Obesidad Infantil. Una revisión de las intervenciones preventivas en escuelas / Childhood obesity. A review of school-based preventive interventions

Resumen Objetivo Evaluar la eficacia que tienen los componentes de las intervenciones preventivas en escuelas para mejorar la calidad nutricional, aumentar la actividad física (AF) y, ulteriormente, reducir la obesidad de los niños y adolescentes. Método Revisión de publicaciones realizadas entre los años 2009 y 2014 comprendidas en cualquiera de las siguientes categorías: revisión sistemática, metaanálisis o informes acerca del impacto de las recomendaciones y políticas gubernamentales específicas y de programas estudios aleatorizados, no aleatorizados, transversales y cuasiexperimentales que informen de medidas objetivas de resultados en un plazo igual o mayor a los 6 meses posteriores a la evaluación. Resultados Veinticinco publicaciones científicas reunieron criterios de inclusión. Conclusión Aunque la heterogeneidad de los estudios limita la posibilidad de generalizar los resultados, pareciera que no hay evidencia de que la implementación de un componente haya resultado más eficaz que otro. Por el contrario, los programas multiintervención, especialmente si combinan cambio de alimentación junto con incremento de AF, parecen contribuir a prevenir la obesidad. La evidencia respecto de las políticas de regulación es dudosa y probablemente requiera intervenciones más abarcativas que tengan en cuenta el contexto sociocultural de la población a la que apuntan.

Abstract Objective Assess the efficacy of the components of school-based preventive interventions in improving the nutritional quality of children's intake, in increasing their time of physical activity (PA), and ultimately in reducing childhood obesity. Methods A review of the research literature published between 2009 -2014 was conducted. Inclusion criteria was: systematic reviews, meta-analysis or reports regarding the impact of recommendations and specific governmental policies as well as of randomized or non-randomized controlled, transversal and quasi-experimental trials with evaluations at 6 or more months after baseline that reported objectives measures of outcome. Results 25 scientific publication met inclusion criteria. Conclusions Although generalizability of results is limited by the heterogeneity of the studies, it appears that there is no evidence that a specific intervention component is more effective. Contrarily, multi-component programs, especially if they combine a change in quality intake together with an increase in PA seem to contribute to prevent childhood obesity. Evidence regarding regulation policies is non-conclusive and probably requires broader interventions that contemplate the socio-cultural context of the target population.

What is the Role of Epidural Injections in the Treatment of Lumbar Discogenic Pain: A Systematic Review of Comparative Analysis with Fusion

BACKGROUND: Lumbar discogenic pain without pain mediated by a disc herniation, facet joints, or the sacroiliac joints, is common and often results in chronic, persistent pain and disability. After conservative treatment failure, injection therapy, such as an epidural injection, is frequently the next step considered in managing discogenic pain. The objective of this systematic review is to determine the efficacy of lumbar epidural injections in managing discogenic pain without radiculopathy, and compare this approach to lumbar fusion or disc arthroplasty surgery. METHODS: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and lumbar fusion or disc arthroplasty in managing lumbar discogenic pain was performed with methodological quality assessment and grading of evidence. The level of evidence was based on the grading of evidence criteria which, was conducted using 5 levels of evidence ranging from levels I to V. RESULTS: Based on a qualitative assessment of the evidence for both approaches, there is Level II evidence for epidural injections, either caudal or lumbar interlaminar. CONCLUSIONS: The available evidence suggests fluoroscopically directed epidural injections provide long-term improvement in back and lower extremity pain for patients with lumbar discogenic pain. There is also limited evidence showing the potential effectiveness of surgical interventions compared to nonsurgical treatments.

Uma visão evidente da prática baseada em evidências na medicina perinatal: ausência de evidência não é evidência de ausência / An evident view of evidence-based pratice in perinatal medicine: absence of evidence is not evidence of absence

OBJETIVO: Proporcionar elementos valiosos e um pouco de humor nesta chamada era da "prática baseada em evidências" com o objetivo de ajudar os clínicos a fazer escolhas melhores no cuidado que eles provêem com base em evidências, e não simples ou exclusivamente com base em um ensaio clínico randomizado (ECR) ou meta-análise (o que pode não ser evidência). FONTE DOS DADOS: Livros e artigos com revisão por pares são citados e listados na bibliografia. Evidências de vida, aprendizado através de nossos próprios erros e muitos outros fatos evidentes que sustentam esta revisão não são citados. SÍNTESE DOS DADOS: 1) "Ausência de evidência não é evidência de ausência" e "falta de evidência de efeito não significa evidência de nenhum efeito". 2) Os ECR com resultado "negativo" e aqueles com resultado "positivo", mas sem os resultados importantes, muitas vezes não podem concluir o que concluem. 3) Os ensaios clínicos não-randomizados e os estudos práticos podem ser importantes. 4) A pesquisa em busca de provas é diferente da pesquisa em busca de aperfeiçoamento. 5) A escolha clínica deve avaliar os efeitos nos desfechos importantes para os pacientes e seus pais. 6) A quantificação de desfechos adversos, do número necessário para causar dano e do número necessário para tratamento não é assim tão simples. CONCLUSÕES: Desafios importantes inerentes à pesquisa em serviços de saúde devem ser correlacionados a possíveis aplicações clínicas usando ferramentas que permitam uma "visão mais clara da prática baseada em evidências" na medicina perinatal, lembrando que a ausência de evidência não é evidência de ausência.

OBJECTIVE: To provide valuable elements and some humor in this so-called era of "evidence-based practice" with the aim of helping clinicians make better choices in the care they deliver based on evidence, not simply or exclusively based on a randomized clinical trial (RCT) or meta-analysis (which may not be evidence). SOURCES: Books and peer-reviewed articles are quoted and listed in the bibliography. Evidence of life, learning from our own mistakes and many other evident facts that support this review are not quoted. SUMMARY OF THE FINDINGS: 1) "Absence of evidence is not evidence of absence" and "lack of evidence of effect does not mean evidence of no effect". 2) RCTs with "negative" results and those with "positive" results, but without outcomes that matter, often cannot conclude what they conclude. 3) Non-randomized clinical trials and practical trials may be important. 4) Research to prove is different than research to improve. 5) Clinical choice must assess effects on outcomes that matter to patients and their parents. 6) Quantifying adverse outcomes, number needed to damage and to treat is not that simple. CONCLUSIONS: Significant challenges inherent to health service research must be correlated to possible clinical applications using tools to have a more "evident view of evidence-based practice" in perinatal medicine, recalling that absence of evidence is not evidence of absence.

A Preliminary Results of a Randomized Trial Comparing Monthly 5-flourouracil and Cisplatin to Weekly Cisplatin Alone Combined with Concurrent Radiotherapy for Locally Advanced Cervical Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: To determine the superior chemotherapeutic regimen between monthly 5-FU plus cisplatin (FP) and weekly cisplatin alone in concurrent chemoradiotherapy for locally advanced cervical cancer, the compliance of treatment, response, survival and toxicities were analyzed between the two arms. MATERIALS AND METHODS: Between March 1998 and December 2001, 61 patients with locally advanced cervical cancer (stage IIB through IVA) and negative para-aortic lymph nodes were randomly assigned to either `monthly FP' (arm I, n=34) or `weekly cisplatin' (arm II, n=27) with concurrent radiotherapy. The patients of arm I received FP (5-FU 1, 000 mg/m2/day+cisplatin 20 mg/m2/day, for 5 days, for 3 cycles at 4 week intervals) and those of arm II received cisplatin (30 mg/m2/day, for 6 cycles at 1 week intervals) with concurrent radiotherapy. The radiotherapy consisted of 41.4~50.4 Gy external beam irradiation in 23~28 fractions to the whole pelvis, with high dose rate brachytherapy delivering a dose of 30~35 Gy in 6~7 fractions to point A. During the brachytherapy, a parametrial boost was delivered. The median follow-up period for survivors was 44 months. RESULTS: The compliance of treatment in monthly FP weekly cisplatin arms were 62 and 81%, respectively. The complete response rates at 3 months were 96 and 88% in arms I and II, respectively. The 4-year overall survival and disease free survival rates were 64 and 54% in the arm I and 77 and 66% in the arm II, respectively. The incidence of hematologic toxicity more than grade 2 was 29% in the arm I and 15% in the arm II. Only one patient in arm I experienced grade 3 gastrointestinal toxicity. No severe genitourinary toxicity was observed. CONCLUSION: No significant difference was observed in the compliance, responses, survival rates and acute toxicities between the two treatment arms. More patients and further follow up will be required.