicos, nenhum deles destaca a avaliação de ações de monitoramento que, constitui, segundo nosso ponto de vista, um elemento importante para assegurar a qualidade dos dados. Objetivo: Apresentar uma reflexão sobre vieses em ensaios clínicos aleatorizados e sobre o papel do monitoramento do estudo no controle e prevenção destes. Métodos: Estudo metodológico que se propôs a avaliar a qualidade de ensaios clínicos aleatorizados incluídos em uma revisão sistemática escolhida ad hoc que tratou do uso de estatinas na prevenção primária de doença cardiovascular. Análise de vieses dos estudos originais incluídos na revisão sistemática utilizando a ferramenta para avaliação de risco de viés em ensaios clínicos aleatorizados descrita no Cochrane Handbook for Systematic Reviews of Interventions (Manual Cochrane para Revisões Sistemáticas de Intervenção), versão 5.1.0. Foram identificadas e descritas em detalhes as ações do monitoramento que poderiam colaborar na minimização ou possível eliminação dos vieses. Foi realizada uma busca nos artigos originais para verificar se existia a descrição das ações relacionadas ao monitoramento. Resultados: Considerando o critério para possibilidade de ocorrência de cada um dos sete tipos de viés, os estudos BONE, CARDS, METEOR e MRC/BHF apresentaram a maior porcentagem (85,7 por cento ) de baixo risco de ocorrência de vieses, indicando possivelmente boa qualidade metodológica. Em contrapartida, em quatro estudos esta porcentagem foi menor que 50 por cento (estudos ASPEN, CERDIA, HYRIM e KAPS), indicando menor qualidade metodológica. Todos os estudos foram classificados como risco incerto para outras fontes de vieses por apresentarem patrocínio por indústria farmacêutica representando, sob nossa avaliação, conflito de interesse. Observou-se que o estudo AFCAPS/TexCAPS indicou que uma empresa que organiza pesquisas foi contratada pelo patrocinador para manejo administrativo e clínico e também dos dados. Porém, não foram descritos maiores detalhes sobre o monitoramento. Neste estudo, observou-se risco incerto para a geração de sequência aleatória, ocultação da alocação e outros vieses. Os demais potenciais vieses foram classificados como baixo risco. Conclusões: No presente trabalho, verificou-se que mesmo um ensaio clínico bem desenhado, relatado e avaliado como baixo risco para a ocorrência de vieses também está sujeito a ocorrência destes durante a sua condução. Vê-se como necessária a inclusão de um item específico sobre viés de conflito de interesse nos instrumentos de avaliação de qualidade metodológica de estudos. Reforça-se o papel do monitoramento para evitar ou minimizar erros sistemáticos, garantindo que o estudo seja realizado conforme o que foi inicialmente proposto. / Background: The clinical practices based on evidences use results obtained from well designed and conducted studies that compiled in systematic reviews assist and guide health professionals to manage patient treatments. In a well conducted study, data collected will have good quality if obtained from protocols that include guidance for patients follow-up and standardized procedures for personnel involved in the study. The study monitoring allows follow-up and control regarding the execution of tasks required by protocol in order to avoid selection bias, performance bias, detection bias, attrition bias or report bias in study results. The available tools to evaluate the quality of reporting of randomized clinical trials do not describe the monitoring actions that we believe are very important for data quality assurance. Objective: To reflect about bias occurrence in randomized clinical trials and the role of study monitoring in its control and prevention. Methods: Methodological study that evaluated the quality of randomized clinical trials included in a systematic review chosen ad hoc regarding the statin use for the primary prevention of cardiovascular disease. Analysis of the original studies using the Cochrane Collaboration´s tool for assessing risk of bias in randomized clinical trials described in Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0. The monitoring actions that could avoid or minimize bias occurrence were identified and described in details. A search for actions related to monitoring was also performed in the original articles. Results: Considering the criteria for the possibility of occurence of each of the seven bias types, the studies BONE, CARDS, METEOR and MRC/BHF presented a higher percentage (85.7 per cent ) of low risk for bias, possibly indicating a good methodologic quality. However, this percentage was less than 50 per cent in four studies (ASPEN, CERDIA, HYRIM e KAPS), indicating a poor methodologic quality. All studies were classified as unclear risk for other bias considering that they were sponsored by pharmaceutical industries representing, according to our evaluation, conflict of interest. It was observed that AFCAPS/TexCAPS study indicated that a company responsible for research organization was contracted by the sponsor for data, administrative and clinical management. However, further information about monitoring was not described. In this particular study, random sequence generation, allocation concealment and other bias were classified as unclear risk. The remaining potential biases were classified as low risk. Conclusion: At the present work, it was verified that even clinical trials that are well designed, reported and with low risk for bias might have problems during the study conduction. We understand as necessary the inclusion of a specific item about the bias of conflict of interest in the tools for evaluation of methodology of studies.We emphasize the role of monitoring to avoid or minimize systematic bias, ensuring that the study is performed according to what was initially proposed.

abstract: This dissertation studies three classes of combinatorial arrays with practical applications in testing, measurement, and security. Covering arrays are widely studied in software and hardware testing to indicate the presence of faulty interactions. Locating arrays extend covering arrays to achieve identification of the interactions causing a fault by requiring additional conditions on how interactions are covered in rows. This dissertation introduces a new class, the anonymizing arrays, to guarantee a degree of anonymity by bounding the probability a particular row is identified by the interaction presented. Similarities among these arrays lead to common algorithmic techniques for their construction which this dissertation explores. Differences arising from their application domains lead to the unique features of each class, requiring tailoring the techniques to the specifics of each problem. One contribution of this work is a conditional expectation algorithm to build covering arrays via an intermediate combinatorial object. Conditional expectation efficiently finds intermediate-sized arrays that are particularly useful as ingredients for additional recursive algorithms. A cut-and-paste method creates large arrays from small ingredients. Performing transformations on the copies makes further improvements by reducing redundancy in the composed arrays and leads to fewer rows. This work contains the first algorithm for constructing locating arrays for general values of $d$ and $t$. A randomized computational search algorithmic framework verifies if a candidate array is $(\bar{d},t)$-locating by partitioning the search space and performs random resampling if a candidate fails. Algorithmic parameters determine which columns to resample and when to add additional rows to the candidate array. Additionally, analysis is conducted on the performance of the algorithmic parameters to provide guidance on how to tune parameters to prioritize speed, accuracy, or a combination of both. This work proposes anonymizing arrays as a class related to covering arrays with a higher coverage requirement and constraints. The algorithms for covering and locating arrays are tailored to anonymizing array construction. An additional property, homogeneity, is introduced to meet the needs of attribute-based authorization. Two metrics, local and global homogeneity, are designed to compare anonymizing arrays with the same parameters. Finally, a post-optimization approach reduces the homogeneity of an anonymizing array. / Dissertation/Thesis / Doctoral Dissertation Computer Science 2019

Background: By 2050, it is estimated that 14 million older Americans will live with Alzheimer’s disease (AD), a progressive form of dementia with unknown cause or cure. Persons with AD and related dementias (ADRD) become increasingly dependent on others as they experience cognitive decline, which concomitantly undermines individuals’ functional skills, social initiative, and quality of life. The Alzheimer’s Association advocates for interventions that address cognition, mood, behavior, social engagement, and by extension, quality of life – goals music therapists often address. Although a small but growing body of literature suggests that clinical music therapy may be effective, the evidentiary support for the use and appropriate application of music as a form of treatment with this population is currently limited. Objectives: This thesis consisted of the development of a Clinical Practice Model of music therapy for persons with ADRD. It also examined the effectiveness of a specific, protocol-based music therapy intervention, grounded in this model, relative to a verbal discussion activity. Methods: The Clinical Practice Model is theoretically grounded in the biopsychosocial model of healthcare (Engel, 1980) and Kitwood’s (1997) personhood framework, and I developed it through extensive literature review and expert input. It includes an organizational schema for applying intervention strategies, per six themes: cognition, attention, familiarity, audibility, structure, and autonomy. The initial model predicts that an intervention built upon this schema will influence social-affective responses, quality of life, and in turn, psychosocial symptoms of ADRD. I tested a singing-based music therapy intervention, grounded in this model, through a randomized clinical crossover trial. I compared participants’ responses to music therapy to a non-music verbal discussion activity, and both conditions followed a protocol. Dependent variables included: (1) affective responses (self-reported feelings, observed emotions, and observed mood), (2) social engagement, and (3) observed quality of life. Thirty-two individuals with ADRD (n = 6 men, n = 26 women) ages 65-97 years old (μ̂ = 84.13) participated in this study. I randomly assigned treatment order; each treatment occurred in small-group format, three times per week in the afternoon (25 minutes each session), for two consecutive weeks. A two-week “wash-out” period occurred between conditions. Credentialed music therapists led both study conditions. This study followed recommendations from the National Institutes of Health Behavior Change Consortium (Bellg et al., 2004) to enhance quality assurance in protocol administration and data collection. Results and Significance: I used a linear mixed model approach to analysis. Music therapy exacted a significant, positive effect on self-reported feelings, observed emotions, and constructive engagement, particularly for individuals with moderate dementia. Results also suggested that men’s feelings improved in response to music therapy only, whereas women responded positively to both conditions. Weekly observations failed to indicate a significant change in mood or quality of life across the eight-week study. Based on these findings, I revised the Clinical Practice Model to include wellbeing (an outcome more concordant with psychosocial change in response to music intervention) rather than global quality of life (affected by numerous aspects of the care milieu). In addition to the Clinical Practice Model to the music therapy profession, contributions of this thesis include a rigorous clinical study and practical implications for music therapy practice, including the importance of considering patient characteristics and careful selection and implementation of music in a music therapy intervention.