Background: During an age of fiscal constraint and increasing pressure to provide timely access to effective, efficient and evidence based care, there is an increased need for research to develop empirically based prevention and intervention strategies for complex psychological difficulties which often present during childhood and adolescence. Child and Adolescent Mental Health Services (CAMHS) are under significant pressure to deliver timely access to services, with demand frequently outstripping capacity to deliver. These challenges have highlighted the need for services to ensure that planning supports continued improvement in quality and delivers the best possible outcomes for service users. Systematic Review: A systematic review of the literature on the efficacy of group based interventions for adolescents with features or a diagnosis of Borderline Personality Disorder (BPD) was conducted. Seven articles met the inclusion criteria and underwent detailed quality analysis. All included studies reported a significant improvement in psychopathology and symptoms of distress as well as an improvement in quality of life for both group based interventions and treatment as usual. Overall, the results hold promise for current work with adolescents with BPD and highlight the importance for future research in this developing area. However, more rigorous research is required to identify the active ingredients of treatments for BPD in adolescents with a view to developing standardised treatment protocols. Empirical Study: A Delphi study was conducted to explore perceptions on the relevance, practicalities, importance and feasibility of implementing nationally agreed CAMHS referral criteria from the perspective of clinicians working in CAMHS in the North of Scotland. In addition, the study aimed to explore and gain consensus on possible factors which support clinicians working in specialist services. A three round electronic Delphi survey, an iterative structured process used to gather information and gain group consensus, was completed by twenty-eight clinicians working in CAMHS. Eight open ended questions in Round 1, were analysed using content analyses resulting in ninety-eight statements to be rated by the same group of clinicians in Round 2 and fifteen statements in Round 3. Of the ninety-eight statements, eighty-four reached consensus. Results indicate that the guidelines are viewed by many clinicians as both acceptable and important, however, implementation of the guidelines can present services with significant challenges and have highlighted the importance of services having the correct infrastructure before it is possible to implement the referral criteria in a consistent and meaningful way.

Introduction: High intensity holistic neuropsychological rehabilitation is the most evidenced-based intervention for post-acute ABI rehabilitation. However, the majority of the current evidence has examined inpatient or residential treatment contexts. Little is known about the efficacy of community neuropsychological rehabilitation interventions or the clinical validity of both high and low intensity forms of rehabilitation in a community rehabilitation setting. The systematic review synthesises the existing evidence for community-based holistic neuropsychological rehabilitation and its psycho-social outcomes. Changes in self and group identity have been suggested to underpin evidence-based neuropsychological rehabilitation. However, little is known about how these processes of identity change following ABI and throughout the rehabilitation process. The empirical study explores key turning points in the self-narratives of individuals with ABI in order to better understand the clinical and contextual factors which influence their rehabilitation. Methods: A search was conducted of Embase, Embase classic, Medline and PsycInfo. Studies were assessed for risk of bias and outcomes were synthesised following the PRISMA guidelines for systematic reviews. A ‘holistic-content’ narrative methodology was then employed to explore the post-acute adjustment and rehabilitation narratives of 11 individuals following ABI. Three-dimensional analysis of interaction, continuity and situation was used to examine individuals’ personal reflections of identity changes across their illness experience; and cross-case comparisons identified common transformational themes. Results: 15 studies were included in the review. Two distinct levels of intervention intensity were identified: high intensity interventions delivered multiple days per week, and low intensity interventions delivered only once a week. A synthesis of nine studies examining high intensity neuropsychological rehabilitation found evidence that these interventions can improve psychological wellbeing and enhance community integration following ABI when delivered on an outpatient basis. A synthesis of six low intensity interventions found limited evidence that they can lead to improved psycho-social outcomes when structure to target specific difficulties, and evidence that they can effectively support the achievement of individual patient goals. Following the analysis of ABI survivor narratives, themes of ‘Rehabilitation focus and psychological distress’, ‘Reclaiming efficacy in valued life domains’, and ‘Social comparisons: inclusion and exclusion’ were identified; each representing a continuum of personal and social understanding along which people moved during their rehabilitation. Conclusions: The systematic review suggested that high intensity forms of outpatient neuropsychological rehabilitation are effective at improving psycho-social outcomes. Low intensity forms of outpatient neuropsychological rehabilitation appear to offer a less favourable alternative to supporting psycho-social adjustment in the community at present. Findings from the empirical paper suggest that illness identity may be co-constructed in the context of early treatment experiences, and appears to influence post-acute rehabilitation focus; and that pre-injury values and self-identity guided participant approaches to re-establishing self-efficacy. These processes were supported by clinical, social and group interactions.

Mais de 50% das amputações não-traumáticas em membros inferiores são atribuídas ao diabetes. Anualmente, 2 a 3% dos pacientes desenvolvem úlceras nos pés e este risco aumenta para 15% no transcurso de sua vida. Freqüentemente, úlceras nos membros inferiores precedem as amputações. Entre os casos graves hospitalizados, 85% foram causados por úlceras superficiais acompanhadas de diminuição da sensibilidade, decorrente de neuropatia diabética. O objetivo do estudo foi elaborar uma proposta assistencial sistematizada para pessoas com diabetes tipo 2, a partir de uma revisão sistemática, visando a prevenir o risco de lesão/ulceração nos pés e avaliar a efetividade dessa proposta em unidades da rede básica. Estudos primários e diretrizes clínicas foram identificados em bases eletrônicas, sites específicos e referências. Para análise dos estudos e diretrizes, utilizaram-se critérios estabelecidos. Na aplicação da proposta de assistência, 101 pessoas com diabetes tipo 2 foram recrutadas para participar do ensaio prospectivo de 12 meses; 49 pessoas participaram de sensibilização e educação intensiva durante seis semanas e, após este período, compareceram a consultas mensais de enfermagem para reforços e cuidados com os pés; outras 52 receberam cuidado convencional e participaram de orientações grupais semestrais. A avaliação semestral dos resultados primários incluiu o conhecimento sobre diabetes e cuidados com os pés e calçados, condições dermatológicas dos pés e uso de calçado apropriado. Os resultados apresentaram a identificação de 3.941 artigos, sendo selecionados apenas 10 estudos primários e nove diretrizes, os quais envolviam a organização do serviço para o cuidado da pessoa com diabetes e intervenções educativas nos pacientes. Os estudos revisados foram inconclusivos, apresentando falhas na qualidade metodológica. As intervenções preventivas se concentraram na realização de screening para identificar alterações estruturais nos pés, comprometimento da sensibilidade protetora plantar, ressaltando antecedente de úlcera, controle glicêmico e aconselhamento sobre a propriedade dos calçados. No ensaio clínico, 20 pessoas abandonaram o estudo. Os grupos foram semelhantes em idade, sexo, escolaridade, tempo de doença, co-morbidades e antecedentes de lesões nos pés. Ao final do primeiro semestre, houve melhora significativa apenas nas variáveis de conhecimento sobre diabetes (p=0,005) e comportamentos de cuidados com os pés (p<0,000). Ao término do ensaio, houve melhora nas condições dermatológicas dos pés (p<0,000) e na utilização de calçado apropriado (p=0,005), sendo mantido o conhecimento atingido previamente (p<0,000). Este trabalho mostrou a importância do monitoramento dos fatores de risco nos pés para lesão/ulceração, destacando o processo educativo entre profissionais e pacientes como medida fundamental de prevenção. Além disso, este estudo proporcionou subsídios para uma proposta efetiva de assistência sistematizada na prevenção de lesões/ulcerações nos pés, com desenvolvimento de consultas mensais e cuidados básicos com os pés entre pessoas de baixo risco / Diabetes is considered responsible for more than 50% of non-traumatic lower limb amputations. Every year, about 2-3% of patients develop foot ulcers, and this risk increases to 15% throughout their lives. Lower limb ulcers frequently precede amputations, 85% of serious hospitalizations cases were caused by superficial ulcers, accompanied by decreased sensibility due to diabetic neuropathy. This study aimed to elaborate a systematic care proposal for patients with type 2 diabetes, based on a systematic review, with a view to preventing the risk of developing foot injury/ulceration, as well as to assess the efficacy of this proposal in district basic health units. Electronic databases, specific sites and references were used to identify primary studies and clinical guidelines. Established criteria were used to analyze the studies and guidelines. In the application of the care proposal, 101 diabetes type 2 patients were recruited to participate in the 12-month prospective trial; 49 persons participated in an intensive six-week educational awareness program, after which they attended monthly appointments for reinforcement and foot care; 52 other persons received conventional care and participated in six-monthly group orientations. The six-monthly evaluation of primary results included knowledge on diabetes, foot and footwear care, dermatological foot conditions and use of appropriate footwear. The results showed that 3,941 articles were identified, of which only 10 primary studies and nine guidelines were selected, which involved service organization for diabetes patient care and educational patient interventions. The reviewed studies were inconclusive and presented methodological flaws. Preventive interventions concentrated on screening to identify structural foot alterations, protective sensibility in the sole of the foot at risk, emphasizing history of ulcers; glycemic control and advice on appropriate footwear. In the clinical trial, 20 persons abandoned the study. The groups had similar age, gender, education, co-morbidity and foot injury antecedent characteristics. At the end of the first semester, only the knowledge variables on diabetes (p= .005) and foot care behavior (p< .000) revealed a significant improvement. At the end of the trial, the improvement in these two variables was maintained (p< .000), and accompanied by an improvement in dermatological foot conditions (p< .000) and in the use of appropriate footwear (p= .005). This research demonstrated the importance of monitoring risk factors for foot injuries/ulceration and highlighted the education process between professionals and patients as a fundamental prevention measure. Moreover, this study provided supported for an efficient systematic care proposal in the prevention of foot injuries/ulcerations, including monthly appointments and basic foot care, for low-risk patients.

Asystematic review of health problems following tsunamis Introduction: Tsunamis are sudden onset disasters with substantial impact on human health. Toidentify the relationship between tsunamis and health problems, the evidence must besystematically reviewed. Through this, health care response can be planned accordingly. Aim: To identify the health problems following tsunamis in order to guide medical response.Methods and materials: Four databases (Medline, Global Health, Web of Science CoreCollection and Embase) were searched using an inclusive search strategy in September 2018.The inclusion criteria were published, peer-reviewed articles on morbidity with data frommedical health facilities following tsunamis, where a control or comparison group was used toanalyze the tsunami outcome. Studies on mental health problems were excluded. The studieswere analyzed through narrative synthesis. Results: Eleven articles were included in the review. There was an increase in non-traumaticconditions reported in the immediate aftermath of tsunamis. Long-term health problems on thetsunami-affected population were seen up to three years after a tsunami. There is a lack of highqualityarticles on health problems after tsunamis. Conclusions: Medical response should prepare for trauma and non-trauma care shortly after atsunami and expect an increase in certain health problems several years post-tsunami. Existing,high-quality research is limited, and this review could not capture all tsunami-related healthproblems. Future studies that identify available evidence on health care needs after tsunamisshould consider using scoping reviews to cover a broader base of literature.

Submitted by Angela Maria de Oliveira (amolivei@uepg.br) on 2017-10-25T16:15:30Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) BARBARA BAIAK.pdf: 851854 bytes, checksum: ec3cb108a9139e9eea278fc05bef5f2e (MD5) / Made available in DSpace on 2017-10-25T16:15:30Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) BARBARA BAIAK.pdf: 851854 bytes, checksum: ec3cb108a9139e9eea278fc05bef5f2e (MD5) Previous issue date: 2017-08-29 / As infecções causadas por nematódeos gastrintestinais em bovinos são comuns, sua patologia prejudica a saúde e bem estar dos animais, resultando em perdas na produção de leite e carne. Como a transmissão destes parasitas se dá no pasto, geralmente o que se encontra são infecções mistas, ou seja, mais de um gênero ou espécie parasitando o mesmo animal. Os anti-helmínticos são utilizados para o controle destes parasitas há anos. O uso indiscriminado, a utilização do mesmo composto químico sem alternância, as subdosagens, são fatores que podem causar a resistência anti-helmíntica. Devido ao aumento nos relatos de resistência à estes compostos em bovinos, o objetivo do trabalho foi estimar através da metaanálise a resistência anti-helmíntica de bovinos aos nematódeos gastrintestinais. Os dados para composição da base foram obtidos a partir de artigos e resumos publicados em bases indexadoras. Os mesmos foram avaliados criteriosamente conforme sua qualidade e importância segundo os objetivos da meta-análise. Foram tabulados informações referentes aos aspectos bibliográficos, anti-helmínticos, animais, métodos de redução, dias após aplicação, tipo de infecção, gêneros dos parasitas, tipo de aplicação e dosagem do antihelmíntico. A base final dos dados foi composta por 80 artigos publicados entre 1986 e 2016, perfazendo um total de 9516 bovinos. A análise gráfica foi utilizada como primeiro passo para observar a distribuição dos dados, seguidas de análise de variância e comparações pelo teste Tukey. Equações de predição foram realizadas a partir dos coeficientes obtidos nas análises de variância-covariância. Para demonstrar o valor sumarizado da meta-análise foi realizado o forest plot. O tipo de aplicação interferiu na eficácia dos anti-helmínticos em bovinos (P<0,05); aplicação oral foi superior a injetável e a pour on. Nos grupos químicos e princípios ativos, o grupo “associados” apresentou média de eficácia superior as lactonas macrocíclicas e ivermectina com as menores médias (P<0,05).O uso composto demonstrou superioridade em relação ao uso único (P<0,05). O tipo de infecção, método de redução, idade e grupo racial não apresentaram interferência (P>0,05) na eficácia dos anti-helmínticos. Em relação aos gêneros de nematódeos gastrintestinais, o princípio ativo levamisol apresentou a maior média de eficácia para os gêneros Cooperia spp. e Trichostrongylus spp. Estes diferiram de Ostertagia spp. (P<0,05). Para os gêneros Ostertagia spp. e Trichostrongylus spp. a eficácia da ivermectina foi de 100%, estes diferiram de Cooperia spp. e infecções mistas (P<0,05). A porcentagem média de eficácia para doramectina foi maior para Ostertagia spp. diferindo de Cooperia spp. (P<0,05). Nos princípios ativos listados na categoria “outros” a maior média foi registrada no gênero Ostertagia spp. diferindo de Haemonchus spp. (P<0,05). Na utilização de princípios ativos associados e moxidectina, não houve diferença (P>0,05) entre os gêneros. Equações de predição demonstraram que para o princípio ativo levamisol a eficácia do anti-helmíntico aumenta proporcionalmente conforme a dose, e que a eficácia diminui conforme o passar dos dias após a aplicação. O forest plot com I²=94% demonstrou alta heterogeneidade entre os dados, sendo o valor sumarizado classificado como resistente (P>0,05). Este estudo evidencia a resistência anti-helmíntica em bovinos em vários continentes, onde apenas o uso associado mostrou eficácia. Portanto, é necessário substituir os esquemas com base no uso exclusivo de compostos químicos para diminuir a pressão de seleção. / Infections caused by gastrointestinal nematodes in cattle are common; they can prejudice the health and welfare of animals, resulting in losses in milk and meat production. As the transmission of these parasites occurs in the pasture, what is usually found are mixed infections, that is, more than one nematode genera parasitizing the same animal. The anthelmintics have been used to control these parasites for years. The indiscriminate use, the utilization of the same chemical compound without alternation, the underdosage, are factors that can cause the anthelmintic resistance. Due to the increase in the reports of resistance to these compounds in cattle, the objective of the study was to estimate through the metaanalysis the anthelmintic resistance in cattle by gastrointestinal nematodes. Data for the composition of the database were obtained from articles and short communications published in index databases. They were carefully evaluated according to their quality and importance according to the meta-analysis objectives. It were tabulated information about the bibliographic, anthelmintic, animal, reduction method, days after application, type of infection, parasite genera, type of application and dosage. The final data base was composed of 80 articles between 1986 and 2016, making a total of 9516 animals. The graphical analysis was used as a first step to observe the data distribution, followed by analysis of variance and comparisons by the Tukey test. Prediction equations were performed from the coefficients obtained in the variance-covariance analyzes. In order to demonstrate the summary value of the meta-analysis, the "forest plot" was performed. The type of application interfered in the efficacy of anthelmintics in cattle (P<0.05), oral application was superior to injectable and pour on. In the chemical groups and active principles, the associated group presented better mean of efficacy (>95%), macrocyclic lactones and ivermectin showed the worse means (P<0.05). The associated use showed superiority in relation to unique use (P<0.05). The type of infection, reduction method, age and racial group did not show interference (P>0.05) in the efficacy of anthelmintics. In relation to nematode genera, levamisole presented the highest average of efficacy for the genera Cooperia spp. and Trichostrongylus spp. differed from Ostertagia spp. with the worse average (P<0.05), ivermectin showed the highest average for Ostertagia spp. and Trichostrongylus spp., Cooperia spp. and mixed infection presented worse average (P<0.05), doramectin presented the highest average for Ostertagia spp., and the worse for Cooperia spp. (P<0.05). In the active principles listed in the category "others" the highest average was recorded in the genera Ostertagia spp. differing from Haemonchus spp. with the worse average (P <0.05). Associated active principles and moxidectin, did not show significance between the nematode genera (P>0.05). Prediction equations showed that for the levamisole the efficacy of the drug increases proportionally according to the dose, and that the efficacy decreases as the days pass after the application. The forest plot showed high heterogeneity among the data, being the summarized value classified as resistant (P>0.05). This study evidences the anthelmintic resistance in cattle on several continents, where only the associated use showed efficacy. Therefore, there is a need to replace the schemes based on the exclusive use of chemical compounds in order to decrease the selection pressure.

Background Health information exchange (HIE) may help healthcare professionals and policymakers make informed decisions to improve patient and population health outcomes. There is, however, limited uptake of HIE in many low- and middle-income countries (LMICs). While resource constraints are an obvious barrier to implementation of HIE, it is important to explore what other political, structural, technical, environmental, legal and cultural factors may be involved. In particular, it is necessary to understand associated barriers in relation to context-specific HIE processes and deployment strategies in LMICs with a view to discovering how these can be overcome. My home country Pakistan is currently struggling to implement HIE at scale and so I undertook a detailed investigation of these issues in the context of Pakistan to generate insights on how best to promote uptake of HIE in Pakistan and in LMICs more generally. Aims The concept of HIE is evolving both over time and by context. To gain a clearer understanding of this terrain, I began by identifying different definitions of HIE in the literature to understand how these had evolved and the underlying conceptual basis for these changes. Second, I sought to understand the barriers and facilitators to the implementation and adoption of HIE in LMICs. Building on this foundational work, I then sought to explore and understand in-depth stakeholders perspectives on the context of and deployment strategies for HIE in Pakistan with a view to also identifying potentially transferable lessons for LMICs. Methods I undertook a phased programme of work. Phase 1 was a scoping review of definitions, which involved systematically searching the published literature in five academic databases and grey literature using Google to identify published definitions of HIE and related terms. The searches covered the period from January 1900 to February 2014. The included definitions were thematically analysed. In Phase 2, to identify barriers and facilitators to HIE in LMICs, I conducted a systematic review and searched for published and on-going (conference papers and abstracts) qualitative, quantitative and mixed-method studies in 11 academic databases and looked for unpublished work through Google interface from January 1990 to July 2014. Eligible studies were critically appraised and then thematically analysed. Finally, in Phase 3 I conducted a case study of HIE in Pakistan. Data collection comprised of interviews of different healthcare stakeholders across Pakistan to explore attitudes to HIE, and barriers and facilitators to its deployment. I also collected evidence through observational field notes and by analysing key international, national and regional policy documents. I used a combination of deductive thematic analysis informed by the theory of Diffusion of Innovations in Health Service Organisations that highlighted attributes of the innovation, the behaviour of adopters, and the organisational and environmental influences necessary for the success of implementation; and a more inductive iterative thematic analysis approach that allowed new themes to evolve from the data. The findings from these three phases of work were then integrated to identify potentially transferable lessons for Pakistan and other LMICs. Results In Phase 1, a total of 268 unique definitions of HIE were identified and extracted: 103 from scientific databases and 165 from Google. Eleven attributes emerged from the analysis that characterised HIE into two over-riding concepts. One was the ‘process’ of electronic information transfer among various healthcare stakeholders and the other was the HIE ‘organisation’ responsible to oversee the legal and business issues of information transfer. The results of Phase 1 informed the eligibility criteria to conduct Phase 2, in which a total of 63 studies met the inclusion criteria. Low importance given to data informed decision making, corruption and insecurity, lack of training, lack of equipment and supplies, and lack of feedback were considered to be major challenges to implementing HIE in LMICs, but strong leadership and clear policy direction coupled with the financial support to acquire essential technology, provide training for staff, assessing the needs of individuals and data standardisation all promoted implementation. The results of Phases 1 and 2 informed the design and content of Phase 3, the Pakistan case study. The complete dataset comprised of 39 interviews from 43 participants (including two group interviews), field observations, and a range of local and national documents. Findings showed that HIE existed mainly in/among some hospitals in Pakistan, but in a patchy and fragmented form. The district health information system was responsible for electronically transferring statistical data of public health facilities from districts to national offices via provincial intermediaries. Many issues were attributed to the absence of effective HIE, from ‘delays in retrieving records’ to ‘the increase in antibiotic resistance’. Barriers and facilitators to HIE were similar to the findings in Phase 2, but new findings included problems perceived to be the result of devolution of health matters from the federal to provincial governments, the politicised behaviour of international organisations, healthcare providers’ resistance to recording consultations to avoid liability and poor documentation skills. Public pressure to adopt mobile technology frameworks was found to be a novel facilitator whereas sharing regional health information with international organisations was perceived by some participants as disadvantageous as there were concerns that it may have enhanced espionage activities in the region. Conclusions HIE needs to be considered in both organisational and process terms. Effective HIE is essential to the provision of high quality care and the efficient running of health systems. Structural, political and financial considerations are important barriers to promoting HIE in LMICs, however, strong leadership, vision and policy direction along with financial support can help to promote the implementation of HIE in LMICs. Similarly, the federal and provincial governments could play an important role in implementing HIE in Pakistan along with the support of international organisations by facilitating HIE processes at federal and provincial levels across Pakistan. This however seems unlikely for the foreseeable future. At a meso- and micro-level, HIE in Pakistan and other LMICs could be achieved through using leapfrog mobile technologies to facilitate care processes for local organisations and patients. Specifically, the study on Pakistan has highlighted that LMICs may achieve modest successes in HIE through use of patient held records and use of now ubiquitous mobile phone technology with some patient and organisational benefits, but scaling these benefits is dependent on the creation of national structures and strategies which are more difficult to achieve in the low advanced informatics skill and resource settings that characterise many LMICs.

Introdução: O Acinetobacter spp. é um cocobacilo gram-negativo de grande importância nas infecções hospitalares, especialmente em pacientes internados em unidades de terapia intensiva (UTI); podendo levar a um aumento na morbidade e mortalidade desses pacientes. Há evidências sustentando associação entre infecção por Acinetobacter baumannii e aumento das taxas de mortalidade bruta e atribuível. Contudo, o papel desse agente como causa direta de mortalidade ainda não está suficientemente caracterizado. Dentre os fatores relacionados com o aumento da mortalidade estão: gravidade do paciente, infecção relacionada à A. baumannii multirresistente, tratamento com antimicrobiano inadequado, tempo de hospitalização com alta permanência, choque séptico e imunossupressão. Objetivos: Estimar a mortalidade bruta e atribuível às infecções hospitalares causadas pelo Acinetobacter baumannii resistente a antimicrobianos carbapenêmicos (CRAB) por meio de revisão sistemática e metanálise de estudos observacionais. Métodos: Foi desenvolvida uma revisão sistemática e metanálise de estudos observacionais publicados nas bases de dados: MEDLINE/Pubmed, CENTRAL/Cochrane Library, EMBASE/Elsevier, SCOPUS/Elsevier, Web of Science/Thomson Reuters e LILACS/BVS, para estimar a mortalidade bruta e atribuível à infecção hospitalar causada pela bactéria A. baumannii resistente a antimicrobianos carbapenêmicos em pacientes adultos e pediátricos internados em unidades de tratamento intensivo e nãointensivo. Os estudos incluídos caracterizaram fatores preditores de mortalidade associada à infecção por CRAB, comparando com pacientes infectados por A. baumannii sensível a carbapenêmicos (CSAB). Primeiramente, foi estimado um modelo de efeitos aleatórios para a medida agregada de mortalidade atribuível não ajustado a fim de avaliar a contribuição direta das infecções na morte. Na sequência, foram avaliados descritivamente os principais aspectos metodológicos necessários aos estudos observacionais, para a análise dos fatores de risco relacionados a mortalidade atribuível em pacientes infectados por CRAB, por meio de instrumento elaborado conforme recomendações internacionais - ORION, TREND, STROBE e CONSORT. Resultados: Com base nos 29 estudos incluídos na metanálise, observou-se um risco atribuível aumentado na mortalidade bruta em pacientes com infecção por CRAB comparativamente aos pacientes com infecção por CSAB (RA = 0,19 (IC95% = 0,14-0,24) com elevada heterogeneidade (I2 = 66,4%, p-valor < 0,001). Como fontes de heterogeneidade investigou-se o tempo de internação, sítio de infecção, gravidade da doença e uso de terapia inapropriada. Entre os estudos que avaliaram exclusivamente pacientes com bacteremia, o risco de mortalidade atribuível foi maior (RA = 0,27; IC95% = 0,19-0,34). Utilizando-se metarregressão foi observada relação linear positiva entre o risco atribuível de mortalidade e a diferença da média padronizada do escore de APACHE II. Para a investigação da presença de risco de viés e confundimento avaliou-se descritivamente os principais aspectos metodológicos necessários aos estudos observacionais que identificam os fatores de risco associados com a mortalidade atribuível em pacientes com infecções por CRAB. Observou-se nesta revisão que os estudos estão sujeitos a confundimento, incluindo a forma inadequada do ajuste para fatores de confusão de variáveis importantes (ex.: seleção de grupo controle, exposição prévia aos antimicrobianos, mensuração do tempo em risco e a gravidade), além da grande heterogeneidade entre os estudos, devido aos desenhos, unidades de análise e abordagens na medida de exposição e desfecho, tornando difícil a comparação e a sumarização das informações. Conclusões: Os dados dessa revisão sistemática fornecem evidências que a mortalidade atribuível relacionada à presença de infecção por CRAB é maior que em pacientes com infecção por CSAB. Contudo, a investigação da mortalidade atribuível apresenta muitas limitações e ainda não é conclusiva em razão da adequação do desenho do estudo aos seus objetivos; definições de medidas de exposição e desfecho; métricas utilizadas na aferição dos resultados; seleção de grupo controle e fatores de confusão. A consciência de todos esses elementos para a interpretação epidemiológica é vital na análise da mortalidade bruta e atribuível. / Introduction: Acinetobacter spp. is a gram-negative coccobacillus of great importance in hospital infections, especially in patients in intensive care units (ICUs); may lead to an increase in morbidity and mortality of these patients. There is evidence supporting association between infection by Acinetobacter baumannii and the increase in crude and attributable mortality rates. However, the role of this agent as a direct cause of death is not sufficiently characterized yet. Among the factors related to the increase of mortality are: severity of the patient, infection related to A. baumannii multidrug-resistant, inappropriate antimicrobial treatment, hospital stay with high permanence, septic shock and immunosuppression. Objectives: To estimate the crude and attributable mortality to hospital-acquired infections caused by carbapenem-resistant Acinetobacter baumannii through systematic review and meta-analysis of observational studies. Methods: A systematic review and metaanalysis of observational studies published in the databases has been developed: MEDLINE/PubMed, CENTRAL/Cochrane Library, EMBASE/Elsevier, SCOPUS/Elsevier, Web of Science/Thomson Reuters and LILACS/BVS to estimate the crude and attributable mortality to hospital infection caused by the bacterium carbapenem-resistant A. baumannii (CRAB) in adult and pediatric patients in intensive and non-intensive care units. The studies included characterized predictors of mortality associated to infection with CRAB, compared to patients infected with carbapenem-susceptible A. baumannii (CSAB). First, a random effects model was estimated for the aggregate measure of non-adjusted attributable mortality in order to assess the direct contribution of infections in death. Following were descriptively assessed the main methodological aspects necessary to observational studies for the evaluation of risk factors related to attributable mortality in patients infected with carbapenem-resistant A. baumannii through instrument designed according to international recommendations - ORION, TREND, STROBE and CONSORT. Results: Through the 29 studies included in the meta-analysis, there was an increased attributable risk in the crude mortality in patients with infections by CRAB compared to patients with infections by CSAB (RA = 0.19 (95% CI = 0.14 to 0.24) with high heterogeneity (I2 = 66.4%, p <0.001). As sources of heterogeneity, it was investigated the length of stay, the site of infection, disease severity and use of inappropriate therapy. Among the studies that evaluated only patients with bacteremia, the risk of attributable mortality was higher (RA = 0.27; 95% CI = 0.19 to 0.34). Using meta-regression was observed a positive linear relationship between the attributable mortality risk and the standardized mean difference of APACHE II score. For investigating the presence of bias and confounding risk was evaluated descriptively the main methodological aspects necessary to observational studies evaluating the risk factors associated with attributable mortality in patients with infections caused by carbapenem-resistant A. baumannii. It was observed in this review that these studies are subject to pitfalls, including the inappropriate mode for adjustment for confounding factors of important variables (eg.: control group selection, previous exposure to antimicrobials, measurement of time in risk and gravity); besides the great heterogeneity between studies due the drawings, units of analysis and approaches to the extent of exposure and outcome, making it difficult comparison and summarization of information. Conclusions: The data of this systematic review provide evidence that attributable mortality related to the presence of infection by CRAB is higher than in patients with infection by CSAB. However, the investigation of attributable mortality has many limitations and is not conclusive yet because of the design adequacy of the study to their goals, definitions of exposure and outcome measures, metrics used in measuring results, control group selection and confounding factors. The awareness of all these elements is vital in analyzing the crude and attributable mortality.

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.

Process modeling is an indispensable task in the discipline of Business Process Management. The process models created in this task help its readers in to acquiring a higher comprehension of a process, allowing for the discovery of opportunities for its improvement. However, the comprehension of a process model is not guaranteed, as process modeling is a complex task that depends on the proficiency of the process modeler to avoid the creation of badly designed constructs. Process modeling guidelines are an essential tool in this regard, though they are dispersed across the many studies of the literature and not all of them have empirical evidence validating their effects. In addition to this problem, it is still an open questions if a set of process modeling guidelines makes the process modeling task more challenging and how effective modelers are in using them. It is also unclear how receptive process analysts are to the modeling guidelines. This dissertation presents a systematic literature review we conducted to collect and analyze the modeling guidelines found in the literature. It investigated a total of 520 articles, extracting a total of 45 modeling guidelines spread across 4 different categories. These 45 guidelines were simplified into a set of 20 guidelines, based on their significance to create more comprehensible process models and their practicality. This dissertation also presents the findings of an empirical experiment performed by 13 subjects that compared the results of two process modeling tasks with and without the support of the 20 modeling guidelines presented by the review, in which it was possible to observe that the subjects recognize the usefulness of the guidelines, but find them difficult to understand and use.

OBJETIVO: Comparar a eficácia e a tolerabilidade dos fármacos antiepiléticos (FAE) no tratamento em monoterapia de pacientes com epilepsia focal ou generalizada. MÉTODOS: Uma revisão sistemática foi realizada por meio da busca nas bases de dados eletrônicas Pubmed, Scopus, Web of Science e Cochrane Register of Controlled Trials. Foram incluídos os ensaios clínicos controlados com pacientes com epilepsia, em tratamento com FAE, via oral, em monoterapia, e que avaliaram o número de pacientes que atingiram a remissão das crises epilépticas, que interromperam o tratamento devido à ineficácia terapêutica ou à ocorrência de reações adversas (RAM) intoleráveis. Meta-análises de comparação de múltiplos tratamentos foram realizadas por meio do modelo bayesiano de efeitos randômicos que permitiu o cálculo do Odds Ratio meta-analítico para os FAE estudados. Também foi realizado um ranqueamento da probabilidade de cada FAE ser a melhor opção em eficácia e tolerabilidade. RESULTADOS E CONCLUSÕES: A busca identificou 18874 publicações, no entanto apenas 71 estudos foram selecionados, compreendendo 17555 pacientes com epilepsia. Vinte e nove estudos apresentaram os desfechos de eficácia no tratamento de crises focais, 19 em crises generalizadas e 58 apresentaram dados de tolerabilidade. Nesses estudos, 15 FAE foram avaliados. No tratamento das crises focais, os FAE de nova geração levetiracetam (LEV), lamotrigina (LTG), oxcarbazepina, sultiame e topiramato (TPM) demonstraram possuir eficácia equivalente à carbamazepina (CBZ), clobazam e valproato (VPA). No entanto, a CBZ apresentou o pior perfil de tolerabilidade devido à grande probabilidade do paciente abandonar o tratamento devido à RAM intoleráveis. Quanto ao tratamento das crises generalizadas, a LTG, LEV e TPM são tão eficazes quanto o VPA para o tratamento de crises generalizadas tônico-clônicas, tônicas e clônicas. O VPA e a etosuximida constituem as melhores opções para o tratamento de crises de ausências, enquanto que a LTG mostrou-se menos eficaz. Para o tratamento de crises mioclônicas e espasmos infantis mais ensaios clínicos randomizados são necessários para fornecer boas evidências que possam guiar a decisão clínica dos profissionais de saúde. Dentre os FAE com perfil de eficácia adequado, a LTG destacou-se pela menor probabilidade de manifestar RAM intoleráveis. / OBJECTIVE: To compare the efficacy and tolerability of the antiepileptic drugs (AED) in monotherapy of patients with focal or generalized epilepsy. METHODS: A systematic review was in the Medline/Pubmed, Scopus, Web of Science and Cochrane Register of Controlled Trials databases. We included randomized clinical trials of patients with epilepsy treated with oral monotherapy AED, which evaluated number of patients becoming seizure free at the maintenance treatment period; number of patients which withdrawals from the study because of therapeutic inefficacy and number of patients which withdrawals from the study because of intolerable adverse reaction. Network meta-analyses were performed using Bayesian random effects model. We also carried out a ranking of the probability of each AED be the best option in the efficacy and tolerability outcomes. Sensitivity analyses were conducted in order to check the robustness of the results. RESULTS AND CONCLUSIONS: The research identified 18,874 publications, but only 71 studies were selected, comprising 17555 patients with epilepsy.Twenty-nine trials showed the efficacy outcomes in the treatment of focal seizures, 19 in generalized seizures and 58 showed tolerability data. In the treatment of focal seizures, levetiracetam (LEV), lamotrigine (LTG), oxcarbazepine, sultiame and topiramate (TPM) have demonstrated equivalent efficacy to carbamazepine (CBZ), clobazam and valproate (VPA). LTG, LEV and TPM are as effective as the VPA for the treatment of generalized tonic-clonic, tonic and clonic seizures. VPA and ethosuximide are the best options for the treatment of absence seizures, whereas LTG was less effective. For the treatment of myoclonic seizures and infantile spasms, more randomized clinical trials are needed to provide good evidence to guide the clinical decision of health professionals. Among the AED with adequate efficacy profile, LTG stands out as the AED with the best tolerability profile, suggesting it may be the best option for the treatment of patients with epilepsy.