Moacyr Roberto Cuce Nobre

The PICO strategy for the research question construction and evidence search

Evidence based practice is the use of the best scientific evidence to support the clinical decision making. The identification of the best evidence requires the construction of an appropriate research question and review of the literature. This article describes the use of the PICO strategy for the construction of the research question and bibliographical search.Evidence based practice is the use of the best scientific evidence to support the clinical decision making. The identification of the best evidence requires the construction of an appropriate research question and review of the literature. This article describes the use of the PICO strategy for the construction of the research question and bibliographical search.Pratica baseada em evidencias e a utilizacao da melhor evidencia cientifica para subsidiar a tomada de decisao clinica. Identificar a melhor evidencia requer adequada construcao da pergunta de pesquisa e de revisao da literatura e este artigo descreve o uso da estrategia PICO para a construcao da pergunta de pesquisa e busca bibliografica.

Effectiveness of school-based nutrition education interventions to prevent and reduce excessive weight gain in children and adolescents: a systematic review.

OBJECTIVE To evaluate the effectiveness of school-based nutrition education in reducing or preventing overweight and obesity in children and adolescents. SOURCES Systematic search in 14 databases and five systematic reviews for randomized controlled trials conducted in schools to reduce or prevent overweight in children and adolescents. Body mass index and fruit and vegetable intake were used as primary and secondary measures of outcome, respectively. There was no restriction by date of publication or language, except for languages with structured logograms. We excluded studies on specific populations presenting eating disorders, dyslipidemia, diabetes, and physical or mental disabilities, as well as studies that used drugs or food supplements as components of the intervention. The assessment by title and abstract and the quality assessment were performed independently by two researchers. We used the Centre for Reviews and Disseminations guidance for undertaking reviews in health care and the software EPPI-Reviewer 3. SUMMARY OF THE FINDINGS From the initially retrieved 4,809 references, 24 articles met the inclusion criteria. The extracted data show that there is evidence of positive effects on anthropometry and of increase in fruit and vegetable consumption. Characteristics of the interventions that demonstrated effectiveness are: duration > 1 year, introduction into the regular activities of the school, parental involvement, introduction of nutrition education into the regular curriculum, and provision of fruits and vegetables by school food services. CONCLUSION Interventions in schools to reduce overweight and obesity, as well as to increase fruits and vegetable consumption, have demonstrated effectiveness in the best-conducted studies.

A estratégia PICO para a construção da pergunta de pesquisa e busca de evidências

Evidence based practice is the use of the best scientific evidence to support the clinical decision making. The identification of the best evidence requires the construction of an appropriate research question and review of the literature. This article describes the use of the PICO strategy for the construction of the research question and bibliographical search.Evidence based practice is the use of the best scientific evidence to support the clinical decision making. The identification of the best evidence requires the construction of an appropriate research question and review of the literature. This article describes the use of the PICO strategy for the construction of the research question and bibliographical search.Pratica baseada em evidencias e a utilizacao da melhor evidencia cientifica para subsidiar a tomada de decisao clinica. Identificar a melhor evidencia requer adequada construcao da pergunta de pesquisa e de revisao da literatura e este artigo descreve o uso da estrategia PICO para a construcao da pergunta de pesquisa e busca bibliografica.

Prevalências de sobrepeso, obesidade e hábitos de vida associados ao risco cardiovascular em alunos do ensino fundamental

BACKGROUND: To study the prevalence of cardiovascular risk associated to the lifestyle of school children from the 5th to 8th grade, in public and private schools. METHODS: Eighty seven randomly selected school rooms were visited adding up to 2,125 students who completed the questionnaire and whose body mass index was calculated. This sample represents around 2% of students from two school districts in the city of Sao Paulo. RESULTS: Of the 2,125 students, 24% were overweight or obese, 53.3% presented inappropriate food habits, 15.4% were sedentary, 62.6% drank alcohol, and 23.1% smoked. Between the 5th and 8th grade, the number of students who drank alcohol doubled and the number of male and female adolescents who tried out smoking increased 3-fold and 5-fold, respectively. Conversely, inappropriate food habits decreased. This situation is found in 40% of students from public schools and in 58% of those in private schools, by the time they reach the 8th grade. Overweight and obesity are more prevalent in private schools and the reduction noted as grades progress did not reach a significance level. Sedentarism is more prevalent in public schools. In private ones, sedentarism is lower among older students, contrary to public schools, where it increases with age. Female adolescents attend fewer physical education classes. Inappropriate food habits were characterized by the habits of adding more salt to pre-prepared food, lower intake of dairy products, fruit and vegetables also a higher intake of soft drinks, butter and snacks. CONCLUSION: Early detection of these cardiovascular risks associated to the lifestyle of these school children endorses the preventive practice of providing health education in schools.

The effect of participation in school-based nutrition education interventions on body mass index: a meta-analysis of randomized controlled community trials

OBJECTIVE The aim of this study was to evaluate the effectiveness of school-based nutrition education interventions in reducing or preventing overweight and obesity among children and adolescents. METHODS We conducted a systematic search of 14 databases until May 2010 and cross-reference check in 8 systematic reviews (SRs) for studies published that described randomized controlled trials conducted in schools to reduce or prevent overweight in children and adolescents. An additional search was carried out using PubMed for papers published through May 2012, and no further papers were identified. Body mass index (BMI) was the primary outcome. The title and abstract review and the quality assessment were performed independently by two researchers. The software EPPI-Reviewer3 was used to store, manage and analyze all data. This SR is registered at ClinicalTrials.gov (NCT00985972). RESULTS From the 4888 references initially retrieved, only 8 met the eligibility criteria for a random-effects meta-analysis. The total population consisted of 8722 children and adolescents. Across the studies, there was an average treatment effect of -0.33 kg/m(2) (-0.55, -0.11 95% CI) on BMI, with 84% of this effect explained by the highest quality studies. CONCLUSION This systematic review provides evidence that school-based nutrition education interventions are effective in reducing the BMI of children and adolescents.

A prática clínica baseada em evidências. Parte I: questões clínicas bem construídas

Clinical decisions in daily practice, to resolve patients problem, are usually based at the conscious use of the available information, through explicit determined rules. Evidence based clinical practice recognize the explicit and tacit knowledge, understanding that it is impossible all the aspects of professional competence become explicit. The doubt becomes part of the decision process, identifying initially the unconscious component involved and after the explicit knowledge used. When we make a structured clinical question with a possible answer, it is necessary to remember that the doubt can be related to basics and of definition aspects of the disease or related to the patients manager, like diagnose, treatment and prognosis. Along our medical life, both types of question are present, with proportional change as the experience increase along the clinical practice. The process to find an appropriate answer to the doubt, came out at patients care, depends on how the parts of this process will be structured. The recommended form is known by PICO abbreviation, that means: P: patient or population, I: intervention or indicator, C: comparison or control and O: outcome, or the answer expected found at the scientific information bases. This is the first basic need to a successful search, and the second need is to find the key words that better describe each of the four components of the questions. Without this caution, the search at compute databases results in absence of information or in a lot of information that it is not related to our interest.

The effect of school-based physical activity interventions on body mass index: a meta-analysis of randomized trials

This study reviewed the effectiveness of school-based physical activity interventions aimed at reducing overweight, obesity and hypertension in children. We searched 14 databases and analyzed studies published between April 2009 and September 2012. Only randomized controlled trials performed at the school level that included elements of physical activity but did not include nutritional co-interventions were analyzed. Studies were assessed by two recommended tools (EPHPP and GRADE), and the standardized mean differences with 95% confidence intervals were collected for a random-effect meta-analysis. A total of 12 papers were included in the meta-analysis, and these were divided according to three outcomes: body mass index (11 trials, n  =  4,273, −0.02, 95% CI: −0.13 to 0.17, p  =  0.8); body weight (5 trials, n  =  1,330, −0.07, 95% CI: −0.18 to 0.04, p  =  0.2); and blood pressure (6 trials, n  =  1,549), including systolic (0.11, 95% CI: −0.10 to 0.31, p  =  0.3) and diastolic pressure (−0.00, 95% CI: −0.10 to 0.10, p  =  0.9). This meta-analysis of data from 11 randomized, school-based physical activity interventions suggests that, regardless of the potential benefits of physical activity in the school environment, the interventions did not have a statistically significant effect. However, it is difficult to generalize from these results because the duration, intensity and type of physical activity used in the interventions varied greatly.

Controle de diabetes Mellitus e hipertensão arterial com grupos de intervenção educacional e terapêutica em seguimento ambulatorial de uma Unidade Básica de Saúde

A educacao em saude, associada ao autocontrole dos niveis de pressao e/ou glicemia, a atividade fisica e a dieta alimentar, e importante instrumento para aumentar a procura por tratamento e controlar os indices de pacientes hipertensos e/ou diabeticos,. O conhecimento das doencas esta relacionado a melhora da qualidade de vida, a reducao do numero de descompensacoes, ao menor numero de internacoes hospitalares e a maior aceitacao da doenca. Na Unidade Basica de Saude Vila Romana, Sao Paulo, foi proposta intervencao em uma populacao de pacientes diabeticos e hipertensos por meio de formacao de grupos para acao educativa, seguimento regular, fornecimento de medicacao, controles periodicos e atendimento de intercorrencias. Nos primeiros 3 meses, ocorreram encontros mensais, seguidos de consultas periodicas, controle das doencas e dispensacao da medicacao por mais 27 meses. Com os 191 pacientes, foram formados grupos de hipertensos e grupos de diabeticos hipertensos. Comparando-se os resultados iniciais com os pos-intervencao, observou-se reducao relativa de 42% e absoluta de 26% no numero de pacientes com pressao moderada e grave. Para os diabeticos, a reducao absoluta foi de 22%, para aqueles com glicemia superior a 200mg/dl, e aumento de 33%, para aqueles com niveis inferiores a 125mg/dl. Para pacientes dependentes do sistema oficial de saude e do fornecimento da medicacao, em grande parte idosos e pessoas com baixa escolaridade, embora nao se tenha obtido no estudo o controle de todos os determinantes de adesao e o controle das doencas, a intervencao se mostrou eficiente. Sugere-se que seja institucionalizada.

A Systematic Review of Topical Treatments to Control the Odor of Malignant Fungating Wounds

CONTEXT Malignant fungating wounds (MFW) result from cutaneous infiltration by carcinogenic cells. Fetid odor, profuse exudate, pain, and infection are common symptoms that add to the physical and psychological suffering of patients with MFW. The topical treatment of MFW remains controversial. OBJECTIVES To collect evidence about topical treatments to control the odor of MFW. METHODS Fourteen sources of data were used, without restriction in terms of language, period, or study design. The patient, intervention, comparison, and outcome strategy for the development of research questions yielded 334 descriptors related to oncology, MFW, topical treatments, medications, and symptoms of these lesions. Data from the abstracts of these articles were extracted by two independent researchers and decisions were reached by consensus among them. Through an analysis of these abstracts, studies that broached the topic of MFW odor were selected. These studies were analyzed in their entirety and were classified according to quality, levels of evidence, and grade of recommendation. RESULTS Of 11,111 studies identified, 325 (2.93%) made reference to the control of some symptoms of MFW by means of topical interventions: 12.4% related to odor, 16.8% to exudate, 17.8% to bleeding, 31.0% to pain, and 22.0% to MFW-related infection. Within the 59 studies that analyzed odor control, seven were clinical trials (35%), five were case series (25%), and eight (40%) were case studies. Eleven topical treatments were identified. Topical metronidazole and Mesalt dressing yielded 2b level of evidence or B grade of recommendation. Activated carbon dressing and curcumin ointment yielded 2c level of evidence or B grade of recommendation. C and D grades of recommendation were observed for seven topical treatments: topical arsenic trioxide, essential oils, green tea extract, hydropolymer dressings, antiseptic solutions, hydrogels, and debridement enzymes. The variety of interventions and of the methodological quality of the studies did not allow for meta-analysis. CONCLUSION Of the 59 studies of odor, 20 fulfilled all the criteria for inclusion. Few studies of high quality were found, and the principal methodological flaws were the design of the studies, the sample size, and the absence of scales to measure odor. Grade B evidence for the treatment of MFW was found with topical metronidazole, Mesalt dressing, activated carbon dressing, and curcumin ointment.

A prática clínica baseada em evidências: Parte III Avaliação crítica das informações de pesquisas clínicas

Evidence based health care begins with a clinical question and the search on data bases to retrieve the relevant information, that was the issue of two preceding articles of this series. At present it will be discussed how to critically appraise the medical literature using the clinical epidemiological methodology. Clinical research aims to develop diagnostic and therapeutic procedures measuring association and causality between the exposure and outcome. In this case the exposures are signs, symptoms, laboratorial or image exam, and therapy intervention. It is a mistake to take surrogate end-points instead of clinical outcomes. The main types of clinical study design are diagnostic, prognostic, therapeutic and harm/etiology. Experimental, physiologic and animal studies are useful for the medical undergraduate education, but do not contribute with clinical decisions. The study designs are classified according with the presence of a control group, patients follow-up, and therapy interventions. The evidence hierarchy was done by the previous characteristics and the presence of systematic bias. Systematic reviews are stronger than the primary observational studies and are on the top when they revised randomized clinical trial. Since 1998 the proportion of evidence based practice guidelines was increasing compared with systematic reviews or other types of practice guidelines, although the former still are in a few numbers. The article critical appraisal must answer the clinical question, and need to have consistent study design and bias under control. In conclusion we ought to offer methodological actualization to interested physicians and put the information already critically assessed on evidence-based practice guidelines.