This thesis examines philosophical controversies surrounding the evaluation of medical treatments, with a focus on the evidential roles of randomised trials and mechanisms in Evidence-Based Medicine. Current 'best practice' usually involves excluding non-randomised trial evidence from systematic reviews in cases where randomised trials are available for inclusion in the reviews. The first paper challenges this practice and evaluates whether adding of evidence from non-randomised trials might improve the quality and precision of some systematic reviews. The second paper compares the alleged methodological benefits of randomised trials over observational studies for investigating treatment benefits. It suggests that claims about the superiority of well-conducted randomised controlled trials over well-conducted observational studies are justified, especially when results from the two methods are contradictory. The third paper argues that postulating the unpredictability paradox in systematic reviews when no detectable empirical differences can be found requires further justification. The fourth paper examines the problem of absence causation in the context of explaining causal mechanisms and argues that a recent solution (Barros 2013) is incomplete and requires further justification. Solving the problem by describing absences as causes of 'mechanism failure' fails to take into account the effects of absences that lead to vacillating levels of mechanism functionality (i.e. differences in effectiveness or efficiency). The fifth paper criticises literature that has emphasised functioning versus 'broken' or 'non-functioning' mechanisms emphasising that many diseases result from increased or decreased mechanism function, rather than complete loss of function. Mechanistic explanations must account for differences in the effectiveness of performed functions, yet current philosophical mechanistic explanations do not achieve this. The last paper argues that the standard of evidence embodied in the ICE theory of technological function (i.e. testimonial evidence and evidence of mechanisms) is too permissive for evaluating whether the proposed functions of medical technologies have been adequately assessed and correctly ascribed. It argues that high-quality evidence from clinical studies is necessary to justify functional ascriptions to health care technologies. / <p>QC 20150312</p>

Diss. (sammanfattning) Umeå : Umeå universitet, 2010.

Essa dissertação tem como objetivo analisar o comportamento manipulador relacionado à aplicação de instrumentos de mensuração de competências socioemocionais no ambiente escolar estimulado por duas abordagens que configuram contextos low-stake: o efeito da disseminação da informação sobre essas competências e suas relações com bem-estar e progresso social e da possibilidade dos professores receberem as respostas individuais dos alunos. Para isso, realizou-se um experimento com 2853 alunos de 10 escolas públicas da rede estadual de São Paulo. Os resultados indicam que os alunos são capazes de inflar suas respostas no sentido da desejabilidade social e que as duas abordagens fazem com que os alunos se sintam mais motivados em manipular suas respostas. Além disso, os resultados mostram que a inclusão de uma notificação sobre um mecanismo de detecção de respostas falsas no questionário cria uma barreira e desestimula o comportamento manipulador. / This dissertation aims to examine faking behaviour in personality assessments at schools. Two approaches that create low-stakes environments are investigated: information spreading about non-cognitive skills and their impact on well-being and social progress and the fact that teachers would receive individual students\' answers. Using a CRT technique with 2853 students from 10 São Paulo state public schools, we find that students are capable to fake their answers and these two approaches turn them more motivated to engage in faking. Moreover, we show that a warning about untruthful answers attached to the questionnaire imposes a cost, discouraging faking behaviour

O envelhecimento populacional é uma preocupação mundial, acarretando prejuízos pulmonares. A cinesioterapia respiratória é muito utilizada, mas pouco relacionada com o meio aquático e idosos. Este estudo analisou os efeitos da cinesioterapia respiratória realizada bem dois meios - aquático e terrestre - na força muscular respiratória, flexibilidade e expansibilidade torácica de idosos. Completaram o estudo 59 sujeitos entre 60 e 65 anos, randomizados em três grupos. Dois deles realizaram exercícios respiratórios em meios aquático e terrestre. O terceiro atuou como controle. Comparando os grupos, observou-se uma melhora estatisticamente significativa da força muscular inspiratória do grupo que realizou atividades na água. As demais variáveis não sofreram alteração significativa / Aging of the population is a mundial concern. It causes damages in the pulmonary system. Respiratory exercises are too much used, but not so much related with the aquatic environment and aged. This study analised the effects of the respiratory exercise realized in two environments - aquatic and earth - in the respiratory muscle strength, thoracic mobility and flexibility in healthy aged. Completed the study 59 subjects between 60 and 65 years, randomized in three groups. Two of then realized respiratory exercises in earth and water and the third one acted as a control. Comparing the groups, there was a stastically significance improve in the inspiratory muscle strength in the water group. All of the other variables analised didn't change with the intervention

No description available.

Background: Higher protein diets, especially from animal sources, have seen a rise in popularity due to potential metabolic. This may have consequences for kidney function particularly in rising middle class populations who are allocating more income towards meat. The objective of this systematic review and meta-analysis was to evaluate the effects of higher versus lower protein intake on glomerular filtration rate (GFR) in adult populations without renal impairment. Methods: Search strategies were developed and electronic databases searched: MEDLINE and EMBASE. Data were extracted up until June 3, 2015. The main outcome measure was GFR and a random effect model (Cochrane’s Review Manager Version 5.3) was used to pool mean differences in GFR values. Results: Database searches yielded 25 trials from 1914 articles that were eligible for analysis based on inclusion/exclusion criteria. 12 studies were randomized controlled trials and 11 studies were crossover trials. As a result of data presented, 2 crossover studies were treated as 4 trials to result in 25 total trials. A total of 810 subjects from 25 trials were included in this systematic review and meta-analyses. The age of participants was 24-62 years and their BMI was 21-36 kg/m2. Higher protein compared to lower protein-containing diets were associated with increased GFR values [mean difference (MD): 8.33 ml/min (95% CI 4.87 to 11.79), P < 0.00001] but this was less pronounced when assessing change from baseline GFR values [MD: 4.71 ml/min (95% CI 0.06 to 9.36), P = 0.05]. Moreover, significant heterogeneity was present and funnel plot asymmetry indicated potential publication bias in both meta-analyses. Conclusion: Higher protein diets were associated with increased GFR, however, these results were inconclusive due to significant heterogeneity and overestimation by random effect analyses. There is still no clear evidence that high protein diets negatively impact renal function in healthy populations. / Thesis / Master of Science (MSc) / Globally, the leading causes of mortality in industrialized countries are cardiovascular disease (CVD), stroke, and type 2 diabetes (T2D). Deaths from these chronic diseases now outpace deaths due to malnutrition. Being overweight and obese increases the risk of both morbidity and mortality from CVD, stroke, and T2D. Global rates of overweight and obesity have now reached ‘epidemic’ proportions and the World Health Organization has stated that, “… [a] global epidemic of overweight and obesity – ‘globesity’ – is taking over many parts of the world. If immediate action is not taken, millions will suffer from an array of serious health disorders.” Over the past 20-30 years, the popularity of higher protein energy restricted diets have grown due to the potential benefits regarding weight loss, appetite regulation, and maintenance of lean (muscle) mass. Additionally, the expansion of the global ‘middle-class’ has resulted in families allocating more income towards meat products as a primary protein source in their diet. A health concern is that higher protein intake may have an adverse effect on kidney function. In individuals with chronic kidney disease, higher protein diets have been shown to result in further renal impairment. However, the effects of increased protein intake in healthy populations are unclear. The aim of this systematic review and meta-analysis was to compare higher versus lower protein diets on kidney function in healthy populations based on the literature to date. This was accomplished by looking at changes in glomerular filtration rate (the rate at which kidneys filter blood), which is the ‘gold standard’ marker of kidney function.

No description available.

Context. One of the most controversial subjects in anaesthesia today is whether or not neuraxial anaesthesia is more efficient to general anaesthesia in high-risk patients undergoing noncardiac surgery. The cumulative results showed that the incidence of postoperative cardiovascular morbidity and mortality is similar, regardless of type of the anaesthesia. So, is relevant to answer the search question: what is the efficiency of the neuraxial anaesthesia compared with general anaesthesia for lower-limbs revascularization in elderly? Objective. It is to determine the efficiency of the neuraxial anaestheisa versus general anaesthesia for lower-limbs revascularization in elderly. Hypothesis. The hypothesis is that the neuraxial anaestesia is more efficient (OR 0.67) than general anaesthesia for lower-limbs revascularization in elderly. Design. Systematic review with meta-analyse of the original articles of the randomized controlled trials. Setting. Federal University of Alagoas, Maceió, AL. Sample. Original articles of the randomized controlled trials that compared two anaesthetic technique (neuraxial anaesthesia vs. general anaesthesia) in elderly submitted to lower-limbs revascularization surgery. The information was accessed from EMBASE, LILACS, MEDLINE, CINHAL and ISI WEB OF SCIENCE. Main outcomes. Primary outcomes: Mortality, cerebral infarction, myocardial infarction, paralysis and postoperative lower limb amputation rate. Secondary outcomes: Duration of hospital stay, postoperative cognitive dysfunction, postoperative wound infection, other postoperative infections, neuraxial haematoma and complications in the anaesthetic recovery room. Complementary data: internal validity, external validity and statistical analyze. Statistical methods. For data analysis the odds ratio were used in the randon effect model with corresponding 95% confidence interval. / Contexto. A controvérsia atual é saber se a anestesia neuroaxial é mais eficiente do que a anestesia geral em pacientes de alto risco submetidos à cirurgia não cardíaca. Os resultados acumulados mostram que a incidência pós-operatória de mortalidade e morbidade cardiovascular é similar independentemente da técnica anestésica. Assim, é relevante responder a pergunta de pesquisa: qual a eficiência da anestesia neuroaxial comparada à anestesia geral para a revascularização dos membros inferiores em idosos? Objetivo. Determinar a eficiência da anestesia neuroaxial comparada à anestesia geral para a revascularização dos membros inferiores em idosos. Hipótese. A hipótese é que a anestesia neuroaxial é mais eficiente (OR 0,67) quando comparada à anestesia geral para a revascularização de membros inferiores em idosos. Tipo de estudo. Revisão sistemática com metanálise de artigos originais de ensaios clínicos aleatórios. Local. Universidade Federal de Alagoas, Maceió, AL. Amostra. Artigos originais de ensaios clínicos aleatórios que comparam duas técnicas anestésicas (anestesia neuroaxial vs. anestesia geral) em idosos submetidos à cirurgia de revascularização dos membros inferiores. Fontes de informação utilizadas: EMBASE, LILACS, MEDLINE, CINHAL e ISI WEB OF SCIENCE. Variáveis. Variáveis primárias: Mortalidade, infarto cerebral, infarto cardíaco, paralisia muscular e taxa pós-operatória de amputação de membro inferior. Variáveis secundárias: Tempo de duração da internação hospitalar, disfunção cognitiva pós-operatória, infecção pós-operatória, outras infecções pósoperatórias, hematoma neuroaxial e complicações na sala de recuperação pósanestésica. Dados complementares: itens da validade interna, itens da validade externa e análise estatística. Método estatístico. A metanálise foi apresentada com o cálculo das variáveis realizado pela odds ratio no modelo de efeito randômico, com respectivo intervalo de confiança de 95%.

O aumento da prevalência de doenças alérgicas como a asma, tem sido atribuído à falta de estímulos infecciosos. A atopia, que embasa as manifestações alérgicas, caracteriza-se por uma disfunção imune com predomínio da resposta do tipo Th2. Experimentos em modelos animais com micobactérias e seus produtos têm demonstrado resultados promissores na proteção e reversão de resposta imune do tipo Th2. A imunoterapia para alérgenos inalatórios tem mostrado resultados positivos e o uso do BCG como adjuvante poderia trazer benefícios adicionais. Em estudo randomizado duplo cego foram avaliados 21 indivíduos de ambos os sexos, com idades de 8 a 17 anos sensibilizados ao Dermatophagoides pteronissynus (Dpt) e portadores de asma leve ou moderada persistentes. Os pacientes foram divididos em dois grupos e tratados com imunoterapia específica (ITE) para Dpt. O Grupo A recebeu como adjuvante, no início da ITE, uma aplicação do diluente do BCG e o Grupo B uma dose da vacina BCG. Na avaliação realizada após o período de indução da ITE constatou-se nos dois grupos diminuição significativa dos sintomas, da necessidade de medicação para asma, da hiperreatividade brônquica inespecífica, da reatividade cutânea ao Dpt juntamente com a melhora da função pulmonar. Houve uma redução no índice de estimulação da cultura de células mononucleares do sangue periférico estimuladas com Dpt, acompanhada de uma elevação da IL-10 no sobrenadante e dos níveis da IgG específica para Dpt e da IgE total. Os eosinófilos, a IgE específica para Dpt do sangue e o óxido nítrico no ar exalado não se alteraram. Não houve diferença na comparação dentre os grupos, exceto na proliferação das células mononucleares do sangue periférico estimuladas com PPD, que foi maior no Grupo B. Conclusão: a ITE levou a resultados satisfatórios com melhora clínica e alterações imunológicas já ao final do período de indução. A avaliação do uso do BCG como adjuvante, não mostrou benefícios adicionais. / The increase of allergic diseases, such as asthma, has often been explained by a decline in infectious stimulation. Atopy that is characterized as an immune dysfunction promotes a strong type Th2 immune response and underlines allergic diseases. Experimental animal models researches with mycobacteria and its products had led to promising results in prevention or reversion of type Th2 response. Positive results have been obtained to allergens specific immunotherapy (SIT) and its association with BCG vaccine, as an adjuvant, could promote additional benefits. In a randomized double blind study 21 patients sensitized to mite Dermatophagoides pteronyssinus (Dpt) with mild or moderate persistent asthma, aged 8 to 17 years of both sex were evaluated. Patients were divided in two groups. Group A received at the beginning of SIT one dose of BCG diluent and Group B one dose of BCG vaccine. After the SIT induction period we observed in both groups a significant decrease in asthma symptoms, bronchial hyperreactivity, immediate cutaneous reactivity to Dpt and the necessity of drugs intake. Specific lymphoproliferation against Dpt significantly decreased while IL-10 levels, specific IgG and total IgE increased. Blood eosinophils, specific IgE, others immunoglobulins levels and nitric oxide in exhaled air didn\'t change. There were no differences in all parameters evaluated between the two groups except on specific lymphoproliferation against PPD that was higher in Group B. Conclusions: improvement in symptoms and immunologicals changes where observed at the end of SIT induction period. BCG as adjuvant didn\'t add additional benefits.

O aumento da prevalência de doenças alérgicas como a asma, tem sido atribuído à falta de estímulos infecciosos. A atopia, que embasa as manifestações alérgicas, caracteriza-se por uma disfunção imune com predomínio da resposta do tipo Th2. Experimentos em modelos animais com micobactérias e seus produtos têm demonstrado resultados promissores na proteção e reversão de resposta imune do tipo Th2. A imunoterapia para alérgenos inalatórios tem mostrado resultados positivos e o uso do BCG como adjuvante poderia trazer benefícios adicionais. Em estudo randomizado duplo cego foram avaliados 21 indivíduos de ambos os sexos, com idades de 8 a 17 anos sensibilizados ao Dermatophagoides pteronissynus (Dpt) e portadores de asma leve ou moderada persistentes. Os pacientes foram divididos em dois grupos e tratados com imunoterapia específica (ITE) para Dpt. O Grupo A recebeu como adjuvante, no início da ITE, uma aplicação do diluente do BCG e o Grupo B uma dose da vacina BCG. Na avaliação realizada após o período de indução da ITE constatou-se nos dois grupos diminuição significativa dos sintomas, da necessidade de medicação para asma, da hiperreatividade brônquica inespecífica, da reatividade cutânea ao Dpt juntamente com a melhora da função pulmonar. Houve uma redução no índice de estimulação da cultura de células mononucleares do sangue periférico estimuladas com Dpt, acompanhada de uma elevação da IL-10 no sobrenadante e dos níveis da IgG específica para Dpt e da IgE total. Os eosinófilos, a IgE específica para Dpt do sangue e o óxido nítrico no ar exalado não se alteraram. Não houve diferença na comparação dentre os grupos, exceto na proliferação das células mononucleares do sangue periférico estimuladas com PPD, que foi maior no Grupo B. Conclusão: a ITE levou a resultados satisfatórios com melhora clínica e alterações imunológicas já ao final do período de indução. A avaliação do uso do BCG como adjuvante, não mostrou benefícios adicionais. / The increase of allergic diseases, such as asthma, has often been explained by a decline in infectious stimulation. Atopy that is characterized as an immune dysfunction promotes a strong type Th2 immune response and underlines allergic diseases. Experimental animal models researches with mycobacteria and its products had led to promising results in prevention or reversion of type Th2 response. Positive results have been obtained to allergens specific immunotherapy (SIT) and its association with BCG vaccine, as an adjuvant, could promote additional benefits. In a randomized double blind study 21 patients sensitized to mite Dermatophagoides pteronyssinus (Dpt) with mild or moderate persistent asthma, aged 8 to 17 years of both sex were evaluated. Patients were divided in two groups. Group A received at the beginning of SIT one dose of BCG diluent and Group B one dose of BCG vaccine. After the SIT induction period we observed in both groups a significant decrease in asthma symptoms, bronchial hyperreactivity, immediate cutaneous reactivity to Dpt and the necessity of drugs intake. Specific lymphoproliferation against Dpt significantly decreased while IL-10 levels, specific IgG and total IgE increased. Blood eosinophils, specific IgE, others immunoglobulins levels and nitric oxide in exhaled air didn\'t change. There were no differences in all parameters evaluated between the two groups except on specific lymphoproliferation against PPD that was higher in Group B. Conclusions: improvement in symptoms and immunologicals changes where observed at the end of SIT induction period. BCG as adjuvant didn\'t add additional benefits.