IntrodTrabCient
Transcrição
IntrodTrabCient
Metodologia Científica INTRODUçÃO NO TRABALHO CIENTÍFICO Partes do Enredo 1.Apresentação 2.Complicação 3.Clímax 4.Desfecho Partes do Enredo 1.Apresentação 2.Complicação 3.Clímax 4.Desfecho DESCRIÇÃO INTRODUÇÃO • 1a parte de uma história • Antecipa o conflito e o desfecho • cada porquinho produz um tipo de casa que podem ser de 3 tipos. • não se sabe qual delas é mais resistente • Testamos com um lobo • Este artigo apresenta o resultado FUNÇÕES 1.Despertar interesse 2.Preparar para entender o trabalho 3 “C”s. • Curta • Clara • Cativante The Three Faces of President Obama MARCH 15, 2014 Thomas L. Friedman BARACK OBAMA is surely the first president to be accused of acting in foreign policy like Pollyanna, John Wayne and Henry Kissinger in the same month. Curta-Clara-Cativante Steve Jobs' 2005 Stanford commencement speech: "You've got to find what you love." I am honored to be with you today at your commencement from one of the finest universities in the world. I never graduated from college. Truth be told, this is the closest I've ever gotten to a college graduation. Today I want to tell you three stories from my life. That's it. No big deal. Just three stories. Curta-Clara-Cativante ‘Esquemas ardilosos’, editorial do Estadão A polêmica decisão do presidente do Senado, Renan Calheiros, de transferir para a Comissão de Constituição e Justiça (CCJ) da Casa a responsabilidade de decidir sobre a ampliação das investigações da Comissão Parlamentar de Inquérito (CPI) da Petrobrás proposta pelo PT, é uma manobra claramente procrastinatória destinada, com o incentivo do Palácio do Planalto, a diluir o impacto do escândalo da Refinaria de Pasadena, que, graças às trapalhadas de Dilma Rousseff, acabou criando riscos para o projeto petista de perpetuação no poder. Trata-se de mais uma chicana política dentre as muitas do amplo repertório de que o notório presidente do Senado se vale para levar vantagem em barganhas com o Executivo. Curta-Clara-Cativante “Se hoje é o dia das crianças, ontem eu disse que criança… o dia da criança é dia da mãe, do pai e das professoras, mas também é o dia dos animais, sempre que você olha uma criança, há sempre uma figura oculta, que é um cachorro atrás.” O Tamanho depende da revista… LEVENTE A. TOTH, MD,*† MICHAEL STEVENSON, BSC, MSC,† USHA CHAKRAVARTHY, MD, FRCS, PHD*† Purpose: To assess the effect of anti-vascular endothelial growth factor treatment on visual acuity outcome in patients with neovascular age-related macular degeneration presenting with very low vision. Methods: Retrospective analysis of electronic patient care record of 420 eyes treated with ranibizumab between March 2010 and June 2013. The authors classified the extracted sample into 3 categories based on the initial best-corrected visual acuity (BCVA) as measured on the Early Treatment Diabetic Retinopathy Study charts: 0 to 35 letters, 36 to 69 letters, and $70 letters. Best BCVA achieved in Year 1, and average BCVA over 36 months was computed. The neovascular lesion type, area of lesion, the presence or absence of hemorrhage, retinal pigment epithelium tear, and atrophy were systematically graded as was extent of fibrosis on a categorical scale of 0 to 4. Regression analysis was performed with the best BCVA achieved in Year 1 as the outcome variable and initial BCVA, person, and lesion characteristics as explanatory variables. Results: The mean change in BCVA from the initial visit to the best-attained BCVA during Year 1 was highly statistically significant with an improvement of 9.95 letters. The improvement from initial BCVA to average BCVA over 36 months was 4.01 letters. Regression analysis identified atrophy and fibrosis as predictors of best BCVA, with the model having an r2 of 0.71. Conclusion: Our study supports the use of anti-vascular endothelial growth factor agents even in eyes with low visual acuity particularly when fibrosis and atrophy are absent and suggests algorithms to predict outcome for combinations of visual acuity and lesion characteristics across the full visual acuity range. LEVENTE A. TOTH, STEVENSON, BSC, MSC,† RETINAMD,*† 0:1–7,MICHAEL 2015 USHA CHAKRAVARTHY, MD, FRCS, PHD*† ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION Outcomes in Eyes With Poor Initial Vision Purpose: To assess the effect of anti-vascular endothelial growth factor treatment on visual acuity outcome in patients with neovascular age-related macular degeneration he current presenting standardwith ofvery care growth factor or inhibit its binding to its cognate receptor low for vision.neovascular Methods: Retrospective analysis of electronic record of 420 treated with age-related macular degeneration (nAMD) is patient arecare now used to eyes ameliorate the unwanted effects of ranibizumab between March 2010 and June 2013. The authors classified the extracted sample anti-vascular endothelial growth factor therapy VEGF in the environment of the Bruch/retinal pigment 1–5 into 3 categories based on the initial best-corrected visual acuity (BCVA) as measured on the (anti-VEGF). Early epithelium (RPE)/photoreceptor interfaces of the eye. Biologicals that either neutralize this Treatment Diabetic Retinopathy Study charts: 0 to 35 letters, 36 to 69 letters, and $70 Notably, exudative manifestations and the unconletters. Best BCVA achieved in Year 1, and average BCVA over 36 the months was computed. The of the neovascular From the *Ophthalmology Directorate, BelfasttheHealth neovascular Service lesion type, area of lesion, presence or trolled absenceexpansion of hemorrhage, retinal pigment complexes that form and Social Care Trust, Belfast, United Kingdom; and †Centre for epithelium tear, and atrophy were systematically graded in as was extentare of fibrosis on a categorical nAMD curtailed by the administration of antiExperimental Medicine, scaleSchool of 0 to of 4. Medicine, RegressionDentistry analysis and wasBiomedperformed with the best BCVA achieved in Year 1 as the VEGFs into the eye. The pivotal licensing trials and ical Sciences, Queen’s University Belfast, United Kingdom. outcome variable and Belfast, initial BCVA, person, and lesion characteristics as explanatory variables. studies have shown improvements in vision L. A. Toth: Conference attendance, grants from from Bayer.the initialsubsequent Results: The meantravel change in BCVA visit to the best-attained BCVA during U. Chakravarthy: Grants to employing institution from Novartis in patients treated manner. Year 1 was highly statistically significant with an improvement of 9.95 letters. in Thethis improvement and Bayer. Attendance at advisory boards, Bayer, Roche, Genentech from M. initial BCVA tohas average BCVA over 36 months was 4.01clinical letters. trials Regression analysis exclude patients when Most and studies and Alimera Sciences. Stevenson no financial/conflicting 2 with in the the model having an r study of 0.71.eye is worse than 23 acuity designated interests to disclose.identified atrophy and fibrosis as predictors of best BCVA, Conclusion: Our study supports the use of anti-vascular endothelial growth factor Reprint requests: Usha Chakravarthy, MD, FRCS, PhD, Centre for Early Treatment Diabetic retinopathy Study letters, that agents even and in eyes with low visual acuity when fibrosis and atrophy Experimental Medicine, Dentistry Biomedical Sciences, Instituteparticularly of 1–12 are absent is Snellen of20/320. for excluding eyes and suggests to predictRoad, outcome visual acuityThe andrationale lesion Clinical Science, Queen’s Universityalgorithms of Belfast, Grosvenor Bel- for combinations fast BT12 6BA, United Kingdom; e-mail: [email protected] characteristics across the full visual acuity range. with poor vision lies in the fact that they are most likely RETINA 0:1–7, 2015 T to have had long-standing disease. The natural history of nAMD is such that there is a rapid reduction in visual acuity at the onset of disease. Once an acuity level worse than 20/200 is reached, the rate of further worsening is usually slower and many eyes will retain levels of acuity between 20/200 and 20/400.13–16 Furthermore, in eyes with low levels of visual acuity, the likelihood of improvement is small, as the chances of having permanent structural damage to key cells such as the photoreceptors and RPE are high. Clinical trials and studies also exclude patients with good visual acuity (.73 letters). The rationale for this type of exclusion is that the commonly used metric of an improvement of $15 letters is unlikely to be achieved, as in this age group of older adults, medial opacity and the degenerative macular changes are likely to limit the maximum achievable vision to less than 20/20 Snellen (83 letters). Therefore, the outcome metric of proportions improving by 15 or more letters would be impossible owing to ceiling effects. These concepts have driven the design and inclusion criteria of the clinical trials in nAMD, and the pivotal licensing trials for the newer generation of anti-VEGF therapies have been no exception.10,11,17 To date, the potential beneficial effect of using antiVEGF agents in patients who present with very low levels of visual acuity has not been systematically studied. There is a strong rationale for estimating this benefit, as anti-VEGF agents, unlike previous treatments, have been shown to result in average improvement in vision, and furthermore, approximately one third of treated eyes will show considerable increases of acuity.18 Therefore, it could be argued that even patients with very low levels of measurable acuity may experience benefits. However, public healthcare systems tend to act to limit the use of expensive technologies to populations with characteristics similar to that enrolled in the clinical trials. In the United Kingdom, the National Institute of Clinical Excellence (NICE) has set the criteria for selection of patients for treatment based on the licensing trials and has issued guidance that states that eyes with nAMD with no prospect of visual improvement should not be treated.19 Despite this guidance, in clinical practice, patients may be offered treatment even when acuity is extremely low, if the affected eye is the better-seeing eye, or if the clinician believes that the majority of the visual loss is related to the presence of hemorrhage or exudation without structural damage such as fibrosis and or atrophy, which are irreversible. Anecdotally, patients have been found to exhibit quantifiable improvements even when presenting visual acuity has been extremely low, but this has not been systemically studied. Hence, this study aimed to assess and predict the probability of improvements in visual acuity in patients with nAMD with very poor initial visual acuity in the treated eye. 3 years, and 47% at 4 years in silicone oil group, and 100% at 6 months and 1 year, and 76% at 2, 3, and 4 years in the control group (P = 0.03). Complications were similar in the 2 groups (P = 0.663). The duration of postoperative topical steroid use was significantly longer in the silicone oil group (P = 0.0003). Silicone oil was identified as a risk factor for surgical failure by the Cox hazard model (risk ratio = 3.43; P = 0.04). METHODS This was a retrospective comparative study, with a concurrent comparison group. The study and data accumulation were carried out with approval from the Institutional Review Board, informed consent was obtained from the patients before surgery, and the study was in Conclusions: The AGV can control the IOP in the majority of eyes accordance with Health Insurance Portability and Accountafter pars plana vitrectomy and silicone oil injection. However, the ability Act (HIPAA) regulations. We reviewed the records presence of silicone oil is associatedSTUDY with increased risk of surgical ORIGINAL failure in eyes treated with the AGV. of consecutive patients who underwent AGV implantation for glaucoma associated with pars plana vitrectomy and RIGINAL KeyTUDY Words: glaucoma drainage implant, silicone oil, intraocular silicone oil injection for complex retinal disease during pressure,Glaucoma refractory glaucoma Ahmed Valve Surgical Outcomes in Eyes the period from 1998 to 2005. All implantations were With and Without Silicone Oil Endotamponade performed for increased IOP that was not responsive to (J Glaucoma 2009;18:325–330) maximum tolerated medical therapy and for eyes considKyoko Ishida, MD,*w Iqbal Ike K. Ahmed, MD,zy and Peter A. Netland, MD, PhD* ered by the retina consultant to be poor candidates for silicone oil removal owing to risk of redetachment. Eyes hen silicone oil tamponade was introduced as an treated with cyclophotocoagulation and the second eyes of improvements in silicone oil preparations have been adjunct toglaucoma parsvalve plana pupillary blockofwas Purpose: To compare the results of Ahmed (AGV)vitrectomy, associated with reduced incidence secondary IOP study patients were excluded. A total of 47 eyes (47 8 implantation in eyes containing silicone oil to those without a common cause of elevated elevation. intraocular pressure (IOP).1 silicone oil. Although eyes with elevated IOP after pars plana patients) with silicone oil consecutively treated with AGV peripheral iridectomy became standard proce-often can be vitrectomy and a silicone oil endotamponade Methods: ThisInferior was a multicenter, retrospective, comparative study implantation were identified. All patients had pars plana medically, some require surgical intervenK. Ahmed, and Peter A. Netland, MD, PhD* of 94 eyes in 94MD, patients zy with mean follow-up of 2 years, comparing 2controlled dure with silicone oil and 3,6,8,9this cause of secondary surgical outcomes in eyes with silicone oil (N = 47) injection, to matched tion. Glaucoma drainage device implantation has been vitrectomy and silicone oil injection for the management of patients without silicone oil (N = 47). is Success was rare. defined as described as a usefulwith treatment option for these refractory elevated IOP now However, even iridectomy, intraocular pressure (IOP) of Z6 and r21 mm Hg and 20% glaucomas, although the statistical power of these studies complicated retinal detachment. Cases were matched to reduction of IOP from reported preoperative level,incidence with or without glaucoma 3,6,8 the of IOP silicone oil haselevation been low owingafter to limited number of cases. In this medicines, and without further glaucoma surgery or loss of light concurrent controls (not treated previously with silicone we investigated the 3–8 clinical outcome of Ahmed perception. injection ranges from 5.9% study, to 56% eyes. Recent glaucoma valveof (AGV) implantation in eyes treated oil) with by age, sex, and ethnicity. Results: The mean IOP and number of medications at the last oil pars preparations plana vitrectomy and silicone oil endotamponade, and improvements in silicone have been follow-up were comparable between the 2 groups (P = 0.26 and compared the results to eyes that had not been treated with The implant used was the AGV (New World Medical alve (AGV) P = 0.12). Theassociated cumulative probability of success by life-table incidence with reduced silicone oil. of secondary IOP analysis was 85% at 6 months,880% at 1 year, 70% at 2 and Inc, Rancho Cucamonga, CA), model S2 or FP7. ose without elevation. 3 years, and 47% at 4 years for in silicone oil group, and 100% at Received publication February 12, 2008; accepted June 9, 2008. Implantation of the AGV was performed as described 6 months and 1 year, and 76% at 2, 3, and 4 years in the control From the *Department of Hamilton Eye METHODS Although eyes with elevated IOP after parsInstitute, plana group (P = 0.03). Complications were similar in the 2 Ophthalmology, groups 8,10 previously. In eyes containing silicone oil, viscoelastic This wasCenter, a retrospective comparative study, with a (P = 0.663). The duration of postoperative steroid useHealth was University of topical Tennessee Science Memphis, TN; vitrectomy and silicone oil endotamponade often can be rative study significantly longer in the silicone oil group (P = 0.0003). Silicone concurrent comparison group. The study and data accuwDepartment of Ophthalmology, Gifu University Graduate School material was used intraoperatively in the anterior chamber oil was identified as a risk factor formedically, surgical failure by the Cox mulation were carried out with approval from the Institucontrolled some require surgical interven, comparing hazard model (risk ratio =Medicine, 3.43; P = 0.04). Gifu, Japan; zDepartment of3,6,8,9 of Ophthalmology, tional Review Board, informed consent was obtained from during tube placement to prevent flow of silicone oil into to matched tion. Glaucoma drainage device implantation has been the Canada; patients before and the study University Toronto, and surgery, yDepartment of was in Conclusions: The AGV can control theof IOP Toronto, in the majority of eyes the tube while the patient was in the supine position for the accordance Health Insurance Portability and Accountvitrectomy and silicone injection. However, the definedafteraspars planadescribed Ophthalmology, University of Utah, Saltwith Lake City, UT. as aoil useful treatment option for these refractory ability Act (HIPAA) regulations. We reviewed the records presence of silicone oil is associated with increased risk of surgical procedure. The AGV implant was placed in one of the The authors have no proprietary interest inpower thepatients material presented g and 20% failure in eyes treated with the AGV. of consecutive underwent AGVinimplantation glaucomas, although the statistical ofwhothese studies for glaucoma associated with pars plana vitrectomy inferior and quadrants (inferotemporal or inferonasal) in all this manuscript. ut glaucoma 3,6,8 Key Words: glaucoma drainage low implant,owing silicone oil,to intraocular has been limited number of cases. In this silicone oil injection for complex retinal disease during Reprints: pressure, refractory glaucoma Peter A. Netland, MD, PhD, Department of Ophthalmology, cases to minimize loss of silicone oil through the tube or oss of light the period from 1998 to 2005. All implantations were study, we investigated the clinical outcome of Ahmed Hamilton Eye Institute, University of Tennessee Health Science performed for increased IOP that was not responsive to (J Glaucoma 2009;18:325–330) tube blockage. In control eyes, the AGV was placed in one maximum tolerated medical therapy for eyes considCenter, 930 Madison Suite 100, TN and 38163 glaucoma valve (AGV)Avenue, implantation in Memphis, eyes treated with ered by the retina consultant to be poor candidatesof for the superior quadrants (superotemporal or superonasal) [email protected]). at the last pars(e-mail: plana vitrectomy and silicone endotamponade, and siliconeoil oil removal owing to risk of redetachment. Eyes r hen silicone oil tamponade was introduced as an inofall cases. 2009 by Lippincott Williams & Wilkins treated with cyclophotocoagulation and the second eyes = 0.26 and adjunctCopyright compared the results eyes to pars plana vitrectomy, pupillaryto block was that had not been treated with study patients were excluded. A total of 47 eyes (47 a common cause of elevated intraocular pressure (IOP).1 by life-table patients) with silicone oil consecutively treated with AGV silicone oil. Inferior peripheral iridectomy became a standard proceimplantation were identified. All patients had pars plana % at 2 dure andwith silicone oil injection,2 !and this cause of secondary J Glaucoma Volume 18, Numbervitrectomy 4, April–May www.glaucomajournal.com | 325 and silicone2009 oil injection for the management of elevated IOP is now rare. However, even with iridectomy, O S Valve Surgical Outcomes in Eyes WOil Endotamponade t Silicone W nd 100% at complicated retinal detachment. Cases were matched to the reported incidence of IOP elevation after silicone oil concurrent controls (not treated previously with silicone the control 3–8 injection ranges from 5.9% to 56% of eyes. Recent oil) by age, sex, and ethnicity. METHODS e 2 groups The implant used was the AGV (New World Medical This 12,was a retrospective comparative study, Inc, Rancho Cucamonga, CA), with model a S2 or FP7. oid use Received was for publication February 2008; accepted June 9, 2008. Implantation of the AGV was performed as described From the *Department of Ophthalmology, Hamilton Eye Institute, 03). Silicone concurrent comparison group.previously. The study datasilicone accu8,10 In eyesand containing oil, viscoelastic University of Tennessee Health Science Center, Memphis, TN; wDepartmentmulation of Ophthalmology, Gifu University Graduate Schoolwith material was used intraoperatively in the anterior chamber by the Cox were carried out approval from the Instituof Medicine, Gifu, Japan; zDepartment of Ophthalmology, University of Toronto, Toronto, Canada; and yDepartment of during tube placement to prevent flow of silicone oil into tional Review Board, informed consent was obtained from INTRODUÇÃO • 1a parte de uma história/Antecipa o conflito • Despertar interesse / Preparar para entender o trabalho • Curta / Clara / Cativante O que faz parte? • Contexto sobre o assunto • A necessidade • O que foi feito para resolver a necessidade • O conteúdo do artigo O que não faz parte • Respostas • Resultados • Conseqüências Conhecido, desconhecido, resto Conhecido, desconhecido e pergunta Contexto (o que se sabe) O que não se sabe O que foi feito a respeito o conteúdo do artigo over the total follow-up (P " 0.007). een the different groups. More Topical specifically, patients in the steroid group Conclusions: ketorolac or fluorometholone for 1neede month the total follow-up (P " 0.007). trabeculectomy outcomes in terms of likelihood of postoperative onclusions:significantly Topical ketorolac fluorometholone 1 month before surgery reducedor need for additional for postoperative IOP-lowering Financial The of author(s) have no needling. proprietary c culectomy outcomes in Disclosure(s): terms of likelihood postoperative In orthe in this article. Ophthalmology 2010;117:1324 –1330 © 2010 by th cantly reduced need for additional postoperative IOP-lowering medication com Conhecido, desconhecido e pergunta nancial Disclosure(s): The author(s) have no proprietary or commercial intere s article. Ophthalmology 2010;117:1324 –1330 © 2010 by the American Aca Trabeculectomy is the treatment of choice to reduce intraocoperative ular pressure (IOP) and to prevent further visual field deteany bene 1–5 rioration in medically uncontrolled glaucoma. However, Preope culectomy is the treatment of choice to reduce intraocoperative subconjunctival one of the main causes of surgical failure is the occurrence tive or ad ressure (IOP) and to prevent further visual field deteany benefits on surgical ou of excessive postoperative 1–5 scarring in the region of the ure has on in medically uncontrolled glaucoma. However, Preoperative anti-inflam scleral flap. Many adjunctive antifibrotic therapies to infiltratio f the main causes of surgical failure is the scarring occurrence tive orinvestiadditional eral approach counteract this conjunctival have been studi cessive postoperative in theantifibrotic region of agents, the ure has been gated.6 –13 scarring Two common mitomycin C associated of IOP-lo l flap. Many antifibrotic therapies to enhance infiltration of fibroblasts an andadjunctive 5-fluorouracil, have been shown to success conjuncti 9 –13 investieract this conjunctival scarring have been rates after trabeculectomy. These agentseral arestudies associ-have provided contribut 6 –13 Two common antifibrotic agents, mitomycin C ofand IOP-lowering medicatio ated with complications such as thin-walled avascufailure af -fluorouracil, been shown wound to enhance conjunctival inflammation. larhave blebs, hypotony, leaks,success blebitis, endophthalmitis, tioned fin 14 –18 and scleral9 –13 melting. Further using anti– conjuncti after trabeculectomy. These agents are clinical associ- trialscontribute to subconjunctiv transforming growth factor !and antibodies post-filtration lowering with complications such as thin-walled avascu-to counteract failure after surge ative IOP-lowering medication compared with the other groups. no proprietary or commercial interest in any materials discussed 330 © 2010 by the American Academy of Ophthalmology. traocdetewever, rrence of the es to vesticin C ccess ssociasculmitis, anti– post- desconhecido operative subconjunctival fibrosis could not demonstrate any benefits on surgical outcome.19,20 Preoperative anti-inflammatory treatment is an alternative or additional approach to counteract fibrosis. Bleb failure has been associated with an increased conjunctival infiltration of fibroblasts and inflammatory cells.21–23 Several studies have provided evidence that the long-term use of IOP-lowering medication is associated with subclinical conjunctival inflammation. This inflammation is assumed to contribute to subconjunctival scarring and subsequent bleb failure after filtration surgery.24 –30 Based on the aforementioned findings, it can be presumed that the suppression of Breusegem et al ! topical NSAID or Steroid befor conjunctival inflammation caused by long-term IOPlowering treatment may help to prevent the excessive scara purse-string ring that leads to bleb failure after trabeculectomy. Thereand dexamet fore, a prospective, randomized, ISSN controlled clinical trial was 0161-6420/10/$–see front matter at the end of conducted to test this hypothesis with regard to clinical doi:10.1016/j.ophtha.2009.11.038 for 8 weeks. infiltration of fibroblasts and inflammatory cells. Several studies have provided evidence that the long-term use of IOP-lowering medication is associated with subclinical conjunctival inflammation. This inflammation is assumed to contribute to subconjunctival scarring and subsequent bleb 24 –30 failure after filtration surgery. Based on the aforementioned findings, it can be presumed that the suppression of Breusegem et al ! topical NSAID or St conjunctival inflammation caused by long-term IOPlowering treatment may help to prevent the excessive scarring that leads to bleb failure after trabeculectomy. Therefore, a prospective, randomized, ISSN controlled clinical trial was 0161-6420/10/$–see front matter doi:10.1016/j.ophtha.2009.11.038 conducted to test this hypothesis with regard to clinical outcomes. O que foi feito Patients and Methods This prospective, randomized, double-blind, placebo-controlled Design: Prospective, randomized placebo-controlled trial. Participants: Sixty-one patients. Methods: Between July 2005 and October 2007, 61 consecutive medically uncontrolled glaucoma patients Participants: Sixty-one patients. Methods: Between July 2005 and October 2007, 61 61 consecutive medically uncontrolled glaucoma patients scheduled for first-time trabeculectomy were randomized 1 of 3 study topical medication groups: nonsteroidal Methods: to Between July 2005 and October 2007, consecutive medically uncontrolled glaucoma patients scheduled for first-time trabeculectomy were randomized to 1toof1 3ofstudy topical medication groups: nonsteroidal scheduled for first-time trabeculectomy were randomized 3 study topical medication groups: nonsteroidal anti-inflammatory drugs (ketorolac), steroidsanti-inflammatory (fluorometholone), or placebo (artificial tears). Patients instilled 1 drugs (ketorolac), steroids (fluorometholone), or or placebo (artificial tears). Patients instilled 1 1 anti-inflammatory drugs (ketorolac), steroids (fluorometholone), placebo (artificial tears). Patients instilled dropdrop 4 times dailydaily for 1formonth before the procedure were examined on on days and 2,4,2, at at weeks 1, 1, 2, 2, and 4, 4, drop 4 times daily for 1 month before the procedure and were examined on days 1and and 2, atexamined weeks 1, 2,1 and 4 times 1 month before the procedure and were days 1 and weeks and andand at months 3, 6,3,12, 18, 18, andand 24 after trabeculectomy. at months 6, 12, 24 after trabeculectomy. and at months 3, 6, 12, 18, and 24 after trabeculectomy. Main Outcome Measures: of postoperative surgical or or medical interventions (needling, laser Main Outcome Measures:Incidence Incidence of postoperative surgical medical interventions (needling, laser Main Outcome Measures: Incidence of postoperative surgical or medical interventions (needling, laser suture lysis, needling revision, and intraocular pressure [IOP]-lowering medication). suture lysis, needling revision, and intraocular pressure [IOP]-lowering medication). Fifty-four patients (54 (54 eyes) were entered for for analysis. TheThe mean number of of preoperative medicasuture lysis, needling revision, and intraocularResults: pressure [IOP]-lowering medication). Results: Fifty-four patients eyes) were entered analysis. mean number preoperative medicationstions waswas 2.3!0.9. The mean baseline IOP was 21.0!6.0 mmHg. The mean postoperative target IOP was 2.3!0.9. The mean baseline IOPnumber was 21.0!6.0 mmHg. The mean postoperative target IOP was Results: Fifty-four patients (54 eyes) were entered for analysis. The mean of preoperative medica16.5!1.8 mmHg. TheThe mean follow-up waswas 23.6!4.0 months. TheThe percentage of of patients requiring needling 16.5!1.8 mmHg. mean follow-up 23.6!4.0 months. percentage patients requiring needling tions was 2.3!0.9. The mean baseline IOPwithin was mmHg. mean postoperative target was the21.0!6.0 firstfirst yearyear waswas 41% in the placebo group, 6%6% in the NSAID, andand 5%5% inIOP the steroid group (P (P "" 0.006). within the 41% in The the placebo group, in the NSAID, in the steroid group 0.006). percentage of patients requiring IOP-lowering medication to reach thethe target IOP at at 1 year was 24% in in thethe 16.5!1.8 mmHg. The mean follow-up wasThe 23.6!4.0 months. The percentage of patients needling The percentage of patients requiring IOP-lowering medication torequiring reach target IOP 1 year was 24% placebo group, 18% in the NSAID group, andand 0%0% in the steroid group (P " 0.054 overall; P" 0.038 forfor steroids placebo group, 18% in the NSAID group, in the steroid group (P " 0.054 overall; P " 0.038 steroids within the first year was 41% in the placebovs. group, 6% in the NSAID, anda significant 5% in the steroid group (Pin " 0.006). others). TheThe log-rank testtest showed (P (P " 0.019) difference medication-free survival curves vs. others). log-rank showed a significant " 0.019) difference in medication-free survival curves The percentage of patients requiring IOP-lowering medication to reach the target IOP at 1 year was 24% insignificantly the less between the different groups. More specifically, patients in the steroid group needed significantly medication between the different groups. More specifically, patients in the steroid group needed less medication over the in total follow-up (P group " over the total follow-up (P0.007). " 0.007). placebo group, 18% in the NSAID group, and 0% the steroid (P " 0.054 overall; P " 0.038 for steroids Conclusions: Topical ketorolac or fluorometholone for for 1 month before surgery was associated with improved Conclusions: Topical ketorolac or fluorometholone 1 month before surgery was associated with improved vs. others). The log-rank test showed a significant (P outcomes " outcomes 0.019) difference in medication-free survival curves trabeculectomy in terms of likelihood of of postoperative needling. In In thethe steroid group, there trabeculectomy in terms of likelihood postoperative needling. steroid group, therewas wasa a between the different groups. More specifically, patients in the steroid group neededIOP-lowering significantly less medication significantly reduced need for additional postoperative medication compared with thethe other groups. significantly reduced need for additional postoperative IOP-lowering medication compared with other groups. Financial Disclosure(s): TheThe author(s) have no no proprietary or commercial interest in any materials discussed Financial Disclosure(s): author(s) have proprietary or commercial interest in any materials discussed over the total follow-up (P " 0.007). in this article. Ophthalmology 2010;117:1324 –1330 © 2010 by by thethe American Academy of of Ophthalmology. in this article. Ophthalmology 2010;117:1324 –1330 © 2010 American Academy Ophthalmology. Conclusions: Topical ketorolac or fluorometholone for 1 month before surgery was associated with improved trabeculectomy outcomes in terms of likelihood of postoperative needling. In the steroid group, there was a significantly reduced need for additional postoperative IOP-lowering compared with the other groups. Trabeculectomy is the ofmedication choice to reduce intraocsubconjunctival fibrosis could notnot demonstrate Trabeculectomy is treatment the treatment of choice to reduce intraoc- operative operative subconjunctival fibrosis could demonstrate 19,20 19,20 (IOP) to further visual field dete-inany any benefits surgical outcome. ular ular pressure (IOP) and and to prevent further visual field detebenefits on on surgical outcome. Financial Disclosure(s): The author(s) have nopressure proprietary orprevent commercial interest any materials discussed 1–5 1–5 rioration in medically uncontrolled glaucoma. However, Preoperative anti-inflammatory treatment alternarioration in medically uncontrolled However, Preoperative anti-inflammatory treatment is is an an alternain this article. Ophthalmology 2010;117:1324 –1330 © 2010 by the glaucoma. American Academy of Ophthalmology. O que é conhecido of main the main causes of surgical failure is the occurrence tivetive or additional approach to counteract fibrosis. Bleb failone one of the causes of surgical failure is the occurrence or additional approach to counteract fibrosis. Bleb failof excessive postoperative scarring in the region of the ureure been associated with increasedconjunctival conjunctival of excessive postoperative scarring in the region of the hashas been associated with an an increased 21–23 21–23 scleral Many adjunctive antifibrotic therapies infiltration of fibroblasts inflammatory cells. Sevscleral flap.flap. Many adjunctive antifibrotic therapies to to infiltration of fibroblasts andand inflammatory cells. Sevcounteract this conjunctival scarring have been investieral studies have provided evidence that the long-term counteract this conjunctival scarring have been investieral studies have provided evidence that the long-term useuse 6 –136 –13 Two common antifibrotic agents, mitomycin C gated. of could IOP-lowering medication is associated with subclinical gated. Two common antifibrotic agents, mitomycin C of IOP-lowering is associated with subclinical Trabeculectomy is the treatment of choice to reduce intraocoperative subconjunctival fibrosis notmedication demonstrate and 5-fluorouracil, have been shown to enhance success conjunctival conjunctival inflammation. This inflammation is assumed 19,20 and 5-fluorouracil, have been shown to enhance success inflammation. This inflammation is assumed to to ular pressure (IOP) and to prevent further visual field deteany benefits on surgical outcome. 9 –139 –13 These rates after trabeculectomy. agents are associ- contribute contribute to subconjunctival scarring and subsequent bleb rates after trabeculectomy. These agents are associto subconjunctival scarring and subsequent bleb 24 –30 24 –30 rioration in medically uncontrolled glaucoma.1–5ated However, Preoperative anti-inflammatory treatment is surgery. ansurgery. alternaated complications as thin-walled avascu- failure failure after filtration Based aforemenwithwith complications suchsuch as thin-walled andand avascuafter filtration Based on on thethe aforemenlar blebs, hypotony, wound leaks, blebitis, endophthalmitis, tioned findings, it can be presumed suppression blebs, hypotony, wound blebitis, endophthalmitis, tioned findings, it can beBleb presumed thethe suppression of of one of the main causes of surgical failure is the lar occurrence tive orleaks, additional approach to counteract fibrosis. fail-thatthat 14 –18 14 –18 scleral melting. Further clinical trials using anti– conjunctival conjunctival inflammation caused long-term topical IOPand and scleral melting. Further clinical trials using anti– inflammation caused by by long-term topical IOPof excessive postoperative scarring in the region of thegrowth ure has associated with anlowering increased conjunctival transforming growth factor ! been antibodies to counteract post- lowering treatment may help to prevent excessive scartransforming factor ! antibodies to counteract posttreatment may help to prevent thethe excessive scar- scleral flap. Many adjunctive antifibrotic therapies to infiltration of fibroblasts and inflammatory cells.21–23 Sev© 2010 the American Academy of Ophthalmology ISSN 0161-6420/10/$–see front matter counteract this conjunctival scarring have been investieral studies have provided evidence that the long-term ISSN use 13241324 © 2010 by thebyAmerican Academy of Ophthalmology 0161-6420/10/$–see front matter Published by Elsevier doi:10.1016/j.ophtha.2009.11.038 Published by Elsevier Inc. Inc. doi:10.1016/j.ophtha.2009.11.038 6 –13 gated. Two common antifibrotic agents, mitomycin C of IOP-lowering medication is associated with subclinical and 5-fluorouracil, have been shown to enhance success conjunctival inflammation. This inflammation is assumed to 9 –13 rates after trabeculectomy. These agents are associcontribute to subconjunctival scarring and subsequent bleb ated with complications such as thin-walled and avascufailure after filtration surgery.24 –30 Based on the aforemenlar blebs, hypotony, wound leaks, blebitis, endophthalmitis, tioned findings, it can be presumed that the suppression of and scleral melting.14 –18 Further clinical trials using anti– conjunctival inflammation caused by long-term topical IOPtransforming growth factor ! antibodies to counteract postlowering treatment may help to prevent the excessive scar- O que é desconhecido 1324 © 2010 by the American Academy of Ophthalmology Published by Elsevier Inc. O que foi feito ISSN 0161-6420/10/$–see front matter doi:10.1016/j.ophtha.2009.11.038 Breusegem et al ! NSAID or Steroid before Trabeculectomy ring that leads to bleb failure after trabeculectomy. Therefore, a prospective, randomized, controlled clinical trial was conducted to test this hypothesis with regard to clinical outcomes. Patients and Methods This prospective, randomized, double-blind, placebo-controlled clinical trial was approved by the Institutional Review Board of University Hospitals Leuven, and it adhered to the tenets of the Declaration of Helsinki. All eligible patients who agreed to participate in the study signed an informed consent before enrollment. This study has been registered on www.clinicaltrials.gov (registration no. NCT00707421). Between July 2005 and October 2007, consecutive patients a purse-string technique. A combination preparation of tobramycin and dexamethasone (Tobradex; Alcon) was applied as an ointment at the end of the surgery and was continued as drops 4 times daily for 8 weeks. An individual target pressure was determined before surgery based on a previously published formula.35,36 Patients were examined on days 1 and 2, at weeks 1, 2, and 4, and at months 3, 6, 12, 18, and 24 after trabeculectomy. All patients continued to be followed up until all patients had completed their 2-year visit. Snellen visual acuity measurements were converted to logarithm of the minimum angle of resolution values enabling descriptive calculations. Intraocular pressure was measured by Goldmann applanation tonometry. If the IOP decreased insufficiently after filtration surgery, needling, laser suture lysis, or needling revision (in case of a flat bleb) was carried out or IOP-lowering medication was restarted to reach the target IOP. Primary outcome measures were incidence of additional surgical or medical interventions AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2014 I NTRAOCULAR PRESSURE (IOP) REDUCTION CAN SLOW the progression of visual field (VF) damage in glaucoma patients; however, despite apparently effective IOP control, some patients continue to progress.1 It is well known that IOP is higher in the supine position than when sitting.2–6 Moreover, the extent of IOP elevation from the sitting to the supine position is greater in primary open-angle glaucoma (OAG), ocular hypertension, and normal-tension glaucoma (NTG) than in normal subjects.6–8 In prospective studies of the effect of the lateral decubitus position on IOP in healthy volunteers, IOP in the lateral decubitus position was consistently higher in the dependent eye (the lower-positioned eye; eg, the right eye in the right lateral decubitus position) than in the nondependent eye (the upper-positioned eye; eg, the left eye in the right lateral decubitus position).9–11 Further, IOP in the dependent eye in the lateral decubitus position was consistently higher than that in the sitting or supine position.9–12 In 2 recent studies on OAG patients, IOP in the lateral decubitus position was consistently higher in the dependent eye than in the fellow eye, and dependent-eye IOP was consistently higher in the lateral decubitus position than in the sitting or supine position.13,14 People generally spend between one-quarter and onethird of their lives sleeping. During sleep, body position varies between the supine position and the lateral decubitus position, often more on 1 side than the other. Thus IOP elevation related to the lateral decubitus position might play a role in glaucoma progression.13,15,16 On the basis of questionnaire data, we previously suggested that the lateral decubitus position habitually preferred by glaucoma patients might be associated with asymmetric VF damage; however, the number of respondents was relatively small.13 In the present study, examining a large subject group, we verified our hypothesis on the association between the preferred sleeping position and asymmetric VF loss between eyes. British Journal of Psychology (2013), 104, 225–234 © 2012 The British Psychological Society www.wileyonlinelibrary.com ‘Beauty is in the eye of the beer holder’: People who think they are drunk also think they are attractive Laurent Bègue1∗ , Brad J. Bushman2,3 , Oulmann Zerhouni1 , Baptiste Subra4 and Medhi Ourabah5 1 University of Grenoble 2, France The Ohio State University, Columbus, Ohio, USA 3 VU University, Amsterdam, The Netherlands 4 University of Paris Descartes, France 5 University of Paris 8, Saint-Denis, France 2 Alcohol has many consequences on social perception and relationships. After a drink, intoxicated people see members of the opposite sex through ‘beer goggles’, which makes them look especially attractive (Jones, Jones, Thomas, & Piper, 2003; Lyvers, Cholakians, Puorro, & Sundram, 2011; Neave, Tsang, & Heather, 2008). But alcohol can also influence self-perceptions. Previous research on alcohol and self-awareness has found that alcohol reduces self-awareness by inhibiting self-relevant encoding processes (Hull, Levenson, Young, & Sher, 1983). The purpose of the present research is to test the hypothesis that alcohol consumption increases self-perceived attractiveness. Whereas meta-analytic reviews indicate that alcohol consumption enhances mood and sexual arousal (Hull & Bond, 1986), the link between alcohol consumption and self-perceived attractiveness remains to be clarified and theoretically developed. • Conhecido - primeira parte - tema geral do trabalho - vai do geral para o específico • Desconhecido - 1 frase - liga conhecido com a questão • O que foi feito - tema específico do trabalho (ligado ao título e ao objetivo) verbo no passado • Descrição do artigo -verbo no presente • Conhecido - primeira parte - tema geral do trabalho - vai do geral para o específico A automatização da perimetria constituiu um passo fundamental para a avaliação do campo visual, proporcionando um exame mais padronizado, mais reprodutível e com menor influência do examinador(1-2). Na clínica diária, as estratégias mais rápidas têm substituído as estratégias convencionais por proporcionarem menor cansaço durante a realização do exame e uma menor fadiga visual, gerando, conseqüentemente, resultados que representam com maior fidelidade o campo de visão(3-5). (...) • Desconhecido - 1 frase - liga conhecido com a questão A automatização da perimetria constituiu um passo fundamental para a avaliação do campo visual, proporcionando um exame mais padronizado, mais reprodutível e com menor influência do examinador(1-2). Na clínica diária, as estratégias mais rápidas têm substituído as estratégias convencionais por proporcionarem menor cansaço durante a realização do exame e uma menor fadiga visual, gerando, conseqüentemente, resultados que representam com maior fidelidade o campo de visão(3-5). (...) A sensibilidade dessa estratégia tem sido avaliada em pacientes glaucomatosos já familiarizados com o exame perimétrico e apresentou valores que variaram de 83% a 100%(6,9-10), de acordo com a severidade do glaucoma. Até onde conhecemos, não existe estudo que avalia a sensibilidade de SS envolvendo pacientes sem experiência prévia com perimetria. • Questão - tema específico do trabalho (ligado ao título e ao objetivo) O objetivo deste estudo é comparar as estratégias FT e SS em pacientes glaucomatosos sem nenhuma experiência perimétrica prévia, determinando a sensibilidade dessas estratégias no diagnóstico do glaucoma. A automatização da perimetria constituiu um passo fundamental para a avaliação do campo visual, proporcionando um exame mais padronizado, mais reprodutível e com menor influência do examinador(1-2). Na clínica diária, as estratégias mais rápidas têm substituído as estratégias convencionais por proporcionarem menor cansaço durante a realização do exame e uma menor fadiga visual, gerando, conseqüentemente, resultados que representam com maior fidelidade o campo de visão(3-5). (...) A sensibilidade dessa estratégia tem sido avaliada em pacientes glaucomatosos já familiarizados com o exame perimétrico e apresentou valores que variaram de 83% a 100%(6,9-10), de acordo com a severidade do glaucoma. Até onde conhecemos, não existe estudo que avalia a sensibilidade de SS envolvendo pacientes sem experiência prévia com perimetria. O objetivo deste estudo é comparar as estratégias FT e SS em pacientes glaucomatosos sem nenhuma experiência perimétrica prévia, determinando a sensibilidade dessas estratégias no diagnóstico do glaucoma. Rui Barroso SchimitiI; Enyr Saran ArcieriII; Rodrigo Rezende AvelinoIII; Tiemi MatsuoIV; Vital Paulino CostaV População e o tipo de estudo • População: geralmente implícito no texto mas pertence aos métodos • Tipo do estudo: ligado ou após o que foi feito tive or additional approach to counteract fibrosis. Bleb failure has been associated with an increased conjunctival 21–23 infiltration of fibroblasts and inflammatory cells. Several studies have provided evidence that the long-term use of IOP-lowering medication is associated with subclinical conjunctival inflammation. This inflammation is assumed to contribute to subconjunctival scarring and subsequent bleb failure after filtration surgery.24 –30 Based on the aforementioned findings, it can be presumed that the suppression of Breusegem et al ! topical NSAID or St conjunctival inflammation caused by long-term IOPlowering treatment may help to prevent the excessive scarring that leads to bleb failure after trabeculectomy. Therefore, a prospective, randomized, ISSN controlled clinical trial was 0161-6420/10/$–see front matter doi:10.1016/j.ophtha.2009.11.038 conducted to test this hypothesis with regard to clinical outcomes. População e o tipo de estudo Referências “Se eu fui capaz de ver mais longe é porque estava em pé nos ombros de gigantes.” Discurso de Martin Luther King Discurso realizado por Martin Luther King sobre as escadarias do Monumento Abraham Lincoln em Washington D.C.. Há cem anos, um grande americano, sob cuja sombra simbólica nos encontramos, assinava a Proclamação da Emancipação. Esse decreto fundamental foi como um raio de luz de esperança para milhões de escravos negros que tinham sido marcados a ferro nas chamas de uma vergonhosa injustiça. Veio como uma aurora feliz para terminar a longa noite do cativeiro. Mas, cem anos mais tarde, devemos enfrentar a realidade trágica de que o Negro ainda não é livre. Referências • Poucas e de preferência as mais relevantes para o assunto Alcohol has many consequences on social perception and relationships. After a drink, intoxicated people see members of the opposite sex through ‘beer goggles’, which makes them look especially attractive (Jones, Jones, Thomas, & Piper, 2003; Lyvers, Cholakians, Puorro, & Sundram, 2011; Neave, Tsang, & Heather, 2008). But alcohol can also influence self-perceptions. Previous research on alcohol and self-awareness has found that alcohol reduces self-awareness by inhibiting self-relevant encoding processes (Hull, Levenson, Young, & Sher, 1983). The purpose of the present research is to test the hypothesis that alcohol consumption increases self-perceived attractiveness. Whereas meta-analytic reviews indicate that alcohol consumption enhances mood and sexual arousal (Hull & Bond, 1986), the link between alcohol consumption and self-perceived attractiveness remains to be clarified and theoretically developed. • A declaração de Helsinki determina que estudos em humanos têm que se basear no conhecimento da literatura • metanálise citada ou ausência de trabalhos Importância do estudo • Implícito no texto ou declarada diretamente. • Cuidado com afirmações de ineditismo! (...) Até onde conhecemos, não existe estudo que avalia a sensibilidade de SS envolvendo pacientes sem experiência prévia com perimetria. O objetivo deste estudo é comparar as estratégias FT e SS em pacientes glaucomatosos sem nenhuma experiência perimétrica prévia, determinando a sensibilidade dessas estratégias no diagnóstico do glaucoma. Cuidado com falsos sinônimos e cognatos • Actually, but not until last year, laser cataract surgery is ... (de fato) • The questionary applicant was a very comprehensive man. (gordo?) • I’m afraid to be equivocated about the results (mentiroso) • An investigator must attend the hole experiment as a positive result could eventually happens (só no final) • The sample was placed in the recipient (no receptor) Ponto e Contraponto ‘Beauty is in the eye of the beer holder’: People who think they are drunk also think they are attractive Laurent Bègue1∗ , Brad J. Bushman2,3 , Oulmann Zerhouni1 , Baptiste Subra4 and Medhi Ourabah5 1 University of Grenoble 2, France The Ohio State University, Columbus, Ohio, USA 3 VU University, Amsterdam, The Netherlands 4 University of Paris Descartes, France 5 University of Paris 8, Saint-Denis, France 2 Alcohol has many consequences on social perception and relationships. After a drink, intoxicated people see members of the opposite sex through ‘beer goggles’, which makes them look especially attractive (Jones, Jones, Thomas, & Piper, 2003; Lyvers, Cholakians, Puorro, & Sundram, 2011; Neave, Tsang, & Heather, 2008). But alcohol can also influence self-perceptions. Previous research on alcohol and self-awareness has found that alcohol reduces self-awareness by inhibiting self-relevant encoding processes (Hull, Levenson, Young, & Sher, 1983). The purpose of the present research is to test the hypothesis that alcohol consumption increases self-perceived attractiveness. Whereas meta-analytic reviews indicate that alcohol consumption enhances mood and sexual arousal (Hull & Bond, 1986), the link between alcohol consumption and self-perceived attractiveness remains to be clarified and theoretically developed. The Steroids for Corneal Ulcers Trial (SCUT): Secondary 12-Month Clinical Outcomes of a Randomized Controlled Trial MUTHIAH SRINIVASAN, JEENA MASCARENHAS, REVATHI RAJARAMAN, MEENAKSHI RAVINDRAN, PRAJNA LALITHA, KIERAN S. O’BRIEN, DAVID V. GLIDDEN, KATHRYN J. RAY, CATHERINE E. OLDENBURG, MICHAEL E. ZEGANS, JOHN P. WHITCHER, STEPHEN D. MCLEOD, TRAVIS C. PORCO, THOMAS M. LIETMAN, AND NISHA R. ACHARYA, FOR THE STEROIDS FOR CORNEAL ULCERS TRIAL GROUP for bacterial corneal ulcers. In order to provide further evidence to guide treatment practices, the Steroids for Corneal Ulcers Trial (SCUT) assessed the effect of adjunctive corticosteroids on clinical outcomes in patients with bacterial corneal ulcers. The primary outcome of this trial revealed no benefit of adjunctive Overall, SCUT found no difference in clinical outcomes at 3 months between patients using corticosteroids vs pla15 cebo, but differences may arise after a longer period of time. It is possible that clinical benefits with corticosteroids are not seen until later because of delayed healing or effects Discurso de Martin Luther King Discurso realizado por Martin Luther King sobre as escadarias do Monumento Abraham Lincoln em Washington D.C.. Há cem anos, um grande americano, sob cuja sombra simbólica nos encontramos, assinava a Proclamação da Emancipação. Esse decreto fundamental foi como um raio de luz de esperança para milhões de escravos negros que tinham sido marcados a ferro nas chamas de uma vergonhosa injustiça. Veio como uma aurora feliz para terminar a longa noite do cativeiro. Mas, cem anos mais tarde, devemos enfrentar a realidade trágica de que o Negro ainda não é livre. Conhecido Pigs are well known for their house construction abilities. They use it for shelter and to prevent predator attacks(1). A pig house can be built out of straw, sticks, or bricks. Straw and sticks are cheaper and easier to use, but bricks usually provide tougher houses(2). The european black wolf is considered to be a very efficient predator. Black wolves are known to destroy pig houses leading to pig casualty in two out of three attempts(3). Desconhecido Although, epidemiological data suggests an association between house material and pig’s lifespan(4), there’s no strong evidence connecting pig's house resilience and successful black wolf attacks. Pergunta - o que foi feito Therefore, we examined the protection abilities of three different pig houses (made with straw, sticks, or bricks) against a single hungry european black wolf. Resumo • Introdução: curta, clara e cativante • Funil • Sabe, não sabe, pergunta • Cuidado com erros • Ponto e contra-ponto Obrigado!