Motivational interviewing (MI) has been used extensively and often effectively in medical settings to support behaviour change in adults. There is emerging evidence that MI may also be a useful approach for working with young people in schools. This thesis investigated the effectiveness of MI in educational settings and is presented in three sections. The first paper is an evaluative systematic literature review examining the evidence for student-focused MI in educational settings. Eleven studies were included in the review, although just eight were identified as 'best evidence' and included in the synthesis. Overall there is evidence for the effectiveness of student-focused MI in the areas of behaviour, school-based motivation and academic achievement. However, a number of methodological weaknesses were identified in the existing literature, which provides clear pointers for future research. Previous research has highlighted the potential usefulness of MI when used as a therapeutic intervention with disaffected students. However, to date, there has been little published research investigating students' views on MI. The second paper aims to investigate students' views on an MI intervention. Three disaffected students took part in an individual MI intervention, which was delivered by three educational psychologists (EPs). Semi-structured interviews were used to obtain the students' views, immediately after the intervention and again at a follow-up interview three months later. The results indicated that students were enthusiastic about the intervention and most perceived that there had been a positive impact on their learning motivation and classroom behaviour. However, these results were not consistent with questionnaire responses and two of the students experienced exclusions around the time of the intervention. The implications of these ambiguous findings are discussed in relation to the use of therapeutic interventions by EPs and the possible factors that are crucial to the success of MI interventions. The third paper provides a critical appraisal of the overall research process, including implications of the work, wider context of the research and dissemination of evidence to professional practice.

Submitted by Shaira Ferrari Rodor Bissoli (shaira.rodor@hotmail.com) on 2019-01-25T17:25:35Z No. of bitstreams: 1 Dissertação e anexos RS - FIM.pdf: 39316469 bytes, checksum: 0f72c48cf723b5f54bf6795ac4173112 (MD5) / Approved for entry into archive by ROSANGELA APARECIDA LOBO null (rosangelalobo@btu.unesp.br) on 2019-01-29T13:02:19Z (GMT) No. of bitstreams: 1 bissoli_sfr_me_bot.pdf: 39316469 bytes, checksum: 0f72c48cf723b5f54bf6795ac4173112 (MD5) / Made available in DSpace on 2019-01-29T13:02:19Z (GMT). No. of bitstreams: 1 bissoli_sfr_me_bot.pdf: 39316469 bytes, checksum: 0f72c48cf723b5f54bf6795ac4173112 (MD5) Previous issue date: 2018-11-27 / Bissoli SFR. Mapeamento das evidências das revisões sistemáticas de oftalmologia da base de dados Cochrane. [dissertação]. Botucatu, SP: Faculdade de Medicina, Universidade Estadual Paulista; 2018. Justificativa e objetivos: A Colaboração Cochrane visa oferecer, por meio da publicação de revisões sistemáticas, informações atualizadas, objetivas e com evidências consistentes para a prática clínica e para o estabelecimento de políticas de saúde. Entretanto, verifica-se, frequentemente, uma inconsistência de evidências e incapacidade de gerar recomendações. O objetivo desse estudo foi analisar as revisões sistemáticas do Grupo Oftalmologia da Colaboração Cochrane e mapear sua utilidade para a prática clínica e para a pesquisa científica. Método: Realizou-se estudo transversal com análise de todas as revisões sistemáticas publicadas no Grupo Oftalmologia da Colaboração Cochrane até maio de 2018, verificando-se qual o tipo de recomendação para a prática clínica e para a pesquisa científica, por meio da análise das conclusões de seus autores. Além disso, computou-se o número de ensaios clínicos e meta-análises por revisão sistemática e por subespecialidade, por ano. Resultados: 202 revisões foram obtidas no período. Evidências que apoiam a intervenção, com recomendação para a realização de mais estudos ou sem recomendação para mais estudos: 36,3% [IC 95% 36,2-36,4] e 5,0% [IC 95% 4,8-5,1], respectivamente. Evidências contrárias à intervenção, com recomendação para realização de mais estudos ou sem recomendação para mais estudos: 3,0% [IC 95% 2,8-3,1] e 3,5% [IC 95% 3,3-3,6], respectivamente. Ausência de evidências, com recomendação para a realização de mais estudos ou sem recomendação para mais estudos: 51,2% [IC 95% 55,1-55,3] e 1% [IC 95% 0,9-1,1], respectivamente. Do total, 90,5% das revisões sugerem a realização de mais estudos independentemente dos resultados obtidos. O número médio de ensaios clínicos nas revisões foi de 7,4, variando entre zero e 137, e o número médio de meta-análises foi igual a 3,1, variando entre zero e 26. Conclusão: A maioria das revisões sistemáticas do Grupo de Oftalmologia da Cochrane apresenta insuficiência ou ausência de evidências para recomendar determinada intervenção na prática clínica e recomenda a realização de novos estudos clínicos controlados e aleatorizados. / Bissoli SFR. Mapping of the evidences of systematic reviews of Ophthalmology Cochrane database. [dissertation]. Botucatu, SP: Botucatu Medical School, State University of São Paulo 2018. Rationale and objectives: The Cochrane Collaboration aims to provide, through the publication of systematic reviews, up-to-date, objective information and with consistent evidence for clinical practice and for the establishment of health policies. However, there is often an inconsistency of evidence and inability to generate recommendations. The objective of this study was to analyze the systematic reviews of the Cochrane Collaboration Ophthalmology Group and to map its usefulness to clinical practice and to scientific research. Methods: A cross-sectional study was carried out with an analysis of all the systematic reviews published in the Ophthalmology Group of the Cochrane Collaboration until May 2018, confirming the type of recommendation for clinical practice and for scientific research, through analysis of the conclusions of its authors. In addition, we counted the number of clinical trials and meta-analyzes by systematic review and by subspecialty, per year. Results: 202 revisions were obtained in the period. Evidence that supports the intervention, with recommendation for further studies: 36.3% [CI 95% 36.2-36.4] or no recommendation for further studies: 5.0% [CI 95% 4.8-5.1]. Evidence contrary to intervention, with recommendation for further studies 3.0% [CI 95% 2.8-3.1] or no recommendation for further studies 3.5% [CI 95% 3.3-3.6). Absence of evidence, with recommendation for further studies: 51.2% [CI 95% 55.1-55.3] or no recommendation for further studies 1% [CI 95% 0.9-1.1] . Of the total, 90.5% of the reviews suggest further studies regardless of the results obtained. The mean number of clinical trials in the reviews was 7.4 (ranging from zero to 137), and the mean number of meta-analyzes was 3.1 (ranging from zero to 26).Conclusion: Most systematic reviews of the Cochrane Ophthalmology Group show insufficiency or lack of evidence to recommend a particular intervention in clinical practice and recommends further controlled and randomized clinical trials.

O objetivo desta revisão sistemática foi analisar os estudos que relacionam doença periodontal e nascimento prematuro e baixo peso, verificando o efeito da doença periodontal materna no desfecho da gestação. Foi realizada pesquisa nas seguintes bases de dados: PubMed, Scielo e LILACS até Dezembro de 2007. A revisão sistemática foi conduzida de forma a identificar os estudos capazes de preencher os critérios de inclusão, apresentando aspectos clínicos, microbiológicos e radiográficos da doença periodontal, assim como os desfechos da gestação, ou seja, nascimento prematuro e baixo peso. Foram então selecionados 35 (trinta e cinco) artigos, sendo 9 (nove) coorte, 16 (dezesseis) casos controles, e 10 (dez) ensaios clínicos. A associação entre a doença periodontal materna e o nascimento de bebê prematuro com baixo peso foi encontrada em 26 (vinte e seis) estudos: 7 (sete) coorte, 11 (onze) casos controles e 8 (oito) ensaios clínicos. Não foi possível realizar uma meta-análise devido à grande heterogeneidade entre os estudos, particularmente no que se refere aos métodos de mensuração da doença periodontal. Um melhor controle em relação aos fatores de confusão também permitiria uma confiança maior nos resultados e conclusões apresentadas. Ainda não é possível ter conclusões adequadas do real efeito da doença periodontal sobre os desfechos da gestação devido a limitações nas metodologias dos presentes estudos. Portanto, a evidência da relação da doença periodontal com o nascimento de bebê prematuro e baixo peso é limitada. Ainda existe a necessidade de novos e bem desenhados estudos observacionais e de intervenção, que possam confirmar o que até agora é visto apenas como uma possível associação, explorando a validade dessas possíveis associações em diferentes populações e controlando adequadamente as variáveis de confusão. / The objective of this systematic review was to analyse the studies that relate the periodontal disease and the preterm and low birth weight deliveries, assessing the effect of the maternal periodontal disease in the pregnancy outcome. A research was conducted in the following databases: PubMed, Scielo and LILACS until December 2007. The systematic review was undertaken to identify the researches that met the inclusion criterias, addresssing aspects of periodontal disease: clinical, radiographic, microbiological and immunological, and pregnancy outcomes, like preterm low birth weight as well. In that case, 35 (thirty five) studies were selected, 9 (nine) cohort, 16 (sixteen) case controls, and 10 (ten) clinical trials. The association between maternal periodontal disease and preterm low birth weight was found in 26 (twenty six) studies: 7 (seven) cohort, 11 (eleven) case controls and 8 (eight) clinical trials. A meta-analysis was not performed due to the extensive and clear heterogenity of the studies, particulary regarding the periodontal disease measures. An adequate control for confounders would permit results and conclusions more reliable. It is not possible to know the real effect of the periodontal disease in the pregnancy outcomes until now, because of the methodology limitations of the current studies. Therefore, the evidence of the relation of the periodontal disease with the preterm low birth weight is limited. There is a need for new and well designed observational and interventional studies to confirm, what so far is only a possible association, to explore the validity of the association in different populations, correctly control for confounders.

Submitted by Jorge Silva (jorgelmsilva@ufrrj.br) on 2018-05-09T17:55:46Z No. of bitstreams: 1 2014 - Thiene Salazar Livio de Moraes.pdf: 2466223 bytes, checksum: 10b082d56f8727cf87f75df80791376b (MD5) / Made available in DSpace on 2018-05-09T17:55:46Z (GMT). No. of bitstreams: 1 2014 - Thiene Salazar Livio de Moraes.pdf: 2466223 bytes, checksum: 10b082d56f8727cf87f75df80791376b (MD5) Previous issue date: 2014-04-30 / Adjustment disorder is a diagnostic criterion associated with stress, which can occur during or after the occurrence of one or more stressful situations. It is a clinical condition which impairs the performance and social functioning and / or occupational functioning of the individual. However, it is noticed that the scientific studies on this topic are scarce. This master?s dissertation investigates the treatment kinds of Adjustment Disorder through a literature review and his prevalence among university students. Thus, this work is presented through two articles. The first is a systematic review of scientific literature of the articles about treatments for the Adjustment Disorder, published in the virtual library collections PsychInfo and PubMed / Medline. The result showed that, among the articles selected through some criteria, none is of Brazilian origin; all are from other countries, and most of the European continent. Therapies indicated in the studies were classified as psychotherapy, pharmacotherapy and herbal medicine. The second article focuses on the mental health of college students at the Universidade Federal Rural do Rio de Janeiro - Serop?dica. The study estimates the occurrence of the Adjustment Disorder among undergraduate students of the UFRRJ and detected the stressors preceding through a quantitative cross search, into a sample of 635 subjects. The results revealed that 19.4% of students matched the diagnostic criteria for the disorder Adaptation, according to the Inventory Valuation Adjustment Disorder (Self Report of the assessment of Adjustment Disorder) and 45.6 % showed susceptibility to development of psychopathological symptoms. Therefore, it is concluded that the mental health of the students in Brazilian universities, especially those that are located far from urban centers, requires scientific attention. Moreover, it is observed that little scientific attention has been given to Adjustment Disorder has collaborated that information on its prevalence in the general population and in specific populations as well as its diagnosis and its treatment remain scarce and inaccurate. / Transtorno de Adapta??o ? um crit?rio diagn?stico associado ao estresse, que pode se manifestar ap?s ou durante a ocorr?ncia de uma ou mais situa??es estressantes. ? um quadro cl?nico que entrava o desempenho e o funcionamento social e/ou ocupacional do indiv?duo. No entanto, percebe-se que os estudos cient?ficos sobre esse tema ainda s?o escassos. Esta disserta??o de mestrado se prop?s a investigar o Transtorno de Adapta??o a partir de uma revis?o de literatura, em torno dos tipos de tratamento e de sua preval?ncia entre estudantes universit?rios. Desse modo, esse trabalho ? apresentado atrav?s de dois artigos. O primeiro trata de uma revis?o sistem?tica da literatura cient?fica no que tange os artigos sobre tratamentos indicados para o Transtorno de Adapta??o, publicados nos acervos bibliogr?ficos virtuais Psycinfo e Pubmed/Medline. O resultado obtido mostrou que, dentre os artigos selecionados a partir dos crit?rios estabelecidos, nenhum ? de origem brasileira; todos s?o oriundos de outros pa?ses, sendo a maior parte do continente Europeu. As terapias indicadas nos estudos foram classificadas como Psicoterapia, Farmacoterapia e Fitoterapia. O segundo artigo enfoca a sa?de mental dos estudantes universit?rios da Universidade Federal Rural do Rio de Janeiro do campus Serop?dica. O trabalho estimou a ocorr?ncia do Transtorno de Adapta??o entre universit?rios da UFRRJ e detectou os fatores estressantes precedentes a ele, atrav?s de uma pesquisa Quantitativa Transversal, em uma amostra de 635 sujeitos. Os resultados revelaram que 19,4% dos alunos corresponderam aos crit?rios para o quadro de Transtorno de Adapta??o, segundo o Invent?rio de Avalia??o de Transtorno de Adapta??o (Self Report of the assessment of Adjustment disorder) e 45,6% demonstraram suscetibilidade ao desenvolvimento de sintomas psicopatol?gicos. Sendo assim, conclui-se que a sa?de mental dos graduandos das universidades brasileiras, principalmente naquelas que est?o localizadas distantes dos centros urbanos, requer aten??o do campo cient?fico. Al?m disso, observa-se que a pouca aten??o cient?fica dada ao Transtorno de Adapta??o tem corroborado para que informa??es sobre sua preval?ncia na popula??o geral e em popula??es espec?ficas, seu diagn?stico e seu tratamento continuem escassos e imprecisos.

Background/Aims: Understanding predictors, moderators and mediators of child externalising behaviour problems could lead to improvements in engagement and outcomes for children and their families. Parental cognitions, including self-efficacy and attributions, have been proposed as mediators in the relationship between parenting and child behaviour problems. Although mediation is increasingly recognised as an effective way of examining relationships between variables, only a small proportion of studies that identify potential mediators actually conduct a mediation analysis. This thesis consists of two studies: a systematic review (Journal Article 1) and an empirical study (Journal Article 2). The systematic review investigated the ways in which mediation analysis has been used to examine the role of parental cognitions in studies of child behavioural problems, and to assess the methodological quality of these studies. The empirical study investigated the role of parental cognitions and characteristics in relation to pre-school child externalising behaviour problems. Methods: In Journal Article 1, a systematic search of three electronic databases, a quality assessment of included studies, and a subsequent narrative synthesis were conducted. In Journal Article 2, 125 parents of children aged 3-6 years old attending a community-based parent management training programme, across three local authorities, completed a battery of self-report questionnaires before and after the intervention. Correlational and mediation analyses were conducted to investigate relationships between child behaviour and parental attachment style, metacognition, dysfunctional attributions and parental stress. We also tested the possibility that parents' reported levels of stress and child behaviour problems, and their demographic variables, played a role in whether they completed the intervention. Results: In Journal Article 1, after screening, 14 studies were reviewed using an adapted quality criteria tool. The most commonly studied parental cognition was parental self-efficacy, with a small number of studies investigating parental attributions. A variety of approaches to mediation analysis had been used and caution should be exercised when interpreting the results of many of the reviewed studies. Despite a growing recognition of the limitations of some traditional methods (e.g. causal steps approach), research into mediators of child externalising behaviour could be improved by a wider adoption of more appropriate tools, in line appropriate theoretical frameworks. In Journal Article 2, as hypothesised, the results indicated significant relationships between parents' attachment insecurity and baseline levels of parental stress, parental attributions and child behaviour problems. Support was found for the hypothesis that parental attributions mediated the relationship between attachment insecurity and child externalising behaviour problems. We did not find significant that any demographic variables other than parent age predicted whether parents completed the programme. Conclusions: Taken together, the two studies provide evidence of a complex relationship between parental factors, particularly parental cognitions, and externalising child behaviour problems. The systematic review found some evidence that parental cognitions mediate how aspects of parenting (e.g. behaviour and affect) and child externalising behaviour problems are associated, and the empirical study also showed that parental attributions are important in relation to child behaviour problems. Of particular interest was the finding that they mediate the relationship between child behaviour problems and attachment insecurity. However, to advance the field both theoretically and clinically, future studies should endeavour to ensure adequate sample size and power, using optimal study designs, in conjunction with strong theoretical grounding. Exploring cognitive mediators beyond self-efficacy, such as parental attributions, will allow us to further develop our understanding of the relationship between child behaviour and parenting.

Objective: The concept of recovery has become an integral part of modern mental health care. Understanding the outcomes and underlying mechanisms of key recovery interventions, such as Wellness Recovery Action Planning (WRAP), is essential in order to expand the theoretical understanding of recovery and inform how to target recovery in treatment. Therefore a systematic review of the literature was conducted to evaluate the mental health outcomes of WRAP for adults. The empirical study then explored three constructs in relation to WRAP and recovery. These were social problem solving, cognitive defusion and social identification. Method: The systematic review of the mental health outcomes of WRAP was conducted by searching four databases, contacting the authors of WRAP research and seeking evaluative information from organisations that deliver WRAP. Fourteen relevant studies met the inclusion criteria. Whereas, the empirical study recruited participants on a trans-diagnostic basis from across Scotland. Using a quantitative cross sectional design, 109 participant's completed 5 self-report questionnaires. These were the Knowledge, Attitudes and Beliefs about WRAP Questionnaire (WRAP beliefs), the Recovery Assessment Scale - Short (RAS-S), the Social Problem Solving Inventory - Revised - Short (SPSI-R-S), the Four Item Measure of Social Identification (FISI) and the Cognitive Fusion Questionnaire (CFQ). Correlation, regression and mediation analysis were used to explore relationships, and in particular, the predictors and mediators of recovery. Results: The systematic review provided strong evidence that WRAP has a significant positive impact on hope and also reduces the symptoms of mental illness. However, whether WRAP improves personal levels of recovery was unclear and a possible risk of disempowerment was found. Promising preliminary mental health outcomes in the areas of confidence in managing mental health, quality of life, service use, self-advocacy and knowledge attitudes and beliefs about recovery were highlighted. Only studies that did not use peer facilitators failed to find significant increases in hope compared to treatment as usual control groups. In the empirical study, the results indicated that all the constructs examined were correlated to recovery. In the regression analysis, WRAP beliefs, social problem solving and cognitive defusion also demonstrated a predictive relationship with recovery. Mediation analysis indicated that, social problem solving mediated two distinct relationships. One between WRAP beliefs and recovery, and another between cognitive defusion and recovery. The social problem solving subscales also showed how the two predictors relate to recovery through social problem solving in different ways. Social identification with the WRAP group did not significantly predict or mediate recovery. Conclusions: The systematic review indicated having peer facilitators delivering WRAP is key to helping participants foster hope and that a further randomised control trial could help clarify if improved personal recovery is an outcome of WRAP. It additionally suggested how the relationship between WRAP beliefs and recovery could be explored, as per the design of the empirical study. Findings from the empirical study implied that improving participants' social problem solving and cognitive defusion should be specifically targeted in WRAP delivery. The studies combined indicate that to achieve the best recovery results interventions, like WRAP, should target inspiring hope through peer support, improving knowledge, attitudes and beliefs about recovery and cognitive defusion from unhelpful thoughts.

Background: Difficulties with anxiety among children and young people are common and can impact upon their developmental trajectory leading to adverse outcomes in later life. There is, therefore, a need to increase access to early intervention services. Existing research has indicated that school-based cognitive behavioural interventions are effective for children and young people experiencing difficulties with anxiety, yet there remains a proportion of the population for whom they are not effective. In addition, there is a lack of research on how these may be implemented in real world settings as opposed to a research trial. The present research focuses on the provision of cognitive behavioural school-based interventions in two parts: a systematic review of psychological, interpersonal and social variables as predictors, mediators and moderators of mental health outcomes following a school-based intervention and an empirical mixed methods evaluation of the facilitators and barriers to the implementation of a school-based intervention. Method: A systematic search of electronic databases for studies examining interpersonal, psychological and social predictors, moderators and mediators of mental health outcome following school-based cognitive behavioural interventions was conducted. Effect sizes for these analyses were calculated and the quality of eligible studies was assessed using a standardised rating tool. Within the empirical project, the implementation of a school-based cognitive behavioural intervention was evaluated through a mixed methods approach. Semi-structured interviews with stakeholders in the intervention were analysed using grounded theory integrated with framework analysis. Quantitative data on the reach of the intervention, practitioner evaluation of training and coaching as well as routine outcome measures from children and young people receiving the intervention was collected. Results: Within the systematic review, twenty-two studies (N=22) met the predefined eligibility criteria. There was heterogeneity in the variables explored, effect size of these on treatment outcome and the quality of the literature within the included studies. Cognitive style was found to mediate treatment outcome, but there was limited evidence for other predictors, mediators and moderators of treatment outcome within the review. Quantitative results of the empirical project indicated that the model of the intervention was acceptable to both practitioners and children and young people, and preliminary data indicated a significant improvement in mental health outcomes. Facilitators that emerged from qualitative data included an enabling context, therapeutic engagement, motivation and congruence, self-efficacy and containment and encouragement. The exclusivity of the intervention, a lack of systemic understanding and transparency as well as demands and pressure on resources were barriers to implementation. Conclusions: Although preliminary evidence for potential predictors, mediators and moderators is presented, further research with improvements in the design and reporting of explanatory variables on treatment outcome is required prior to informing clinical decision-making. The successful implementation of school-based interventions requires multi-agency integration and collaboration as well as on-going support in managing systemic pressures and skill development.

Myocardial infarction is a leading cause of morbidity and mortality worldwide. The purpose of this thesis was to develop strategies for the assessment of patients with suspected myocardial infarction using a high-sensitivity cardiac troponin I assay, and to evaluate the relationship between the aetiology of myocardial infarction and long term clinical outcomes to identify opportunities to modify outcomes. In the United Kingdom, approximately 1 million patients present to hospital with chest pain each year and are assessed for suspected myocardial infarction, yet fewer than 20% of patients receive this diagnosis. Prior clinical standards mandated the admission of patients for serial cardiac troponin testing to identify myocardial necrosis and determine if myocardial infarction had occurred. However, new high-sensitivity assays offer a magnitude improvement in diagnostic precision, and as such provide a novel approach to diagnose or exclude myocardial infarction at an earlier stage. In our first study, I evaluate the performance of a high-sensitivity cardiac troponin I assay as a risk stratification tool in patients with suspected acute coronary syndrome. A systematic review and individual patient-level data meta-analysis was performed, including prospective studies measuring high-sensitivity cardiac troponin I in patients with suspected acute coronary syndrome, where the diagnosis was adjudicated according to the universal definition of myocardial infarction. The primary outcome was myocardial infarction or cardiac death during the index hospitalization or at 30 days. Meta-estimates for primary and secondary outcomes were derived using a binomial-normal random effects model. Performance was evaluated in subgroups and across a range of troponin concentrations (2-16 ng/L) using individual patient data. A total of 22,457 patients were included in the meta-analysis (age 62 [15.5] years; n=9,329 (41.5%) women), of whom 2,786 (12.4%) experienced myocardial infarction or cardiac death at 30 days. Cardiac troponin I concentrations were < 5 ng/L at presentation in 11,012 (49%) patients, with a negative predictive value of 99.5% (95% confidence interval [CI] 99.3-99.6) for myocardial infarction or cardiac death at 30 days. Lower thresholds did not improve safety, but did significantly reduce the proportion identified as low risk. This threshold of 5 ng/L formed the basis for the development of a diagnostic pathway for patients with suspected acute coronary syndrome. In a cohort study of 1,218 patients with suspected acute coronary syndrome who underwent high-sensitivity cardiac troponin I measurement at presentation, 3 and 6 or 12 hours, I derived and validated a novel pathway (rule out myocardial infarction if < 5 ng/L at presentation, or change < 3 ng/L and < 99th centile at 3 hours), and compared this with the established European Society of Cardiology 3-hour pathway (rule out myocardial infarction if < 99th centile at presentation, or at 3 hours if symptoms < 6 hours). The primary outcome was a comparison of the negative predictive value (NPV) of both pathways for myocardial infarction or cardiac death at 30 days. The primary outcome was evaluated in pre-specified subgroups stratified by age, gender, time of symptom onset and known ischaemic heart disease. In those < 99th centile at presentation, the ESC pathway ruled out myocardial infarction in 28.1% (342/1,218) and 78.9% (961/1,218) at presentation and 3 hours respectively, missing 18 index and two 30-day events (NPV 97.9%, 95% confidence intervals [CI] 96.9-98.7%). The novel pathway ruled out 40.7% (496/1,218) and 74.2% (904/1,218) at presentation and 3 hours, missing two index and two 30-day events (NPV 99.5%, 95% CI 99.0-99.9%; P < 0.001 for comparison). The NPV of the novel pathway was greater than the ESC pathway overall (P < 0.001), and in all subgroups including those presenting early or known to have ischaemic heart disease. There are a number of additional approaches for the rule out of myocardial infarction. Clinical risk scores apply conventional risk factors to estimate the probability of myocardial infarction. The most widely implemented scores, HEART, EDACS, GRACE and TIMI, have been extensively validated when used alongside contemporary troponin assays, however, their impact on pathways applying high-sensitivity cardiac troponin testing is less clear. In 1,935 patients with suspected acute coronary syndrome, I evaluated the safety and efficacy of our novel pathway or the European Society of Cardiology 3-hour pathway alone, or in conjunction with low-risk TIMI (0 or 1), GRACE (≤108), EDACS (< 16) or HEART (≤3) scores. Myocardial infarction or cardiac death at 30-days occurred in 14.3% (276/1,935). The ESC pathway ruled out 70% with 27 missed events giving a negative predictive value (NPV) of 97.9% (95% confidence interval [CI], 97.1 to 98.6%). Addition of a HEART score ≤3 reduced the proportion ruled out by the ESC pathway to 25%, but improved the NPV to 99.7% (95%CI 99.0 to 100%, P < 0.001). The novel pathway ruled out 65% with three missed events for a NPV of 99.7% (95%CI 99.4 to 99.9%). No risk score improved the NPV, but all reduced the proportion ruled out (24-47%, P < 0.001 for all). Whilst myocardial infarction due to atherosclerotic plaque rupture and thrombosis (type 1) is well described, the natural disease course of myocardial infarction due to oxygen supply-demand imbalance without atherothrombosis (type 2) is poorly understood. I aimed to define long-term outcomes and explore risk stratification in patients with type 2 myocardial infarction and myocardial injury. Consecutive patients (n=2,122) with elevated cardiac troponin I concentrations (≥0.05 μg/L) were identified at a tertiary cardiac centre. All diagnoses were adjudicated as per the Universal Definition of Myocardial Infarction. The primary outcome was all-cause death. Secondary outcomes included major adverse cardiovascular events (MACE; non-fatal myocardial infarction or cardiovascular death) and non-cardiovascular death. To explore competing risks, cause-specific hazard ratios were obtained using Cox regression models. The adjudicated index diagnosis was type 1 or type 2 myocardial infarction or myocardial injury in 1,171 (55.2%), 429 (20.2%) and 522 (24.6%) patients, respectively. At five years, all-cause death rates were higher in those with type 2 myocardial infarction (62.5%) or myocardial injury (72.4%) compared with type 1 myocardial infarction (36.7%). The majority of excess deaths in those with type 2 myocardial infarction or myocardial injury were due to non-cardiovascular causes (HR 2.32, 95%CI 1.92-2.81, versus type 1 myocardial infarction). Despite this, the observed crude MACE rates were similar between groups (30.6% versus 32.6%), with differences apparent after adjustment for co-variates (HR 0.82, 95%CI 0.69-0.96). Coronary heart disease was an independent predictor of MACE in those with type 2 myocardial infarction or myocardial injury (HR 1.71, 95%CI 1.31-2.24). Patients with type 2 myocardial infarction were less likely to receive secondary prevention therapy, suggesting a treatment gap may exist and there may be potential to modify clinical outcomes. A risk stratification threshold has been defined using high-sensitivity cardiac troponin I which identifies patients at very low risk of myocardial infarction or cardiac death. A diagnostic pathway incorporating this risk stratification threshold appears safer than established guidelines which apply the 99th centile alone. The use of clinical risk scores does not appear to improve the safety of this approach, however, does significantly reduce efficacy. Overall, these findings demonstrate the potential of high-sensitivity cardiac troponin testing to improve the efficiency of the assessment of patients with suspected acute coronary syndrome without compromising patient safety. The observations in those with myocardial injury and infarction have identified a phenotype of patients with type 2 myocardial infarction and coronary artery disease who are at increased cardiovascular risk, and who may benefit from targeted secondary prevention. The studies presented will inform the design of future clinical trials, and may inform international guidelines for the assessment of patients with suspected acute coronary syndrome.

Justificativa: As técnicas de reprodução assistida (TRA), usadas para o tratamento de infertilidade/subfertilidade, incluem manipulação in vitro de oócitos e esperma, ou embriões, com o objetivo de alcançar gravidez e nascimentos vivos. O recrutamento de múltiplos folículos é fundamental para o aumento das taxas de gravidez, e isso é alcançado por meio do estímulo ovariano controlado (EOC). A monitorização do EOC é realizada por contagem de folículos ovarianos e medidas ultrassonográficas, associadas ou não à dosagem hormonal. Justificase monitorar a fase folicular para decisões a respeito da dose de gonadotrofinas administradas, detecção do risco de ocorrência da síndrome de hiperestímulo ovariano (SHO) e do planejamento do triggering da maturação final; porém a necessidade da monitorização intensiva da EOC é controversa, pois a combinação dos métodos consome mais tempo, recursos e está associada com maior desconforto para a paciente. Objetivo: Avaliar a eficácia e segurança da monitorização da EOC em ciclos de reprodução assistida, usando somente ultrassonografia (US). Métodos de busca: As buscas por estudos randomizados foram realizadas nos principais bancos de dados eletrônicos. Além disso, foram examinadas, manualmente, as listas de referências dos estudos incluídos em revisões semelhantes. A última busca eletrônica foi realizada em 12 de março de 2015. Critérios de Seleção: Apenas estudos verdadeiramente randomizados, que comparassem a monitorização do EOC por US associado à dosagem hormonal e US isoladamente, monitorização do EOC por US2D e US3D, bem como US2D e telemonitorização endovaginal operada pela própria paciente (SOET), foram considerados elegíveis. Os estudos que permitiam a inclusão de uma mesma paciente duas vezes foram incluídos apenas se os dados do primeiro ciclo estivessem disponíveis. Coleta e Análise de Dados: Dois revisores avaliaram, independentemente, a elegibilidade, extração de dados e os riscos de viéses dos estudos incluídos. Quaisquer discordâncias foram resolvidas em consulta com um terceiro revisor. Quando necessário, os autores dos estudos incluídos foram contatados para maiores informações. Resultados: Foram selecionados 1717 registros, 10 dos quais eram elegíveis. Nenhum estudo relatou nascidos vivos. Seis estudos compararam a monitorização do EOC por US isolada com US associada à dosagem hormonal. Os intervalos de confiança (IC) foram extensos e não permitiram concluir a existência de benefício nem prejuízo associado ao uso de US isolada, em relação aos desfechos SHO (odds ratio - OR=1.03, IC95% 0.48 a 2.18, p=0.95) e abortamento (risco relativo - RR=0.37, IC95% 0.07 a 1.79, p=0.21). Para gravidez clínica, o IC foi compatível com pequeno benefício a pequeno prejuízo (RR=0.96, IC95% 0.80 a 1.16, p=0.70). Para número de oócitos captados, o IC foi compatível com apreciável benefício a não efeito (Diferença média MD=0.92 oócitos captados, CI95% -0.19 a 2.04, p=0.70). Dois estudos compararam US3D e US2D e os IC foram extensos e não permitiram concluir pela existência de benefício nem prejuízo associado à monitorização por US3D para os desfechos: gravidez clínica (RR=1.00, IC95% 0.58 a 1.73) e número de oócitos captados (MD= -0.37 oócitos, IC95% -3.63 a Resumo 2.89). Apenas um estudo comparou monitorização por US2D convencional com SOET, e o IC observado foi amplo e não permitiu concluir pela existência de benefício nem prejuízo associado à SOET, considerando se gravidez clínica (RR=0.95, IC 95% 0.52 a 1.75) e número de oócitos captados (MD=0.50, CI 95% - 2.13 a 3.13). Conclusão: No que concerne à eficácia, as evidências atuais sugerem que monitorizar o EOC apenas com US não deva alterar, substancialmente, as chances de se alcançar gravidez clínica. O número de oócitos captados é similar ao se comparar com a monitorização por US associada à dosagem hormonal. Quanto à segurança, também não houve aumento no risco de desenvolvimento de SHO. Contudo, a interpretação dos resultados deve ser realizada com cautela, já que para todos os desfechos e todas as comparações, os dados disponíveis são inconclusivos, pois a qualidade de evidência foi comprometida por imprecisão e falha dos estudos em relatar a metodologia aplicada. Por isso acredita-se que serão necessários mais estudos avaliando o procedimento ideal para monitorização da EOC / Background: The assisted reproductive techniques (ART) for the treatment of infertility/subfertility, include in vitro handling of both human oocytes and sperm or of embryos with the objective of achieving pregnancy and live birth. The recruitment of multiple follicles is often necessary for better results in pregnancy rates and it\'s achieved by performing controlled ovarian stimulation (COS). COS monitoring is performed by ovarian follicle counting and ultrasonography measurements and / or hormones dosage. It is appropriate to monitor the follicular phase for decisions regarding administered of gonadotropin dose, to assess the risk of ovarian hyperstimulation syndrome (OHSS), to determine the best time to trigger final follicular maturation. However, the need for intensive COS monitoring is controversial: the combination of the methods adds costs and discomfort for the woman who is undergoing ART and requires additional time. Objectives: To evaluate the efficacy and safety of monitoring controlled ovarian stimulation by ultrasound in assisted reproduced tecniques. Search Methods: The searches for randomized controlled trials (RCT) were performed in the main electronic databases; in addition, we hand searched the reference lists of included studies and similar reviews. We performed the last electronic search on March 29, 2015. Selection Criteria: Only truly randomized controlled trials comparing COS monitoring by ultrasonography and/or hormonal assessment, as studies comparing COS monitoring by 2DUS and 3DUS were considered eligible. We included studies that permitted the inclusion of the same participant more than once (cross-over or \'per cycle\' trials) only if data regarding the first treatment of each participant were available. Data Collection and Analysis: Two reviewers independently performed study eligibility, data extraction, and assessment of the risk of bias and we solved disagreements by consulting a third reviewer. We corresponded with study investigators in order to resolve any queries, as required. Results: The search retrieved 1717 records; ten studies were eligible. No study reported live birth. Six studies compared US only vs. US + Hormones. The confidence intervals (CI) were large and did not allow us conclude benefit or harm associated with the US Only for both OHSS (Odds ratio - OR=1.03, 95%CI 0.48 to 2.18, P=0.95), and miscarriage (relative risk - RR=0.37, 95%CI 0.07 to 1.79, P=0.21). For clinical pregnancy, the CI was compatible with small benefit to small harm (RR=0.96, 95%CI 0.80 to 1.16, P=0.70). For the number of oocytes retrieved, the CI was compatible with appreciable benefit to no effect (Mean difference - MD=0.92 oocytes, 95%CI -0.19 to 2.04, P=0.70). Two studies compared 3DUS vs. 2DUS: the confidence intervals (CI) were large and did not allow us conclude benefit or harm associated with 3DUS regarding clinical pregnancy (RR=1.00, CI95% 0.58 to 1.73) and number of oocytes retrieved (MD= -0.37 oocytes, 95%CI -3.63 to 2.89). One study compared 2DUS vs. SOET, the CI was large and did not allow us conclude benefit or harm associated with SOET regarding clinical pregnancy (RR=0.95, 95%CI 0.52 a 1.75) and number of oocytes retrieved (MD=0.50, 95%CI -2.13 a 3.13). Authors\' Conclusions: Regarding effectiveness, current evidence suggests that monitoring COS only by US only should not change substantially the chances of achieving clinical pregnancy. The number of retrieved oocytes is similar to compare with the monitoring by US associated with hormonal assessment. security also seems not to increase the risk of developing OHSS. However the interpretation of results should be performed with caution, since for all outcomes and comparisons, the available data are inconclusive because the quality of evidence was compromised by inaccuracy and poor reporting of study methodology. So we believe that further studies evaluating the ideal procedure for monitoring the COS are needed

O conceito \"plataforma\" tem sido explorado em pesquisas sobre desenvolvimento de produtos, estratégia tecnológica e economia industrial. O uso de plataformas dentro das empresas e, mais recentemente, para mediar atividades de aglomerados ou ecossistemas de empresas têm sido reconhecidos como de grande importância na gestão de novos negócios, no desenvolvimento de novos produtos e na inovação. Google, Facebook, SAP, Microsoft e Apple são exemplos de empresas do setor de software cujas plataformas têm inspirado muitas outras empresas a desenvolverem produtos e serviços complementares. Ao analisar sistematicamente a literatura sobre plataformas, combinando análises bibliométricas e de conteúdo, foi possível verificar a existência de lacunas a serem estudadas no que se refere à teoria da evolução das plataformas e às adaptações organizacionais das empresas que se baseiam em plataformas para o desenvolvimento de seus produtos. Visando estender essa teoria, o objetivo desta tese foi investigar capacitações vinculadas ao relacionamento entre proprietárias de plataformas e desenvolvedores que complementam estas plataformas, como meio para compreender como elas evoluem de internas para externas. A abordagem metodológica escolhida foi a pesquisa qualitativa realizada mediante estudo de casos múltiplos em empresas nacionais e internacionais que atuam no setor brasileiro de software. Foram analisadas seis plataformas em organizações que são proprietárias de plataformas de software, e dezesseis empresas desenvolvedoras que contribuem com produtos ou serviços complementares a estas plataformas. Os resultados trouxeram algumas contribuições; a revisão sistemática da literatura, por exemplo, permitiu uma melhor compreensão e clareza sobre a evolução do conceito plataforma com identificação de tendências e temas emergentes para pesquisa. O estudo de casos realizado contribuiu com a identificação e a classificação de um conjunto de capacitações por tipo de plataforma, considerando a perspectiva do proprietário da plataforma e dos desenvolvedores. E como principal contribuição deste trabalho, tanto para teoria como para prática, fica a proposição de um quadro teórico estendido, que indica que para evoluir de uma plataforma interna para uma plataforma externa, as proprietárias de plataformas desenvolvem determinadas capacitações vinculadas ao relacionamento com desenvolvedores de software, de acordo com o tipo de plataforma. Em relação aos desenvolvedores, esse quadro aponta para o desenvolvimento de capacitações adaptadas ao tipo de plataforma. Espera-se que este trabalho contribua para o debate sobre plataformas e capacitações. / The concept of \"platform\" has been explored in many studies on product development, technology strategy, and industrial economy. The use of platforms within companies and, more recently, in mediating the activities within clusters or ecosystems of businesses, has been recognized as highly significant for the management of new businesses, for the development of new products, and for innovation. Google, Facebook, SAP, Microsoft and Apple are examples of companies in the software industry whose platforms have inspired many other businesses to develop complementary products and services. By systematically analyzing the literature on platforms, combining bibliometric analyses with content analyses, it was possible to observe the existence of gaps to be filled concerning the theory of the evolution of platforms, and the processes of organizational adaptation that platform-based companies undergo in the development of their products. Aiming at extending the theory, the objective of this work has been that of investigating capabilities associated to the relationships between platform owners and developers as a means to understand how platforms evolve from internal platforms to external platforms. The methodology chosen for this work was a qualitative study conducted via case study of multiple cases with national and international companies present in the Brazilian software industry. Six examples of software platform owners were examined, along with sixteen developers that contribute with products and services that extend those platforms. The results of the study make a few contributions to this topic; the systematic review of the literature, for example, allows a better, clearer understanding of the evolution of the concept of platform, identifying trends and emerging themes for research. The case studies contribute to identify and classify a set of capabilities by type of platform, considering the perspective of the owner and that of the developers. And as the main contribution of this work, both for theory and for practice, we have the proposition of an extended theoretical framework that indicates that, in order to evolve from an internal platform to an external one, the platform owners develop certain capabilities associated to their relationship with software developers, according to the type of platform. Regarding developers, this framework points to the development of capabilities adapted to the type of platform. We hope that this work will contribute to the ongoing debate about platforms and capabilities.