Background: Pain is frequently reported by people with multiple sclerosis (MS). It has been associated with decreased quality of life, psychiatric morbidity, interference with day to day activities, and frequent healthcare attendance. It has been reported by people with multiple sclerosis to be one of their most important symptoms, and available treatments are limited in their effectiveness. Despite this, our understanding of the epidemiology and mechanisms of pain in people with MS are limited. Our understanding of the interactions of central nervous system mechanisms and pain states overall is growing. However, the application of this knowledge to MS is incomplete. Previous studies have shown that the descending pain modulatory system (DPMS) is an endogenous network of cortical and subcortical brain structures which act to limit, or accentuate, an individual’s perception of pain, via descending brainstem pathways. Associated clinical measures include depression, anxiety, and cognitive flexibility. Our understanding of the function or dysfunction of this system in MS is limited. We do not know if the MS disease process may adversely affect the structure or function of the DPMS. Hypothesis: In people with neuropathic limb pain in relapsing remitting MS (RRMS), compared to people with RRMS who do not have pain, there will be disruption of the endogenous descending pain modulatory system. This will manifest as impaired descending inhibition of pain. Aims and Methods Establishing the background using systematic reviews: The first aim of this thesis was to establish the prevalence, natural history and associations of pain (and pain syndromes) occurring in people with MS. The second aim was to explore existing knowledge of how the MS disease process may contribute to pain states, using a systematic review of neuroimaging studies. Prospective clinical study: A case-control study of 47 people with RRMS was then carried out. 31 of these had neuropathic pain in the limbs, and 16 did not have pain. Using targeted assessments, function of the descending pain modulatory system was assessed in the following ways: First: Detailed clinical, behavioural and neuropsychological assessment, focussing on cognitive, behavioural and affective features known to be closely related to the DPMS. Second: MRI imaging of brain structure, focussing on the volume and location of MS lesions, as well as the volume of key grey-matter structures involved in the DPMS. Third: Resting state functional MRI imaging of the brain, focussing on functional connectivity between the rostral anterior cingulate cortex and two other key DPMS structures (dorsolateral prefrontal cortex, and periaqueductal gray). Results: Systematic reviews: Meta-analysis of existing prospective studies confirmed that pain is very common in MS, affecting about 63% of people with MS on average (95%CI between 55 and 70%). Many different types of pain contribute to this overall estimate. No significant associations with disease course or stage emerged. Several neuroimaging studies have assessed people with MS-associated pain using MRI. These studies were often small, and with associated methodological issues. It is likely that location of MS lesions is implicated in aetiology of pain syndromes in some cases, though our overall knowledge is limited. Prospective study: In a prospective study, people with and without pain were matched for age and gender. Furthermore, groups were balanced for a range of other variables. The pain group more frequently received gabapentinoid medications. The presence of pain was significantly associated with increased scores for depression, fatigue and catastrophising, as well as with specific impairments at neuropsychological assessment, including cognitive flexibility. Many of these impairments are directly relevant to existing models of the DPMS. Overall volume of MS lesions was not different in people with pain, though lesions were more likely to occur in the brainstem. Some alterations of grey-matter volumes in people with pain which mirrored studies of pain disorders outside MS were found, but these did not involve structures key to the DPMS. Affected structures included trigeminothalamic nucleus (relative volume increase in pain group), posterior cingulate cortex and parahippocampal gyrus (volume decrease in pain group). Functional connectivity of the rostral anterior cingulate cortex to the periaqueductal grey matter, a key structure in the descending modulation of pain, was stronger in the group without pain. Conversely, functional connectivity to the dorsolateral prefrontal cortex, repeatedly implicated in the DPMS and thought to be involved in cognitive evaluation and flexibility, was stronger in the pain group. MS lesion volume appeared to account for some of this difference in a multivariate analysis. Limitations: Key limitations of this work include cross-sectional design, small sample size, and number of statistical comparisons carried out. Conclusions: Systematic reviews examined the prevalence, natural history and associations of pain in MS, as well as examining existing neuroimaging studies which investigated how the MS disease process could contribute to pain states. A prospective study found evidence of both emotional/affective and cognitive dysfunctions relevant to the hypothesis of dysfunction in the DPMS. Higher likelihood of MS lesions in the brainstem could be relevant to DPMS function. Separately, there were structural grey-matter volume alterations reflecting those found in many pain studies outside MS. Importantly, however, these did not affect key DPMS structures. Resting state functional MRI however demonstrated altered connectivity of core DPMS structures, which may be partly mediated by MS lesion volume. Functional connectivity findings could be consistent with the hypothesis of impaired descending pain inhibition, in people with relapsing remitting MS affected by neuropathic limb pain.

Introduction: There is an increased acceptance and demand for online and mobile health (mHealth) interventions to support physical and mental health problems. However, the uptake and engagement of these interventions is relatively low and the evidence base for these interventions requires continual updating in line with technological advances. A systematic review was conducted, focusing on anxiety and depression, to explore the existing evidence base of both physical health and mental health mobile applications. The first research paper explores the acceptability of mHealth interventions for both mental health and physical health problems. The final research paper explores use and strategies when searching for mental health information online. Additionally, perceived quality, sentiment and barriers to online health information was explored. Methods: Studies were identified by searching for articles published between January 2008 and January 2016. Databases included: PsycINFO, MEDLINE, CINAHL PLUS and the Cochrane Central Register of Controlled Trials for 2016. In the research articles, 218 people completed an online survey in January 2016 exploring, online health seeking for mental health and physical health problems, and acceptability of mHealth interventions. Sentiment of online health resources was explored by extracting 432 individual tweets from Twitter. Results: The systematic review revealed twenty-seven studies for inclusion; 10 with a physical health focus and 17 with a mental health focus. Targeted depression applications have the superior evidence base; however, no firm conclusions can be made regarding interventions that targeted physical health, or those measuring anxiety. The first research paper found that face-to-face therapy would more likely meet expectations for treatment of both physical and mental health problems compared to mHealth interventions. Computerised interventions were more likely to meet expectations than mobile applications. Expectations of treatment were higher for the treatment of mental health problems than physical health problems. The second research paper found that a large proportion of the public use the internet to search for information on mental health, with half citing it as their primary source for mental health information. The online survey found that the quality of mental health information available on the internet was rated favourably, compared to mobile applications. Overall, the sentiment towards specific online mental health resources was generally positive. Conclusions: Research into online and mHealth interventions has developed considerably in recent years in line with advances in technology. These interventions have the potential to be an effective treatment of common mental health problems. The systematic review highlighted that depression applications are more established and effective than applications targeting anxiety. The first research paper suggests that mHealth interventions fall short of public expectations for treatment of health problems. The final research paper reflects that the perceived quality of online mental health information is rated favourably. However, many barriers still limit uptake. Future research could focus on continually developing and evaluating evidence based online and mHealth interventions and the outcome of this study suggests that incorporating them more widely into existing care systems, alongside face to face interventions could increase the public’s confidence in these interventions.

Magister Artium - MA (Psychology) / Honours students in Psychology typically form larger cohorts with numbers ranging from 20 to 40 students in comparison to other disciplines that have fewer than 10 students in a cohort. The National Qualifications Framework (NQF) requires Honours students to complete a thesis that is equivalent to 300 notional hours or 30 credits. The learning outcome is that students conduct low level research that prepares them for conceptualizing, executing and writing up a research project. The thesis requirement should also prepare them for future studies. The larger cohorts and revised NQF thesis requirement places increased pressure on the staff compliment of Psychology departments. Some of the ways in which departments have attempted to cope with this increased demand include conducting group-based research projects, and secondary research projects. One of the concerns raised is whether these particular types of methodology prepared students adequately for reactive research in further studies. This study aimed to explore students' subjective perceptions about the extent to which group-based systematic review methodology in the Honours year adequately prepared students for conducting research during their masters-level studies. An explorative study was conducted to explore the experiences of purposively selected recent graduates from two identified Honours programmes that have progressed to Masters level studies. Participants were invited on the basis of being graduates or alumni rather than their registration status as Masters students at particular universities.

Background: Antibiotics are prescribed frequently for upper respiratory tract infections (URTIs) despite the fact that most of them do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem. Physicians perceive that patients’ expectations influence their antibiotic prescribing practice. Methods: As the first phase of the thesis, we conducted a systematic review to determine the effectiveness of patient-oriented interventions to reduce unnecessary use of antibiotics for URTIs. As the second phase, we conducted a qualitative descriptive study to explore patients’ views about URTIs and identify ways they manage them by using semi-structured interviews based on Common Sense-Self-Regulation Model (CS-SRM). Results: Our systematic review included 14 studies which based on their interventions were classified into two major categories: delayed prescriptions and patient/public information and education interventions. Our meta-analysis revealed that almost all studies with delayed prescription significantly reduced use of antibiotics for URTIs. Our subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects regarding antibiotic use. The small number of included studies in the patient/public information and education group did not allow us to make a definite conclusion on their effectiveness. For the qualitative study, 15 individuals were interviewed. almost all participants mentioned that they only visited their doctor if their symptoms got progressively worse and they could no longer self-manage URTI symptoms. When visiting a doctor, most participants reported that they expected to receive an examination and an explanation for their symptoms. Discussion: Patient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic use or prescription for URTIs in patients. Further research is needed to investigate the costs and feasibilities of implementing these interventions as part of routine clinical practice. Our participants reported good knowledge regarding the likely lack of benefit from antibiotics for URTIs. The results suggest a discrepancy between our participants’ reported reasons for visiting doctors and doctors’ perceptions about patients’ reason for their visit identified in previous studies. Focusing on interventions that facilitate the communication between patients and doctors, instead of providing more education to public may help in reducing the use of unnecessary antibiotics.

Introdução: Rupturas do tendão calcâneo (TC) afetam 18 em 100.000 pessoas todos os anos. A mobilização precoce vem sendo preconizada como uma estratégia eficaz para acelerar o processo de recuperação funcional. Entretanto, a escolha do método de reabilitação após o reparo cirúrgico permanece controversa devido à ausência de evidências clínicas. Objetivo: Verificar o efeito de intervenções aceleradas e tradicionais de fisioterapia em indivíduos que realizaram sutura do TC, por meio de revisão sistemática com metanálise. Metodologia: A busca incluiu as bases de dados MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, Scopus, Science Direct, Lilacs, PEDro, além de busca manual de artigos científicos até início de janeiro de 2014. Foram incluídos ensaios clínicos randomizados e não randomizados comparando intervenções aceleradas e tradicionais após sutura do TC sobre as variáveis: força muscular, amplitude de movimento (ADM) e capacidade funcional do tornozelo. Dois revisores independentes avaliaram os estudos de acordo com critérios de inclusão e exclusão pré-estabelecidos. Resultados: Dos 2194 artigos identificados, 8 estudos foram incluídos. A revisão sistemática evidenciou alta variabilidade entre os estudos em relação as intervenções de fisioterapia. Quanto à metanálise, realizamos a avaliação dos desfechos no período de 6 meses de pós-operatório devido a ausência de dados dos mesmos em outros períodos. Na comparação entre diferentes intervenções de fisioterapia não foram observadas melhoras significativas em relação a variável força muscular (-19,66; IC95%: -74,03 a 34,71) assim como na ADM de flexão plantar (-0,05; IC95%: -3,07 a 2,97) e flexão dorsal (1,94; IC95%: -2,12 a 5,99). Conclusão: A intervenção acelerada de fisioterapia não apresentou melhora significativa da força muscular e na ADM após sutura do TA aos 6 meses de pós-operatório. / Introduction: Achilles tendon (AT) ruptures affect 18 in 100,000 people each year. Early mobilization has been recommended as an effective strategy for accelerating functional recovery. However, the choice of the best rehabilitation method after surgical repair remains controversial due to the absence of clinical evidence. Objective: To investigate the effect of traditional and accelerated rehabilitation protocols on plantiflexores muscular strength, ankle range of motion (ROM) and ankle functional capacity in subjects who underwent Achilles tendon suture, through a systematic review with meta-analysis. Methodology: The search included MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, Scopus, Science Direct, LILACS, PEDro, and manual search of manuscripts until January 2014. Randomized and non-randomized clinical trials were included comparing traditional and accelerated rehabilitation protocols after AT suturing on the following variables: muscle strength, ankle ROM and functional capacity. Two independent reviewers assessed studies according to inclusion and exclusion criteria previously established. Results: Of the 2194 articles identified, 8 studies were included. High variability between studies in relation to the rehabilitation protocols was observed in the systematic review. As for the meta-analysis, we conducted an evaluation of the outcomes up to 6 months postoperatively due to missing data from these outcomes at other time periods. When comparing the different rehabilitation protocols, no significant improvements were observed in muscle strength (-19.66, 95% CI -74.03 to 34.71) as well as in plantarflexor (-0.05; 95 %: -3.07 to 2.97) and dorsiflexor (1.94, 95% CI: -2.12 to 5.99) ROM. Conclusion: The accelerated protocol showed no significant improvement in muscle strength and ROM at 6 months post-surgical repair of the AT.

Introdução A prevalência de sobrepeso e obesidade em adolescentes brasileiros tem sido investigada em diferentes regiões e períodos do tempo. Estudos observacionais de base escolar apresentam baixo custo e são facilmente conduzidos, comparativamente a estudos de base populacional, que requerem maior custo e tempo. Objetivos Comparar medidas sumárias de prevalências de sobrepeso e obesidade no Brasil, obtidas em metanálise de estudos observacionais de bases escolar e populacional, realizados em amostras aleatórias. Métodos Bases de dados Medline, Embase, Lilacs, IBECS, Scielo, Adolec e Banco de Teses da Capes foram revisadas sistematicamente, buscando-se estudos de prevalência de sobrepeso e obesidade realizados no Brasil, em adolescentes, com 10 a 19 anos, entre 1990 e 2010. Estudos de prevalência, transversal ou de coorte, publicados em revistas com “peer review” e na literatura “cinza”, foram identificados por dois revisores independentemente, a partir de título e resumo, e, após comparação, um terceiro decidiu discordâncias. Dados foram extraídos por dois pesquisadores independentes utilizando protocolo padronizado, discordâncias decididas por consenso ou árbitro. A classificação de sobrepeso, obesidade e/ou excesso de peso foi definida pelos critérios utilizados em cada estudo. A análise dos dados utilizou modelo aleatório, realizada no Software 6 Comprehensive Meta-Analysis 2.0®. Resultados Entre 1939 artigos elegíveis, 138 preencheram os critérios de inclusão, 58 foram excluídos, sendo 30 exclusões pelo motivo de dados em duplicata, 17 por não utilizarem amostras aleatórias populacionais ou escolares representativas e 11 por não apresentarem os dados requeridos no protocolo da metanálise. Vinte e cinco estudos foram considerados perdas por não apresentarem a prevalência de obesidade em adolescentes, após três tentativas de contato com os autores. Dos 55 estudos incluídos na metanálise, 14 eram estudos observacionais com amostras de base populacional e 41 de base escolar. A prevalência de sobrepeso e obesidade em adolescentes encontrada em estudos de base populacional foi 16,7% (95% CI: 13,2-20,8) e 5,5% (95% CI: 4,2-7,1) e nos de base escolar foi 11,9% (95% CI: 10,3-13,3) e 5,1% (95% CI: 4,3-6,0), respectivamente. A heterogeneidade encontrada nos estudos de base populacional foi Q=8,17 (P < 0,001) para sobrepeso e Q=5,88 (P < 0,001) para obesidade, enquanto nos de base escolar foi Q=30,6 (P < 0,001) e Q=33,6 (P < 0,001), respectivamente. Apesar dos estudos com amostras de base escolar mostrarem maior inconsistência dos resultados quando comparados com os estudos de amostra de base populacional (I²=7,74 vs. 0), esses valores não são considerados altos. Conclusão Estudos com amostras de adolescentes de base populacional e escolar apresentam estimativas pontuais similares de prevalência de obesidade, porém apresentam diferenças nas prevalências pontuais de sobrepeso. / Introduction In Brazil, overweight and obesity prevalence in adolescents has been investigated in different regions and periods of time. Studies of school-based samples have low cost and are easily conducted, being widely used. Otherwise, population-based studies require greatest investments, more time and researches, besides high complexity to minimize bias. Objective To undertake meta-analysis of observational studies conducted in Brazilian adolescents to calculate pooled estimates for overweight and obesity prevalence for school-based versus population-based samplings. Methods Data sources included Medline, Embase, Bireme, and CAPES-Thesis database searching for articles and grey literature about overweight and obesity prevalence in adolescents aged 10 to 19 years, from studies conducted in Brazil from 1990 to 2010. Studies were systematically reviewed, with no language restriction, and independently extracted by two investigators using a standardized protocol. Overweight, obesity and/or overweight plus obesity were defined according to the criteria used in each study. Data analysis was performed by Comprehensive Meta-Analysis 2.0®, using random effect model. Results Among 1939 articles reviewed, 138 met the inclusion criteria, 58 were excluded, and 25 were not retrieved after three attempts to contact authors. Among 55 studies included in meta-analysis 14 were population-based and 41 school-based samples. Overweight and obesity prevalence in population-based studies was 16.7% (95% CI: 13.2-20.8) and 5.5% (95% CI: 4.2-7.1) and in school-based studies it was 11.9% (95% CI: 10.3-13.3) and 5.1% (95%CI: 4.3-6.0), respectively. The heterogeneity founded in population-based studies was Q = 8.17 (P < 0.001) for overweight and Q = 5.88 (P < 0.001) for obesity, while in school-based studies it was Q=30.6 (P < 0.001) and Q=33.6 (P < 0.001), respectively. Although school-based studies showed higher inconsistency measure in the results compared with population-based samples studies (I²=7,74 vs. 0), these values are not considered high. Conclusion School-based studies as well population-based studies conducted in adolescents provide similar point estimate of obesity prevalence, but there is a difference for point prevalence of overweight.

Introdução: A Síndrome Metabólica (SM) tem sido associada à proteinúria a redução da taxa de filtração glomerular. Em transplantados renais a imunossupressão aumenta a incidência de fatores de risco cardiovasculares, predispondo à síndrome. O objetivo dessa revisão sistemática e metanálise é buscar informações precisas, visando esclarecer qual o impacto da SM no pós- transplante. Métodos: Estratégias de buscas foram utilizadas no MEDLINE, no EMBASE e na Cochrane Library até o dia 4 de Outubro de 2014. Foram selecionados estudos que compararam indivíduos com e sem SM, submetidos a transplante renal e que avaliaram os seguintes desfechos: perda de enxerto, eventos cardiovasculares (ECV), morte por doença cardiovascular (DCV) e morte por todas as causas. Dois revisores independentes extraíram os dados e avaliaram a qualidade dos estudos. Resultados: Dos 585 estudos inicialmente identificados, 5 foram selecionados, incluindo um total de 1269 pacientes. A SM mostrou-se associada à perda de enxerto (risco relativo, 3,02; intervalo de confiança (IC) 95%,2,17-4.32; I²=0%; P heterogeneidade= 1,35), ECV (risco relativo, 3,53; IC95%, 1,27-9.85; I²= 0%; P heterogeneidade= 1,81) e morte por DCV (risco relativo, 2,61; IC 95%, 0,70-9,81; I²=58%; P heterogeneidade= 0.76). Não foi encontrada associação entre a SM e morte por todas as causas. Conclusão: Encontrou-se associação entre perda de enxerto, ECV e morte por DCV com o diagnostico de SM após transplante renal. Estudos com maior tamanho amostral e poder devem ser realizados para que se possa avaliar a possível associação entre mortalidade por todas as causas e SM após o transplante renal. Há necessidade de estudos clínicos randomizados a fim de verificar se intervenções em cada componente da síndrome resultariam em melhores desfechos após o transplante renal. / Background: Metabolic syndrome (MS) has been associated with proteinuria and reduced glomerular filtration rate. Immunosuppressive agents increase the incidence of traditional cardiovascular risk factors and thus have expected effects on components of MS after transplantation. The purpose of this systematic review and meta-analysis is provide valid information regarding the syndrome and clarify this question. Methods: MEDLINE, EMBASE and Cochrane Library were searched up to October 4, 2014. Papers that compared MS and non-MS patients who underwent renal transplantation and assessed one of the following outcomes: graft loss, cardiovascular events (CVE), death by cardiovascular disease (CVD) and all-cause-mortality were included. Two independent reviewers summarized the data and evaluated the quality of the articles. Results: From 585 studies identified, 5 were included (1269 patients). MS was related to graft loss (relative risk, 3.02; 95% confidence interval, 2.17-4.32; I²= 0%; P heterogeneity= 1.35), CVE (relative risk, 3.53; 95% confidence interval, 1.27-9.85; I²= 0%; P heterogeneity= 1.81) and death by CVD (relative risk, 2.61; 95% CI, 0,70-9,81; I²=58%; P heterogeneity= 0.76). No association was found between MS and all cause-mortality. Conclusion: Graft loss, CVE and death by CVD were associated with the MS diagnoses after kidney transplantation. Larger studies should be design to elucidate its association with mortality by all-causes, since the combined sample size from the available studies still lack power. Lastly, prospective randomized clinical trials should be conducted in order to define if interventions on each MS component would result in better outcomes after kidney transplantation.

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.

Os prejuízos causados pelo aumento do tempo de permanência hospitalar de um paciente devido ao retardo na cicatrização de feridas têm sido foco de preocupação em diferentes contextos das práticas de saúde. Nesse sentido, o grupo de Prevenção e Tratamento de Feridas (PTTF) do Hospital de Clínicas de Porto Alegre (HCPA) vem desenvolvendo estudos sobre esta temática, a fim de contribuir à assistência de pacientes portadores de feridas. Neste sentido, o objetivo deste trabalho foi identificar o curativo prevalente que constitui tratamento para as FOs abdominais com complicações, visando à busca de evidências que possam subsidiar o desenvolvimento de um protocolo institucional para o tratamento das mesmas. Para tanto, desenvolveu-se uma revisão sistemática que teve como pergunta norteadora Qual é o curativo prevalente no tratamento dos pacientes com complicações de feridas operatórias abdominais? Sendo P = paciente cirúrgico com idade igual ou maior que 18 anos, I = tipo de curativo utilizado para o tratamento de FOs abdominais e O = número de dias para a cicatrização. Foram utilizados MeSH controlados e não controlados e operador booleano AND. Foram utilizadas sete base de dados eletrônicas:PubMed, CINAHL, Cochrane, Scopus, Web of Science, Lilacs e Scielo, resultando em 6.107 artigos. Nessa etapa, realizou-se o Teste de Relevância Preliminar, o excluindo as produções através do título e do resumo breve apresentado nos resultados das buscas em cada base, sendo excluídos 5.578 artigos. Os 426 artigos selecionados foram submetidos ao Teste de Relevância I, o qual consistiu na avaliação dos resumos dos estudos. Nessa fase, foram excluídos 372 artigos, pois não estavam em consonância com a questão norteadora. Ao final desse teste, 54 artigos estavam adequados para prosseguir no estudo. Seguiu-se, então, para a avaliação dos estudos na íntegra através do Teste de Relevância II, em que se avaliou a qualidade metodológica, a relevância e a adequação dos resultados em atenção à questão norteadora. Nessa etapa, foram excluídos 19 artigos que possuíam nível de evidência e qualidade metodológica ruim, restando 35 artigos considerados adequados para prosseguir, sendo submetidos ao Teste de Relevância III, o qual avalia a qualidade metodológica dos estudos. Ao final desse teste, decidiu-se excluir os estudos que tivessem nível de evidência maior que 4, escore de qualidade abaixo de 14 e escala de Jadad menor que 3. Assim, foram excluídos nove estudos, compondo a amostra final 26 estudos. Em resposta a questão norteadora, 16 trabalhos apontaram o uso do curativo a VAC como o mais indicado para tratar FOs abdominais que tiveram complicações. Para tanto, recomenda-se pressão negativa de 75 a 125mmHg, com trocas a cada 72 horas, mostrando uma média de cicatrização que variou entre 13,2 e 18 dias. Sugere-se novas pesquisas, como ensaio clínico randomizado, ou estudo de caso controle, para que se possa avaliar a efetividade e a viabilidade da terapia VAC na nossa realidade. / The damages caused by the increased length of a patient's hospital stay due to a delay in wound healing have been a focus of concern in different health practice contexts. The Wound Prevention and Treatment Group (WPTG) of Porto Alegre's Hospital de Clínicas (HCPA) has been conducting studies on this subject in order to contribute to the care of wounded patients. In this sense, the aim of this study was to identify the dressings used to treat abdominal surgical wounds with complications, in order to look for evidence that supports the development of an institutional protocol for handling these wounds. For this purpose, a Systematic Review was developed, which had as a guiding question: What is the prevalent dressing in the treatment of patients with dehiscence in abdominal surgical wounds? Where P = surgical patients over 18 years old, I = type of dressing used to treat abdominal surgical wounds and O = the number of days for healing the wound. MeSH were used to search for the largest possible number of studies, being used both the controlled and the uncontrolled studies and their connections via the Boolean operator AND. Seven electronic databases were used: PubMed, CINAHL, Cochrane, Scopus, Web of Science, Lilacs, and Scielo. The search for articles in databases resulted in 6,107 articles. At this stage, the Preliminary Test of Relevance was undertaken, analizing articles by the title and the brief summary presented in the search results on each base, resulting in the exclusion of 5,578 articles. The 426 remaining articles were submitted to the Relevance Test I, which consisted in the evaluation of their abstracts. At this stage, 372 articles were excluded because they did not match the research question. At the end of this test, 54 articles were considered appropriate to continue the study. The remaining studies were evaluated in their entirety through the Test Score II, which assessed the methodological quality, relevance and adequacy of the results in their relevance to the research question. At this stage, we excluded 19 articles that had a poor evidence level and methodological quality. The remaining 35 articles that were considered appropriate to proceed were submitted to the Relevance Test III, which assesses the methodological quality of studies. At the end of this test, studies that had an evidence level of more than 4, a quality score below 14 and a Jadad scale of less than 3 were excluded. Thus, 9 studies were excluded, defining a final sample of 25 studies. In response to the guiding question, 16 studies have shown the use of the VAC dressing as the best suited to treat abdominal surgical wounds with complications. To this end, a negative pressure of 75 to 125mmHg is recommended, with changes every 72 hours, showing an average healing ranging from 13.2 to 18 days. Further research is suggestes, such as a randomized clinical trial or a case-control study, so that the effectiveness and feasibility of VAC therapy in our reality can be assessed. / Los perjuicios causados por el aumento del tiempo de permanencia hospitalaria de un paciente debido al retardo en la cicatrización de heridas ha sido foco de preocupación en diferentes contextos de las prácticas de salud. En este sentido, el grupo de Prevención y Tratamiento de Heridas (PTTF) del Hospital de Clínicas de Porto Alegre (HCPA) viene desarrollando estudios sobre esta temática, a fin de contribuir con la asistencia de pacientes portadores de heridas. En este sentido, el objetivo de este estudio fue identificar los curativos que constituyen tratamiento para las FOs abdominales con complicaciones, visando la búsqueda de evidencias que puedan subsidiar el desarrollo de un protocolo institucional para el tratamiento de las mismas. Por tanto, se desarrolló una Revisión Sistemática que tuvo como pregunta orientadora ¿Cuál es el curativo prevalente en el tratamiento de los pacientes con dehiscencia de heridas operatorias abdominales? P= paciente quirúrgico con edad igual o mayor a 18 años, I= tipo de curativo utilizado para el tratamiento de FOs abdominales y O= número de días para la cicatrización. Fueron utilizadas siete bases de datos electrónicas: PubMed, CINAHL, Cochrane, Scopus, Web of Science, Lilacs y Scielo. Fueron utilizados MeSH controlados y no controlados y operador booleano AND, resultante en 6107 artículos. En esta etapa, se realizó el Test de Relevancia Preliminar, el cual constituye en la exclusión de los artículos a través del título y del resumen breve presentado en los resultados de las búsquedas en cada base, siendo excluidos 5578 artículos. Los 426 artículos seleccionados fueron sometidos al Test de Relevancia I, el cual constituyó en la evaluación de los resúmenes de los estudios. En esta etapa, fueron excluidos 372 artículos, pues no estaban en consonancia con la cuestión orientadora. Al final de este test, 54 artículos fueron considerados adecuados para proseguir en el estudio. Se siguió para la evaluación de los estudios en la íntegra a través del Test de Relevancia II, en el que se evaluó la calidad metodológica, la relevancia y la adecuación de los resultados en atención a la cuestión orientadora. En esta etapa, fueron excluidos 19 artículos que poseían un mal nivel de evidencia y calidad metodológica, restando 35 artículos que fueron considerados adecuados para proseguir, siendo sometidos al Test de Relevancia III, el cual evalúa la calidad metodológica de los estudios. Al final de este test, se decidieron excluir los estudios que tuviesen nivel de evidencia maior a 4, score de calidad por debajo de 14 y escala de Jadad menor a 3. Así, fueron excluidos 9 estudios, componiendo la muestra final 26 estudios. En respuesta a la pregunta orientadora, 16 estudios apuntaron el uso del curativo VAC como el más indicado para tratar FOs abdominales que tuvieron complicaciones. Por tanto, se recomienda presión negativa de 75 a 125mmHg, con cambios cada 72 horas, mostrando un promedio de cicatrización que varió de 13,2 a 18 días. Se sugieren nuevas investigaciones, como un ensayo clínico aleatorio, o estudio de caso control, para que se pueda evaluar la efectividad y viabilidad de la terapia VAC en nuestra realidad.