Apuntes sobre ciencia de frontera: ¿investigar en los bordes?

El presente artículo tiene como objetivo valorar la necesidad de acercarse al conocimiento de la ciencia de frontera, como alternativa de búsqueda transformadora para los complejos problemas actuales. La reflexión realizada se centra en el referente de la complejidad, con el abordaje de pensadores que, a modo de confluencias y disentimientos, se articulan en la toma de conciencia sobre el desplazamiento de la enunciación, en el plano metodológico de la ciencia actual. Se brindan reflexiones sobre aportes y limitaciones de la ciencia moderna, los nuevos escenarios de debate epistemológico que se abren a nivel internacional, a partir de urgencias de un mundo colapsado, inmerso en la cuarta revolución tecnológica, pero incapaz de solucionar las necesidades más perentorias de la vida.

The objective of this article is to assess the need to approach the knowledge of frontier science, as a transformative search alternative for today's complex problems. The reflection carried out focuses on the referent of complexity, with the approach of thinkers who, as confluences and dissents, are articulated in the awareness of the displacement of the enunciation, in the methodological field of current science. Reflections are offered on the contributions and limitations of modern science, the new scenarios of epistemological debate that are opening at the international level, from the urgencies of a collapsed world, immersed in the fourth technological revolution, but unable to solve the most urgent needs of life.

Teoría de la complejidad en la atención del paciente con dolor musculoesquelético / Complexity theory in the management of patients with musculoskeletal pain

Los sistemas no lineales no son susceptibles de ser investigados con métodos reduccionistas. En este sentido, la teoría de la complejidad ofrece un enfoque alternativo para cuantificar la importancia de los factores contextuales en el paciente con dolor musculoesquelético. El resultado del uso positivo (placebo) o negativo (nocebo) de factores contextuales en el entorno terapéutico, podría ser responsable de gran parte de un componente inespecífico en la eficacia del tratamiento, afectando directamente la calidad de los resultados relacionados con la salud del paciente (por ejemplo, dolor, funcionalidad o satisfacción). En los últimos años, se ha incrementado la comprensión del valor de estos efectos. A pesar del creciente interés, el conocimiento y el reconocimiento de los efectos terapéuticos, continúan siendo limitados y heterogéneos entre los fisioterapeutas, lo cual reduce su valor traslacional en el campo de la fisioterapia. El propósito de este estudio es presentar el abordaje el paciente con dolor musculoesquelético desde la perspectiva la teoría de la complejidad.

Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients' health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy. The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.

Una mirada histórico-geográfica de las pandemias: para entender de manera compleja la COVID-19 / A Historical-Geographical View of Pandemics: to Understand COVID-19 in a Complex Way

RESUMEN El abordaje para la investigación de brotes/pandemias es una actividad desafiante, necesaria y retadora para los salubristas y epidemiólogos. Esta actuación permite que los servicios de epidemiología y de vigilancia profundicen el conocimiento de la enfermedad, recaben datos históricos de episodios pandémicos, caractericen vulnerables, planteen hipótesis e intervengan los factores de riesgos en un contexto ambiental y sociocultural determinado con una actuación local y una perspectiva global. Se considera un abordaje sindémico, de tal manera que conjugan aspectos de determinantes sociales interconectados y profundizando en la pandemia.

ABSTRACT The outbreak/pandemic investigation approach is a challenging, necessary and challenging activity for health professionals and epidemiologists. This approach allows epidemiology and surveillance services to deepen their knowledge of the disease, collect historical data on pandemic episodes, characterize vulnerabilities, develop hypotheses and intervene risk factors in a given environmental and sociocultural context with local action and a global perspective. A syndemic approach is considered, in such such a way that it combines aspects of interconnected social determinants and deepening in the pandemic.

Complexidade do sistema sociotécnico hospitalar e o ambiente de prática profissional do enfermeiro: implicações para a qualidade do cuidado e segurança do paciente / Complexity of the socio-technical hospital system and the professional nursing practice environment: implications for the quality of care and patient safety

Introdução: as atividades assistenciais têm envolvido, cada vez mais, uma ampla gama de pessoas, processos, tecnologias e dispositivos, de forma que o dinamismo das inúmeras e diversas interações ocasiona circunstâncias nem sempre previsíveis, caracterizando um sistema sociotécnico complexo. Nesse contexto, percebe-se que os aspectos que remetem à qualidade do cuidado e segurança do paciente estão atrelados à complexidade do sistema e ao ambiente de prática profissional, definido pelas características organizacionais que facilitam ou dificultam o desenvolvimento das ações de cuidado. A aproximação dos construtos sobre a complexidade nos sistemas de saúde e o ambiente de prática da enfermagem possibilita a reflexão e o aprofundamento acerca do trabalho de enfermagem, oportunizando melhores resultados aos pacientes. Desta forma, surgem as seguintes questões de pesquisa que embasaram a presente investigação: como os enfermeiros percebem o ambiente de prática profissional e a complexidade do trabalho em suas áreas de atuação? Qual a influência das características e elementos percebidos para a qualidade do cuidado e segurança do paciente? Objetivo geral: para tal, objetivou-se analisar a complexidade do ambiente de prática profissional do enfermeiro, em unidades de internação clínica e cirúrgica, emergência e terapia intensiva de pacientes adultos, bem como as implicações para a qualidade do cuidado e segurança do paciente. Método: o estudo, delineado como método misto do tipo explanatório sequencial, ocorreu em um hospital universitário, acreditado e de grande porte da região sul do Brasil. A população compreendeu todos os enfermeiros das unidades de internação clínico-cirúrgica, emergência e terapia intensiva de pacientes adultos. Na etapa quantitativa a amostra, aleatória e estratificada, abrangeu 132 enfermeiros com vínculo empregatício ativo na instituição e no setor atual por um período igual ou superior a 90 dias. A coleta de dados transcorreu entre novembro de 2018 e abril de 2019, empregando-se o instrumento de caracterização demográfica e profissional com mensuração da qualidade do cuidado e segurança do paciente, a escala Practice Environment Scale versão brasileira e o questionário de caracterização da complexidade. A análise dos dados foi realizada utilizandose o software Statistical Package for Social Science 18.0. A etapa qualitativa contemplou 18 enfermeiros interessados em discutir a temática e com participação prévia na primeira fase da pesquisa. As entrevistas semiestruturadas ocorreram entre setembro e dezembro de 2019, subsidiadas pelos resultados preliminares da análise quantitativa. Os relatos foram organizados no software NVivo 11 e submetidos à análise temática de conteúdo. O estudo foi aprovado nas instâncias éticas pertinentes, apresentando Certificado de Apresentação de Apreciação Ética número 99441118.8.0000.5327 na Plataforma Brasil. O Termo de Consentimento Livre e Esclarecido foi aplicado aos participantes em todas as etapas previstas no estudo. Resultados: quanto à caracterização demográfica e profissional houve o predomínio do sexo feminino 116 (87,9%), titulação de especialista 88 (66,7%), média de idade 41,6 ± 8,2 anos e tempo de vínculo institucional mediana de 8,1 anos (0,8-38,5). O ambiente de prática profissional revelou-se favorável sendo que, de maneira geral, a terapia intensiva apresentou os melhores escores nas subescalas. A emergência apresentou médias mais baixas, em especial na subescala "Adequação da equipe e de recursos", avaliada como desfavorável neste setor (1,88 ± 0,61). No que tange o número de pacientes atribuídos aos profissionais no último plantão e a percepção sobre a qualidade do cuidado e segurança do paciente houveram variações entre as áreas, pressupondo-se que mais pacientes atribuídos por profissional influencia na qualidade do cuidado ofertado e ocasiona riscos que comprometem a assistência. Quanto aos atributos de complexidade, os enfermeiros identificaram no ambiente de prática profissional a presença de características referentes ao "Grande número de elementos que interagem dinamicamente", "Grande diversidade de elementos" e "Resiliência". Em contrapartida, os aspectos relacionados à "Variabilidade inesperada" se mostraram pouco presentes, ainda que tenha sido o único atributo que demonstrou diferença estatisticamente significativa entre as áreas em estudo. Ao relacionar a Practice Environment Scale versão brasileira e o questionário de caracterização da complexidade evidenciou-se correlação moderada e inversa, estatisticamente significativa, entre todas as subescalas e o atributo "Variabilidade inesperada", expressando que um ambiente fortalecido organizacionalmente pode minimizar os efeitos da variabilidade. A partir dos discursos dos participantes emergiram três categorias: "Um ambiente onde o humano e o técnico se complementam, "O olhar dos enfermeiros para a complexidade" e "Qualidade do cuidado e segurança do paciente em um ambiente complexo". Considerações finais: o referencial teórico da complexidade auxiliou na explicitação de fatores contextuais dos ambientes de prática estudados, possibilitando comparações e a identificação de características que minimizam a variabilidade dos processos, mantendo o sistema mais estável e, consequentemente, fortalecendo a qualidade do cuidado e segurança do paciente.

Introduction: assistance-related activities have increasingly involved a wide range of people, processes, technologies and devices, so that the dynamism of the countless and various interactions generates circumstances that are not always foreseeable, characterizing a complex socio-technical system. In this context, it is noticed that the aspects referring to care quality and patient safety are linked to the complexity of the system and to the professional practice environment, defined by the organizational characteristics that facilitate or hinder development of the care actions. Approximation of the constructs on the complexity of health systems and the Nursing practice environment enables reflection and deepening about the Nursing work, providing better results for the patients. Consequently, the following research questions emerge, which were the basis for this survey: How do nurses perceive the professional practice environment and the complexity of work in their areas of performance? Which is the influence of the perceived characteristics and elements on care quality and patient safety? General objective: to this end, the objective was to analyze the complexity of the nurses' professional practice environment in clinical and surgical hospitalization units, in emergency services and in intensive care units for adult patients, as well as the implications for care quality and patient safety. Method: designed as a mixed method of the sequential explanatory type, the study took place in a large accredited university hospital in the Brazilian South region. The population comprised all the nurses from the clinical-surgical hospitalization units, emergency services and intensive care units for adult patients. In the quantitative stage, the random and stratified sample comprised 132 nurses with active employment contracts in the institution and in the current sector, for a minimum period of 90 days. Data collection took place between November 2018 and April 2019, employing the demographic and professional characterization instrument with assessment of care quality and patient safety, the Brazilian version of the Practice Environment Scale and the questionnaire to characterize complexity. Data analysis was performed using the Statistical Package for Social Science software, version 18.0. The qualitative stage included 18 nurses interested in discussing the theme, and with prior participation in the first phase of the research. The semistructured interviews took place between September and December 2019, supported by the preliminary results of the quantitative analysis. The reports were organized in the NVivo 11 software and submitted to thematic content analysis. The study was approved by the relevant ethical bodies, presenting Certificate of Presentation for Ethical Appreciation number 99441118.8.0000.5327 in Plataforma Brasil. The Free and Informed Consent Form was applied to the participants in all the foreseen stages of the study. Results: regarding the demographic and professional characterization, there was predominance of the female gender (116; 87.9%), specialist qualification (88; 66.7%), mean age of 41.6 ± 8.2 years old and median time of institutional employment contract of 8.1 years (0.8-38.5). The professional practice environment proved to be favorable, with intensive care presenting the best scores in the subscales in general. Emergency presented lower mean values, especially in the "Staffing and Resources Adequacy" subscale, assessed as unfavorable in this sector (1.88 ± 0.61). Regarding the number of patients assigned to the professionals in the last shift and the perception about care quality and patient safety, there were variations across the areas, assuming that more patients assigned per professional exerts an influence on the quality of the care offered and generates risks that compromise assistance. As for the complexity attributes, the nurses identified in the practice environment the presence of characteristics referring to the "Important number of elements that interact dynamically", "Great diversity of elements" and "Resilience". On the other hand, the aspects related to "Unexpected variability" showed little presence, even though it was the only attribute that presented a statistically significant difference across the areas under study. When relating the Brazilian version of the Practice Environment Scale and the questionnaire to characterize complexity, a statistically significant, moderate and inverse correlation was evidenced between all the subscales and the "Unexpected variability" attribute, expressing that an organizationally strengthened environment minimizes the effects of variability. Three categories emerged from the participants' speeches, namely: "An environment where the human and the technical complement each other", "Nurses' perspective on complexity" and "Care quality and patient safety in a complex environment". Final considerations: the theoretical framework of complexity helped to clarify contextual factors of the practice environments under study, enabling comparisons and the identification of characteristics that minimize variability in the processes, keeping the system more stable and, consequently, strengthening care quality and patient safety.

Small-Sided Games as Holons in the Football: a hierarchical systems approach / Jogos Reduzidos como Hólons no Futebol: uma abordagem sistêmica hierárquica

abstract Sports science has showed benefits in the use of small-sided games in the teaching-learning and training processes of football. We propose that such benefits occur because the small-sided games are holons of a hierarchically organized that maintain the same characteristics of game, regardless the reduced complexity. The hierarchical model of football considers the numerical relations of cooperation and opposition in specific spaces of play. It characterizes a nested hierarchy model because it deals with both the parts and the different processes of game. Such a hierarchical model contains five levels, in which the upper level is the football game and the elementary level a game situation, that is, a small-sided game. As any open system of hierarchical organization, the small-sided games present simultaneously invariant characteristics of whole and the specificities of the parts according the context and level of analysis. The adoption of such a hierarchical perspective allows setting goals as well as selecting the teaching-learning and training's contents at different analysis levels by considering the autonomy-dependency in each one.

resumo A ciência do esporte traz benefícios na utilização de jogos reduzidos nos processos de ensino-aprendizagem e treinamento do futebol. Nós propomos que tais benefícios ocorrem porque os jogos reduzidos são hólons de um sistema organizado hierarquicamente que mantém as características do jogo, apesar da complexidade reduzida. O modelo hierárquico do jogo de futebol considera as interações de cooperação e oposição entre os jogadores em um espaço específico de jogo. O modelo é caracterizado como uma hierarquia aninhada porque leva em consideração as diferentes partes e processos do jogo. O modelo possui cinco níveis hierárquicos, em que no nível superior se encontra o jogo de futebol como todo e no nível elementar se encontram situações de jogo, que caracterizam os jogos reduzidos enquanto intervenção. Como qualquer sistema aberto organizado hierarquicamente, os jogos reduzidos apresentam simultaneamente as características invariáveis ​​do todo e as especificidades das partes de acordo com o contexto e nível de análise. A adoção dessa perspectiva hierárquica permite definir objetivos, bem como selecionar conteúdos no ensino-aprendizagem e treinamento do futebol em diferentes níveis de análise, mantendo a autonomia-dependência de cada um.

Impactos do avanço da pandemia de COVID-19 na saúde mental de profissionais de saúde / Impacts of COVID-19 pandemic advancement on healthcare workers mental health / Impactos del avance de la pandemia COVID-19 en la salud mental de los profesionales sanitarios

O estudo verificou a associação e a influência entre variáveis sociodemográficas, laborais, impactos da pandemia (desesperança, contaminação, óbito na família), traços de personalidade e de saúde mental em profissionais de saúde brasileiros em dois tempos distintos da pandemia de COVID-19. Foram incluídos 155 profissionais que responderam um questionário online. Foi utilizado o modelo de redes para a análise dos dados. Os sintomas de depressão, ansiedade e estresse foram os mais influentes no modelo testado e apresentaram associações com a desesperança nos dois tempos. No tempo 1, o estigma foi uma das variáveis mais influentes. No tempo 2, o estigma e a ansiedade reduziram sua influência, enquanto o estresse e a desesperança tornaram-se mais influentes. Os alvos das intervenções para os profissionais de saúde podem ser diferenciados no início e no avanço do contexto pandêmico, mas cabe contínua focalização do estresse e da desesperança

The study verified the association and influence between sociodemographic and labor variables, pandemic impacts (hopelessness, contamination, death in the family), personality and mental health traits in Brazilian health professionals at two different times of the COVID-19 pandemic. There were 155 professionals included who replied to an online questionnaire. The network model was used for data analysis. Symptoms of depression, anxiety, and stress were the most influential variables in the model tested and showed connections with hopelessness at both times. At time 1, stigma was one of the most influential variables. At time 2, stigma and anxiety reduced their influence, while stress and hopelessness became more prominent. The targets of interventions for health professionals can be differentiated in relation to the onset and progression of the pandemic context, but with a continuous focus on the level of stress and hopelessness for intervention

El estudio verificó la asociación e influencia entre variables sociodemográficas y laborales, impactos de la pandemia (desesperanza, contaminación, muerte en la familia), rasgos de personalidad y salud mental en trabajadores sanitarios brasileños en dos momentos de la pandemia del COVID-19. Se incluyeron 155 profesionales que respondieron a un cuestionario en línea. Se utilizó el modelo de red para el análisis. Los síntomas de depresión, ansiedad y estrés fueron las variables más influyentes y mostraron conexiones con la desesperanza en ambos momentos. En el momento 1, el estigma fue una de las variables más influyentes. En el momento 2, el estigma y la ansiedad redujeron su influencia y el estrés y la desesperanza se hicieron más prominentes. Los objetivos de las intervenciones para los trabajadores sanitarios se pueden diferenciar en el inicio y en el avance de la pandemia, pero es necesario un enfoque continuo en el estrés y desesperanza

Modelos evaluativos para intervenciones complejas en salud / Evaluative models for complex health interventions

RESUMEN Este artículo presenta los modelos evaluativos para intervenciones complejas en salud. Dichas intervenciones se caracterizan por ser dinámicas, altamente influenciadas por el contexto (político, social, económico y cultural), y cuentan con múltiples actores y multicomponentes. Las intervenciones complejas en salud se ejecutan simultáneamente con otras intervenciones de otros sectores; requieren tiempo para mostrar resultados y a veces es difícil estimar su contribución social e individual a la población blanco. Este artículo pretende identificar los modelos evaluativos propuestos para intervenciones complejas en salud con sus respectivas características, a fin de tener referentes teóricos para evaluaciones de programas de esta naturaleza. Por mucho tiempo las intervenciones en salud y su evaluación se entendieron de manera lineal; sin embargo, bajo la perspectiva teórica de la complejidad (en la que se integran múltiples dimensiones del fenómeno), el contexto tiene un papel central. Esto permite entender que las intervenciones no tienen el mismo resultado en diferentes espacios y que esta forma de evaluación permite dar cuenta de ello.

ABSTRACT This paper presents evaluative models for complex health interventions. The complex health interventions are characterized by being dynamic, highly influenced by the con-text (political, social, economic, and cultural), which have multiple actors, multicomponent. Furthermore, they are executed simultaneously with other interventions from other sectors, they require time to show results and sometimes it is difficult to estimate the contribution to the social and individual impact of the target population. This paper aims to identify the proposed evaluative models for complex health interventions with their respective characteristics, to have theoretical references for evaluations of pro-grams of this nature. For a long time, health interventions and their evaluation were understood in a linear manner, however, under the theoretical perspective of the complexity (in which multiple dimensions of the phenomenon are integrated), the context plays a central role, making it possible to understand that interventions do not have the same result in different spaces and that this form of evaluation allows to account for it.

La pandemia de COVID 19 y sus implicaciones en la concepción, diseño e instrumentación didáctica de la educación médica superior cubana / COVID 19 pandemic and its implications in the conception, design and didactic implementation of Cuban higher medical education

RESUMEN La actual pandemia de COVID 19 producida por el virus SARS-CoV2, dada su condición de proceso emergente, presenta una serie de características clínicas, evolutivas y epidemiológicas que permiten catalogarla como fenómeno complejo. Evidentemente dicha pandemia constituye un reto para las ciencias médicas en los aspectos atencionales, investigativos y de la educación médica. Para la actividad docente actual y futura, con vistas a su perfeccionamiento y sostenibilidad, nuestros directivos, profesores y tutores, en quienes descansa la dirección del aprendizaje de los estudiantes en nuestras universidades de ciencias médicas tanto en la formación inicial de pregrado como en las diferentes formas del posgrado, las conclusiones preliminares derivadas de la lectura crítica e inferencial de dicha pandemia exigen interpretaciones que deriven en concepciones, diseños curriculares, procesos docentes, trabajo metodológico, evaluaciones y actividad científica que contengan aquellas esencialidades que los autores catalogan como categorías primordiales y obligatorias que deben abarcar los diferentes procesos referidos de la educación médica superior cubana, objetivo pretendido de este trabajo. Mediante la utilización de diferentes métodos teóricos y empíricos, se desarrolla una sistematización que resume y explicita las categorías de problemas complejos, inter-transdisciplinariedad, teoría de sistemas, multimorbilidad, multireferencialidad, actividad científica desde la universidad, tecnologías de la información y la comunicación y sus necesarios abordajes en la concepción, diseño e instrumentación didáctica de la educación médica superior cubana, de interés para el perfeccionamiento de dichos procesos.

ABSTRACT Due to its emerging process status, the current COVID 19 pandemic caused by the SARS-CoV2 virus presents a series of clinical, evolutionary and epidemiological characteristics which allow it to be classified as a complex phenomenon. Obviously, this pandemic constitutes a challenge for medical sciences in assistance, research and medical education aspects. Preliminary conclusions derived from the critical and inferential reading of this pandemic require interpretations that derive in conceptions, curricular designs, teaching processes, methodological work, evaluations and scientific activity that contain those essentialities that the authors classify as essential and mandatory categories that must cover the different referred processes of Cuban higher medical education, the intended objective of this work. Through the use of different theoretical and empirical methods, a systematization is developed which summarizes and makes explicit the categories of complex problems, inter-transdisciplinarity, systems theory, multimorbidity, multireference, scientific activity from the university, information and communication technologies, and its necessary approaches in the conception, design and didactic instrumentation of Cuban higher medical education, of interest for the improvement of these processes.

System dynamics modeling for tooth decay treatment in Brazilian children

Abstract Prevention and health promotion are considered important strategies to control oral diseases. Dental caries is preventable disease and remains the most common chronic disease that affects mainly low income children and still considered the main cause of tooth loss in adulthood in Brazil. The aim of this study is to present a System Dynamics model (SDM) specifically developed with the Stella Architect software to estimate the cost and clinical hours required to control the evolution of dental caries in preschool children in Maringá, Brazil. Two main strategies to control caries were considered in the model: the application of fluoride varnish on teeth presenting white spots, and the use of Atraumatic Restorative Treatment (ART) in cavitated carious lesions without pulp involvement. The parameters used in the model were: number of people covered by a local oral health team = 4,000; number of children up to 5 years = 7% of the population; children's decayed, missing, filled teeth (dmft) index = 2.4; time/cost of 4 applications of fluoride varnish = 5 minutes/US$ 0.716; and time/cost of each ART restoration = 15 minutes/US$ 1.475. The SDM generated an estimated total cost of US$698.00, and a total of 112 clinical hours to treat the population in question. The use of the SDM presented here has the potential to assist decision making by measuring the material and human resources required to prevent and control dental caries at an early age.

Evaluation of a closed-loop intravenous total anesthesia delivery system with BIS monitoring compared to an open-loop target-controlled infusion (TCI) system: randomized controlled clinical trial / Evaluación de un sistema de administración de Anestesia Total Intravenosa en lazo cerrado con neuromonitoría, comparado con un sistema de lazo abierto de infusión controlada por objetivo (TCI): Ensayo clínico controlado

Abstract Introduction: Intravenous general anesthesia is an anesthetic technique that can be administered with TCI (target-controlled infusion) or closed-loop systems. The authors designed an automatic delivery system using clinical variables such as bispectral index (BIS), heart rate, and blood pressure. Objective: To evaluate the clinical and technical performance of this controller by comparing it to a TCI system. Methods: This was a single-blind, randomized, controlled clinical trial in which 150 patients were recruited: 75 for the TCI group and 75 for the closed loop with BIS. Clinical performance was determined according to the mean percentage of time spent in the BIS range of 40 to 60 during anesthetic maintenance. In addition, adequate intraoperative analgesia, technical performance, intraoperative awakening, and intraoperative recall were evaluated. Results: The primary outcome showed a mean BIS time between 40 and 60 for the closed loop of 75.24% (± 15.78) versus 59.5% (± 20.3) for the TCI system, with an absolute difference of 15.8%, 95% confidence interval (CI): 9.9 to 21.65, P < 0.0001. The mean time in intraoperative analgesia was 82.4% (25.1) in closed loop and 70.77% (± 32.8) in TCI, with a difference of 4.76 (95% CI: 2.23-21.06), P = 0.016. There was no difference in intraoperative recall. Conclusion: The closed-loop system was better at maintaining a BIS in the range of 40 to 60 during a general anesthetic than the open system or TCI.

Resumen Introducción: La anestesia total endovenosa es una técnica anestésica que puede administrarse con sistemas de TCI (Target Controlled Infusión) o de lazo cerrado. Los autores diseñaron un sistema de administración automática empleando variables clínicas como índice biespectral (BIS), frecuencia cardiaca y presión arterial. Objetivo: Evaluar el desempeño clínico y técnico de este controlador, comparándolo con un sistema de TCI. Métodos: Este fue un ensayo clínico controlado, aleatorizado y de ciego único, en el cual se reclutaron 150 pacientes: 75 en el grupo de TCI y 75 en lazo cerrado con BIS. El desempeño clínico fue determinado de acuerdo al porcentaje promedio de tiempo de permanencia en el rango de BIS entre 40-60 durante el mantenimiento anestésico. Adicionalmente se evaluó analgesia intraoperatoria adecuada, desempeño técnico, despertar intraoperatorio y recuerdo intraoperatorio. Resultados: Para el desenlace primario se encontró un tiempo promedio de BIS entre 40-60 para el lazo cerrado de un 75.24% (+/-15.78) vs. 59.5% (+/- 20.3) para el sistema TCI, con una diferencia del 15.8%, IC del 95%: 9.9 a 21.65, p < 0.0001. El promedio de tiempo en analgesia intraoperatoria adecuada fue del 82.4% (25.1) en lazo cerrado y 70.77% (+/- 32.8) en TCI, con una diferencia de 4.76 (IC del 95%: 2.23 a 21.06), p=0.016. No hubo diferencias en recuerdo intraoperatorio. Conclusión: El sistema de lazo cerrado fue mejor para mantener un BIS en rango de 40-60 durante un acto anestésico que el sistema abierto o TCI.

Evaluation of usability of a neonatal health information system according to the user's perception / Avaliação da usabilidade de um sistema de informação em saúde neonatal segundo a percepção do usuário

ABSTRACT Objective: To measure the level of satisfaction regarding the usability of a neonatal health information system and identify if demographic factors can influence the usability of a health information system. Methods: A cross-sectional, exploratory study was carried out with a convenience sample of 50 users of the Brazilian Neonatal Research Network. The instrument chosen for the usability evaluation was the System Usability Scale between February and March 2017. The statistical analysis of the collected variables was carried out in order to describe the sample, to quantify the level of satisfaction of the users and to identify the variables associated with the level of satisfaction. Results: The female gender represented 75% of the sample. The mean age was 52.8 years; 58% had a doctoral degree, average time of graduation was 17 years, with area of practice in medicine (neonatology), with intermediate knowledge in computer science (74%) and mean system use time of 52 months. Regarding usability, 94% rated the system as "good", "excellent" or "better than imaginable". The usability of the system was not associated with age, gender, education, profession, area of practice, knowledge in computer science and time of system use. Conclusion: The level of satisfaction of the computerized health system user was considered good. No demographic factors were associated with the satisfaction of the users.

RESUMO Objetivo: Mensurar o grau de satisfação de profissionais de saúde quanto à usabilidade de um sistema de informação em saúde neonatal e identificar os fatores que podem influenciar na satisfação do usuário frente à usabilidade. Métodos: Estudo transversal e exploratório realizado com 50 profissionais de saúde integrantes dos centros da Rede Brasileira de Pesquisas Neonatais. Para avaliação da usabilidade foi utilizado o instrumento System Usability Scale entre fevereiro e março de 2017. Realizou-se a análise estatística descritiva e inferencial das variáveis coletadas, com a finalidade de descrever a amostra, quantificar o grau de satisfação dos usuários e identificar as variáveis associadas ao grau de satisfação do usuário em relação à usabilidade. Resultados: Da população avaliada, 75% era do sexo feminino, com idade média 52,8 anos, 58% com pós-graduação (doutorado); tempo médio da última formação de 17 anos; área de atuação em medicina (neonatologia), grau intermediário de conhecimento em informática e tempo de utilização média do sistema de 52 meses. Quanto à usabilidade, 94% avaliaram o sistema como "bom", "excelente" ou "melhor impossível". A usabilidade do sistema não foi associada a idade, sexo, escolaridade, profissão, área de atuação, nível de conhecimento em informática e tempo de uso do sistema. Conclusões: O grau de satisfação do usuário do sistema informatizado de saúde foi considerado bom. Não foram identificados fatores demográficos que influenciassem sua avaliação.

Systematic review of clinical practice guidelines for kidney disease in China: application of the Appraisal of Guidelines Research and Evaluation-China / 中华肾脏病杂志

Objective@#To evaluate the quality of clinical practice guidelines for kidney diseases in China and provide reference for selecting suitable high-quality guidelines for primary care and developing standardized guidelines.@*Methods@#The China Guideline Clearinghouse, China Biology Medicine disc, VIP Database, Wanfang Database and CNKI, and other resources were searched from January 2013 to July 2018. In accordance with the criteria for inclusion and exclusion, the published guidelines for kidney diseases were screened. The Appraisal of Guidelines Research and Evaluation-China (AGREE-China) was used to systematically assess the current status of domestic guidelines for kidney diseases.@*Results@#A total of 18 guidelines for kidney diseases were included, covering different types of kidney disease such as glomerulonephritis, nephrotic syndrome, end-stage renal disease and other diseases. The overall score ranged from 30 to 68, with an average score of 47.3. The average scores of these guidelines were 20.1, 12.8, 0.5, 9.9 and 3.9 in five review fields including scientificity/rigorism, effectiveness/safety, economy, availability/feasibility, and conflicts of interest, respectively. Of these 18 guidelines, 8(44.4%) guidelines were strongly recommended, and 10(55.6%) guidelines were weakly recommended.@*Conclusions@#There are still deficiencies in scientificity/rigorism and economy in current guidelines for kidney diseases in China. The AGREE-China can be used as an evaluation tool for guidelines for kidney diseases in accordance with China's situation, while its practicability and feasibility still need further verification and improvement.

Effectiveness of exercise and nutrition interventions on older adults with frailty status / 中华老年医学杂志

Objective To synthesise evidences from randomised controlled trials (RCTs)to evaluate the effectiveness of exercise and nutrition interventions on functioning,muscle strength and body composition in older people with frailty.Methods A systematic review and meta analysis was performed.The electronic databases of Pubmed,Ovid,Web of Science EMBASE and Cochrane were consulted.We included RCT trials of exercise and nutrition interventions for older people with frailty identified through a validated frailty scale of Fried phenotype.The related articles were extracted and cross-checked independently by two reviewers.Methodological quality of trials was evaluated according to Cochrane Handbook criteria.Meta analysis was conducted using RevMan software.The outcomes of performance-based physical function such as gait speed,timed up and go(TUG),muscle strength(knee extension strength or leg extension strength)and body lean mass,fat mass,appendicular lean mass (ALM)were assessed.Results We included 13 articles reporting on 9 trials of exercise interventions (total n=1 034 participants)and included 5 trials of nutrition interventions(n=423 participants).Overall,exercise interventions had a significant beneficial effect on knee extension strength post-intervention compared to usual care control[standardised mean differences (SMD) =1.20,95 ％ CI:0.32-2.08,Z =2.67,P =0.008,I2 =62.0％].We found no effects upon gait speed or TUG time (both P＞0.05).Exercise and nutrition interventions had some effects on ALM,but no significant different(SMD 0.45,95％CI:-0.18-1.09,Z=1.40,P =0.163,I2 =82.2％)compared to control.There were no differences in gait speed or leg extension strength after nutrition interventions (both P＞0.05).The effects of exercise and nutrition interventions on body composition index were inconsistent.Conclusions Exercise interventions had some positive effects on functioning for older people with frailty,but these were based on small,low quality studies.Further large scale and high quality studies of rigorously RCT interventions are needed.

The prevalence of hypothyroidism among adults in China: A systematic review / 中华地方病学杂志

Objective To systematically review the prevalence of hypothyroidism from 2000 to 2016 in China.Methods Twenty-five researches were selected from the database of Wanfang,CNKI,CBM,PubMed and Embass according to the inclusion and exclusion criteria and reviewed systematically.Overall prevalence and 95％CI were calculated and forest plots were drawn by Stata 12.0.Results Based on the results from the existing data,the prevalence of hypothyroidism was 9.3％ (7.1％ for male and 12.2％ for female),compared with the group of 60 and over (11.8％),other age groups had lower prevalence of hypothyroidism (the groups of 18-＜ 40 and 40-＜ 60 was 7.4％ and 9.1％,respectively).The prevalence of clinical hypothyroidism and subclinical hypothyroidism was 1.1％ and 8.7％,respectively.In northwest area,the prevalence of hypothyroidism (14.9％) was significantly higher than those of other regions (the east area was 7.7％,north area was 8.0％,southwest area was 13.4％).The prevalence of hypothyroidism from 2011 to 2016 (10.8％) was higher than those of 2002 to 2010 (5.0％).The prevalence of iodine excess group (15.3％) was higher than that of iodine adequate group (8.9％) and that of iodine deficiency group (3.0％).Conclusion The prevalence of hypothyroidism in China has a tendency to increase in recent years,and the preventive and curative strategies to control hypothyroidism need to be further studied.

Accuracy of intraoral and extraoral digital data acquisition for dental restorations

ABSTRACT The computer-aided design (CAD) and computer-aided manufacturing (CAM) process chain for dental restorations starts with taking an impression of the clinical situation. For this purpose, either extraoral digitization of gypsum models or intraoral digitization can be used. Despite the increasing use of dental digitizing systems, there are only few studies on their accuracy. Objective This study compared the accuracy of various intraoral and extraoral digitizing systems for dental CAD/CAM technology. Material and Methods An experimental setup for three-dimensional analysis based on 2 prepared ceramic master dies and their corresponding virtual CAD-models was used to assess the accuracy of 10 extraoral and 4 intraoral optical non-contact dental digitizing systems. Depending on the clinical procedure, 10 optical measurements of either 10 duplicate gypsum dies (extraoral digitizing) or directly of the ceramic master dies (intraoral digitizing) were made and compared with the corresponding CAD-models. Results The digitizing systems showed differences in accuracy. However, all topical systems were well within the benchmark of ±20 µm. These results apply to single tooth measurements. Conclusions Study results are limited, since only single teeth were used for comparison. The different preparations represent various angles and steep and parallel opposing tooth surfaces (incisors). For most digitizing systems, the latter are generally the most difficult to capture. Using CAD/CAM technologies, the preparation angles should not be too steep to reduce digitizing errors. Older systems might be limited to a certain height or taper of the prepared tooth, whereas newer systems (extraoral as well as intraoral digitization) do not have these limitations.

A system dynamics model for study of military medical expenses in PLA hospitals / 军事医学

Objective To explore the application of a system dynamics(SD) model to military medical expenses in PLA hospitals.Methods According to relevant theories of SD, the study has selected some important variables and defined the primary function relations in order to establish a military medical expenses SD model.Results and Conclusion The SD model is suited to modeling the PLA medical expenses and can serve as a theoretical basis for the policy innovation of the PLA medical system.

Meta-analysis of long-term survival of standard and extended pancreaticoduodenectomy for carcinoma of the head of pancreas / 中华普通外科杂志

Objective To compare the complication and long-term efficacy of standard and extended pancreaticoduodenectomy for carcinoma of the head of pancreas by meta-analysis.Methods A literature search was performed of PubMed,Web of Science,Springer,WanFang,CNKI and CBMDisc databases from January 1990 to August 2014.Qualitative analysis of these literatures was conducted using Jadad evaluation.Patients with pancreatic head carcinoma undergoing extended radical resection and standard radical resection were divided into treatment group (extended pancreaticoduodenectomy group,EPD) and control group (standard pancreaticoduodenectomy group,SPD),respectively.Based on the heterogeneity test,meta-analysis of a fixed-or random-effect model were used.Results A total of 5 studies suitable for the selection criteria were chosen,involving 597 patients (299 in EPDs and 298 in SPDs).The results of meta-analysis showed that the EPDs have significantly longer operative time (MD =64.36,95％ CI =23.88-104.85,P =0.002) and more dissected lymph nodes (MD =16.45,95％ CI =9.61-23.29,P ＜ 0.000 01) than SPDs.There was no statistical difference (OR =1.76,95 ％ CI =0.66-4.65,P =0.26) in postoperative complications (46.3％ vs 36.0％) mortality (OR =1.31,95％ CI =0.47-3.69,P =0.61),1-year survival rate (OR =0.70,95 ％ CI =0.49-0.99,P =0.05),3-year survival rate (OR =0.79,95％ CI =0.55-1.15,P =0.22),and 5-year survival rate (OR =-0.02,95％ CI =-0.17-0.12,P =0.77).Conclusions Compared with standard radical resection,extended radical resection for pancreatic head carcinoma does not prolong the postoperative 1-,3-,and 5-year survival rates with comparable postoperative mortality and morbidity and prolonged operative time.

Análisis de sostenibilidad de la política de control de malaria del municipio de El Bagre, Colombia / Sustainability Analysis of the Malaria Control Policy in the Municipality of El Bagre, Colombia / Análise de sustentabilidade da política de controle de malária do município de El Bagre, Colombia

El objetivo de esta investigación fue analizar la sostenibilidad de la política de control de malaria en el municipio de El Bagre durante el año 2011. Se llevó a cabo un estudio de diseño mixto de modelo dominante CUAL-cuan, de carácter exploratorio. Se hicieron catorce entrevistas y una revisión documental, para identificar procesos sociales y ecológicos involucrados con la malaria, y también para describir y analizar la política de control de esta enfermedad. Se encontró que la minería, las migraciones, las prácticas y creencias culturales, el conflicto armado y las variaciones climáticas se relacionaban con la dinámica de la enfermedad y, asimismo, que la estructura de la política de control da cuenta de escasa capacidad de los actores para adaptar las acciones de control a estos procesos socioecológicos de la región. La política de control mostró ser efectiva aunque, bajo los supuestos del modelo, es escasamente sostenible.

The objective of this research was to analyze the sustainability of the malaria control policy in the municipality of El Bagre, during 2011. We performed a mixed-design study with a dominant model QUAL^quan, of exploratory character. We carried out fourteen interviews and a review of the documentation to identify social and ecological processes involved with malaria, and also to describe and analyze the control policy for this illness. We found that mining, migrations, cultural practices and beliefs, the armed conflict and climate variations are related with the dynamic of the illness. Likewise, we found that the structure of the control policy accounts for the limited capacity of the actors to adapt the control actions to the socio-ecological processes of the region. The control policy showed to be effective, although, under the assumptions of the model, it is barely sustainable.

O objetivo desta pesquisa foi analisar a sustentabilidade da política de controle de malária no município de El Bagre durante o ano 2011. Efetuou-se estudo de desenho misto de modelo dominante QUAL-quan, de caráter exploratorio. Foram feitas quatorze entrevistas e uma revisao documental, para identificar processos sociais e ecológicos envolvidos na malária, mesmo para descrever e analisar a política de controle desta doenca. Encontrou-se que a mineracao, migra-coes, práticas e crencas culturais, o conflito armado e as variacoes climáticas relacionavam-se com a dinámica da doenca e, do mesmo modo, que a estrutura da política de controle mostra escassa capacidade dos atores para adaptar as acoes de controle a esses processos socioecológicos da regiao. A política de controle mostrou ser efetiva embora, sob os supostos do modelo, escassamente sustentável.

Quality evaluation of Meta-analyses published on Chinese journals of geriatrics / 中华老年医学杂志

Objective To evaluate the reporting quality of Meta-analyses published on Chinese journals of geriatrics.Methods Papers of Meta-analyses on geriatrics published in nine major Chinese journals of geriatrics before November 21,2013 were retrieved,their basic information were abstracted and evaluated through system assessment and preferred reporting items for systematic reviews and Meta-analyses (PRISMA) statement.Statistical analyses were performed with the SPSS17.0 software.Results Among the 71 internalized papers,1 was from 《Geriatrics & Health Care》,1 from 《Practical Geriatrics》,10 from 《Chinese Journal of Geriatric Care》,45 from 《Chinese Journal of Gerontology》,3 from 《Chinese Journal of Multiple Organ Diseases in the Elderly》,1 from 《Chinese Journal of Geriatric Dentistry》,5 from 《Chinese Journal of Geriatric Heart Brain and Vessel Diseases》,5 from 《Chinese Journal of Geriatrics》.55 papers (77.5％) were published in recent 3 years.The mean overall PRISMA score was(16.75±3.04)ranged from 4 to 24.The main influencing factor for the quality of Meta-analyses was the year of publication (adjusted β=-0.342,P=0.003).Conclusions The quantity and quality of Meta-analyses published on Chinese journals of geriatrics are increased and improved in recent years,but there are still some problems on the writing norms.We should promote PRISMA statement and standardize reporting format to improve the quality of Meta-analyses in the field of geriatric medicine.

Alendronate for osteoporotic fractures prophylacsis in postmenopausal women: a meta-analysis / 中华老年医学杂志

Objective To systematically evaluate the efficacy of alendronate on the primary and secondary preventions of osteoporotic fractures in postmenopausal women.Methods Literatures and related references were searched from MEDLINE (from 1966 to April 2011),Embase (from 1966to April 2011),Cochrane Library (the second Issue,2011),CBM disc,CNKI,WANFANG and VIP database by Cochrane systematical evaluation.All related randomized controlled trials were collected,and Meta analysis was performed by RevMan 5.0 soft ware provided by Cochrane collaboration.Results Totally 11 randomized controlled trials were evaluated.Meta-analysis showed that 10 mg oral alendronate daily for secondary prevention could reduce the incidence of spine,hip,wrist and non vertebra fractures (RR 0.57,95％ CI:0.49-0.67),but for the primary prevention,alendronate could not reduce the fracture incidence except for spine fracture (RR=0.55,95％CI:0.38-0.80).Adverse events associated with alendronate were not increased,and the sensitivity analysis results were not changed (RR =0.95,95％ CI:0.83-1.09).Conclusions Alendronate can reduce osteoporotic fractures in postmenopausal women for the secondary prevention,but the effect of alendronate on osteoporotic fractures for the primary prevention needs further study.