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Falavigna M, de Araujo CLP, Barbosa AN, Belli KC, Colpani V, Dal-Pizzol F, da Silva RM, de Azevedo LCP, Dias MBS, do Amaral JLG, Dorneles GP, Ferreira JC, Freitas APDR, Gräf DD, Guimarães HP, Lobo SMA, Machado FR, Nunes MS, de Oliveira MS, Parahiba SM, Rosa RG, Santos VCC, Sobreira ML, Veiga VC, Xavier RM, Zavascki AP, Stein C, de Carvalho CRR. The II Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19 Joint Guidelines of the Associação Brasileira de Medicina de Emergência, Associação de Medicina Intensiva Brasileira, Associação Médica Brasileira, Sociedade Brasileira de Angiologia e Cirurgia Vascular, Sociedade Brasileira de Infectologia, Sociedade Brasileira de Pneumologia e Tisiologia and Sociedade Brasileira de Reumatologia. Crit Care Sci 2023; 35:243-255. [PMID: 38133154 PMCID: PMC10734807 DOI: 10.5935/2965-2774.20230136-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/09/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To update the recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. METHODS Experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. RESULTS Twenty-one recommendations were generated, including strong recommendations for the use of corticosteroids in patients using supplemental oxygen and conditional recommendations for the use of tocilizumab and baricitinib for patients on supplemental oxygen or on noninvasive ventilation and anticoagulants to prevent thromboembolism. Due to suspension of use authorization, it was not possible to make recommendations regarding the use of casirivimab + imdevimab. Strong recommendations against the use of azithromycin in patients without suspected bacterial infection, hydroxychloroquine, convalescent plasma, colchicine, and lopinavir + ritonavir and conditional recommendations against the use of ivermectin and remdesivir were made. CONCLUSION New recommendations for the treatment of hospitalized patients with COVID-19 were generated, such as those for tocilizumab and baricitinib. Corticosteroids and prophylaxis for thromboembolism are still recommended, the latter with conditional recommendation. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and to promote resource economy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Juliana Carvalho Ferreira
- Sociedade Brasileira de Pneumologia e Tisiologia - São Paulo
(SP), Brazil
- Associação de Medicina Intensiva Brasileira -
São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cinara Stein
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
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Wei WQ, Yan C, Grabowska M, Dickson A, Li B, Wen Z, Roden D, Stein C, Embí P, Peterson J, Feng Q, Malin B. Leveraging Generative AI to Prioritize Drug Repurposing Candidates: Validating Identified Candidates for Alzheimer's Disease in Real-World Clinical Datasets. Res Sq 2023:rs.3.rs-3125859. [PMID: 37503019 PMCID: PMC10371084 DOI: 10.21203/rs.3.rs-3125859/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Drug repurposing represents an attractive alternative to the costly and time-consuming process of new drug development, particularly for serious, widespread conditions with limited effective treatments, such as Alzheimer's disease (AD). Emerging generative artificial intelligence (GAI) technologies like ChatGPT offer the promise of expediting the review and summary of scientific knowledge. To examine the feasibility of using GAI for identifying drug repurposing candidates, we iteratively tasked ChatGPT with proposing the twenty most promising drugs for repurposing in AD, and tested the top ten for risk of incident AD in exposed and unexposed individuals over age 65 in two large clinical datasets: 1) Vanderbilt University Medical Center and 2) the All of Us Research Program. Among the candidates suggested by ChatGPT, metformin, simvastatin, and losartan were associated with lower AD risk in meta-analysis. These findings suggest GAI technologies can assimilate scientific insights from an extensive Internet-based search space, helping to prioritize drug repurposing candidates and facilitate the treatment of diseases.
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Affiliation(s)
| | - Chao Yan
- Vanderbilt University Medical Center
| | | | | | | | | | - Dan Roden
- Vanderbilt University Medical Center
| | - C Stein
- Vanderbilt University Medical Center
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Degro CE, Jiménez-Vargas NN, Schincariol HM, Tsang QK, Guzman-Rodriguez M, Lomax AE, Reed DE, Stein C, Bunnett NW, Vanner SJ. A277 A NOVEL PH-SENSITIVE Μ-OPIOID RECEPTOR AGONIST THAT DOES NOT INDUCE TOLERANCE IN A COLITIS MOUSE MODEL. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991237 DOI: 10.1093/jcag/gwac036.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Adequate pain control in inflammatory bowel disease (IBD) can require opioids due to their high analgesic potency. The long-term use of opioids, however, is limited by the development of tolerance. This leads to reduced analgesic efficacy over time, resulting in escalating opioid dosing and thus increased risk of serious side effects. We previously demonstrated the safety and effectiveness of a novel pH-sensitive µ-opioid receptor (MOR) agonist, NFEPP, in a murine colitis pain model, but its tolerance potential with chronic administration is unknown. Purpose To assess the tolerance potential of NFEPP compared to its parent compound fentanyl during acute colitis in a preclinical mouse model. Method Acute colitis in C57BL/6 mice was induced using 2.5% dextran sulphate sodium for 5 days. NFEPP or fentanyl were then administered s.c. every 4 hours between 7am and 11pm over 5 days in daily increasing concentrations (0.4-1.5 mg/kg/d). Analgesic tolerance to opioids was assessed in conscious mice by measuring visceromotor responses (VMRs) to noxious colorectal distensions. Tolerance to the MOR agonist DAMGO in NFEPP or fentanyl treated mice was evaluated using patch-clamp recordings from dorsal root ganglion (DRG) neurons and extracellular recordings from lumbar splanchnic nerves that innervate the colon. Inflammation was assessed by macroscopic analyses, histological scoring and tissue-pH measurements of the inflamed colon. Group differences were analyzed using two-way ANOVA with Bonferroni′s or Tukey′s post-test (p-value <0.05). Result(s) NFEPP significantly reduced VMRs before and after chronic NFEPP treatment (39% reduction, p<0.05 vs. 41% reduction, p<0.05, compared to baseline at 80 µl). No differences of NFEPP induced antinociceptive actions were observed comparing VMR measurements before and after chronic administration (p=0.44). However, the analgesic activity of fentanyl decreased over time with less VMR inhibition observed after chronic treatment compared to fentanyl naïve mice (p<0.05). Cross tolerance testing between these two opioids revealed a loss of NFEPP- induced VMR inhibition in fentanyl treated mice, but fentanyl effects in the NFEPP treatment group remained unchanged. In patch-clamp recordings, DAMGO (100nM) evoked antinociceptive actions in DRG neurons from NFEPP treated mice (rheobase increase: 50%, p<0.05, compared to vehicle) whereas no change in rheobase with DAMGO was observed in DRG neurons from fentanyl treated mice. Afferent nerve activity from lumbar splanchnic nerves in response to von Frey filament probing decreased after DAMGO (100nM) application in NFEPP treated mice (p<0.05, compared to control probing), but showed no change in fentanyl treated mice. Colonic length, diameter, histological damage and tissue-pH did not differ between the two opioid treatment groups. Conclusion(s) Chronic administration of NFEPP during acute murine colitis does not lead to analgesic tolerance within the visceral nociceptive system, in contrast to its parent compound fentanyl. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest None Declared
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Affiliation(s)
- C E Degro
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
| | - N N Jiménez-Vargas
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
| | - H M Schincariol
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
| | - Q K Tsang
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
| | - M Guzman-Rodriguez
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
| | - A E Lomax
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
| | - D E Reed
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
| | - C Stein
- Department of Experimental Anaesthesiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - N W Bunnett
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, United States
| | - S J Vanner
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Canada
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Haibel H, Sieper J, Poddubnyy D, Rios Rodriguez V, Proft F, Rademacher J, Igel S, Martus P, Stein C. OP0050 INTRAARTICULAR MORPHINE IN CHRONIC KNEE-ARTHRITIS – RESULTS OF A RANDOMIZED PLACEBO-CONTROLLED TRIAL. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundPatients with chronic inflammatory arthritis (e.g. rheumatoid arthritis; RA) or inflammatory exacerbations of chronic degenerative joint diseases (e.g. osteoarthritis; OA) suffer from recurrent pain, restricted function and reduction of daily activities. The current standard of intraarticular (i.a.) therapy is the injection of steroids, which can increase risk of infection, cartilage degenerations, and other well-known systemic side effects. A novel approach without such complications could be the activation of peripheral opioid receptors, e.g. by i.a. application of small, systemically inactive doses of morphine.ObjectivesThe aim of this randomized placebo-and active drug controlled double blind trial was to investigate reduction of pain in chronic knee arthritis patients following i.a. injections of morphine, a standard steroid (triamcinolone), or placebo. The primary hypothesis was that i.a. morphine results in significantly lower pain scores than placebo. The primary outcome parameter was reduction of the Visual Analogue Scale (VAS) pain at day 7.MethodsAdult patients with chronic knee arthritis because of osteoarthritis (OA) or inflammatory arthritis (IA, rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, oligoarthritis or monarthritis) and a high level of pain (VAS pain ≥ 4 out of 10) at baseline received a single dose of either morphine 3 mg i.a., or triamcinolone 40 mg i.a., or placebo (NaCl 0.9%) i.a., Patients were monitored closely throughout the entire study period with a total of 4 visits over weeks and documented pain in the morning and evening in a patient´s diary. Safety data was collected during the whole study period. P-values were calculated using two-sided T-tests.Results114 patients were screened, 93 were treated and 89 (96%) completed day 7. Of these n= 61 (66%) were diagnosed with OA and n= 32 (34%) with IA 48 (52%) patients were female, mean age was 58.5 (SD 14 years) and mean disease duration 6.7 years (median 2 years, range <1 year – 42 yearss, IQR <1 – 10 years). The mean VAS pain improvement at day 7 for morphine, triamcinolone and placebo was -22.8, -37.7, and -19.8 respectively. The differences were not significant (p=0.69) for placebo vs. morphine, but significant for placebo vs. triamcinolone and for triamcinolone vs. morphine (p=0.013 and p=0.006). Mean improvements of the everyday pain documentation are shown in Figure 1. During the study period, there were no serious adverse events and 45 adverse events, most of them were mild.Figure 1.Mean VAS pain over one week in patients with chronic knee arthritis treated with morphine, triamcinolone or placebo as a single intraarticular injection.ConclusionIn this randomized, placebo and active controlled double blind trial a single dose of 3 mg i.a. administered morphine did not lead to significant improvements in comparison to placebo and was inferior to triamcinolone at day 7. The same was true during the first 7 days as shown in the pain documentation in patient diaries. These data does not support the use of i.a. morphine for pain reduction in patients with chronic arthritis.Disclosure of InterestsHildrun Haibel Speakers bureau: AbbVie, MSD, Janssen, Roche and Pfizer, Consultant of: Roche, Boehringer, Janssen, MSD, Novartis, and Sobi, Grant/research support from: BMBF Neuroimpa 01EC1403F, Joachim Sieper Speakers bureau: Abbvie, Janssen, Lilly, Merck,Novartis, UCB, Consultant of: Abbvie, Lilly, Merck, Novartis, UCB, Denis Poddubnyy Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, and Pfizer, Valeria Rios Rodriguez: None declared, Fabian Proft Speakers bureau: Abbvie, BMS, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: Novartis, Judith Rademacher: None declared, Sabrina Igel: None declared, Peter Martus: None declared, Christoph Stein Grant/research support from: BMBF Neuroimpa 01EC1403F.
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Stein C, Helal L, Migliavaca CB, Sangalli CN, Colpani V, Raupp da Rosa P, Beck-da-Silva L, Rohde LE, Polanczyk CA, Falavigna M. Are the recommendation of sodium and fluid restriction in heart failure patients changing over the past years? A systematic review and meta-analysis. Clin Nutr ESPEN 2022; 49:129-137. [DOI: 10.1016/j.clnesp.2022.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/18/2022] [Accepted: 03/19/2022] [Indexed: 12/15/2022]
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Falavigna M, Belli KC, Barbosa AN, Zavascki AP, Nastri ACDSS, Santana CM, Stein C, Gräf DD, Cadegiani FA, Guimarães HP, Monteiro JT, Ferreira JC, de Azevedo LCP, Magri MMC, Sobreira ML, Dias MBGDS, de Oliveira MS, Corradi MDFDB, Rosa R, Heinzelmann RS, da Silva RM, Junior RB, Cimerman S, Colpani V, Veiga VC, de Carvalho CRR. Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT). Braz J Infect Dis 2022; 26:102347. [PMID: 35341739 PMCID: PMC8926872 DOI: 10.1016/j.bjid.2022.102347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 11/26/2022] Open
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Degro CE, Jiménez-Vargas NN, Tsang QK, Yu Y, Stein C, Bunnett NW, Lomax AE, Reed DE, Vanner S. A53 A NOVEL PH-SENSITIVE OPIOID ANALOGUE PROVIDES SUSTAINED ANALGESIA DURING COLONIC INFLAMMATION AND LACKS COMMON SIDE EFFECTS. J Can Assoc Gastroenterol 2022. [PMCID: PMC8859131 DOI: 10.1093/jcag/gwab049.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Opioids provide effective pain relief during flares of inflammatory bowel disease but are limited by serious side effects. We showed that acute administration of a novel pH-sensitive opioid agonist, NFEPP, had potent analgesic effects in inflamed acidified colonic tissues without opioid typical side effects. However, the effects of repeated application of NFEPP during the course of an acute flare of colonic inflammation are unknown.
Aims
To assess the analgesic and side effect profile resulting from repeated NFEPP applications during the course of acute colitis.
Methods
Acute colitis in C57BL/6 mice was induced via 2.5% dextran sulfate sodium dissolved in drinking water for 5 days. Mice were then randomly group assigned to either vehicle, fentanyl or NFEPP. Drugs and vehicle were administered sc. BID for 5 days (0.4 mg/kg), with a final injection on Day 6 (Day 1–6). Visceral nociception was evaluated by performing visceromotor responses (VMRs) to colorectal distension at different time points during colitis. Side effects were assessed using 1) a combination of oral contrast-enhanced abdominal CT-scans (before/after treatment) and defecation assessments to analyze gastrointestinal transit and isometric tension recordings to evaluate colon motility 2) pulse oximeter measurements to reveal cardiorespiratory effects. Inflammation was assessed by histological scoring, myeloperoxidase activity assay and tissue pH measurement of colon samples.
Results
NFEPP decreased VMRs to colorectal distension over the entire period of acute DSS colitis (Day 6: 40.54%, p<0.001, reduction compared to baseline). However, strongest VMR inhibition was observed at Day 3 (66.7%, p<0.05), concordant with the peak of inflammation (MPO: 3.5 U/mg tissue, p<0.001; tissue Damage-Score: 3.0, p<0.001; tissue pH: ΔpH= -0.28, p=0.001, all compared to healthy control). Treatment with NFEPP did not delay gastrointestinal transit (GIT, p=0.37, compared to baseline) nor fecal output (p=0.45, compared to vehicle) whereas fentanyl decreased transit (GIT: p<0.05; fecal output: p<0.05). Colonic contractile responses evoked by electrical field stimulation were reduced in fentanyl treated mice compared to NFEPP (10 Hz: p<0.05). Fentanyl significantly reduced oxygen saturation (15 min: 85% SpO2, p<0.01) and caused a sustained reduction in heart rate at Day 2 (60 min: Δ BPM -91.8 from baseline, p=0.001) whereas NFEPP did not affect oxygen saturation (p=0.95) and revealed minor, transient effects on heart rate (15 min: Δ BPM -75.6, p<0.01) which recovered after 60 min.
Conclusions
Prolonged NFEPP administration effectively inhibits visceral nociception during acute colitis in a preclinical mouse model without altering gastrointestinal transit, colon motility and oxygen saturation.
Funding Agencies
CCC
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Affiliation(s)
- C E Degro
- GIDRU, Queen’s University, Kingston, ON, Canada
| | | | - Q K Tsang
- Medicine, Queen’s University, Kingston, ON, Canada
| | - Y Yu
- GIDRU, Queen’s University, Kingston, ON, Canada
| | - C Stein
- Charite Universitatsmedizin Berlin, Berlin, Berlin, Germany
| | | | - A E Lomax
- Queen’s University, Kingston, ON, Canada
| | - D E Reed
- GIDRU Wing, Kingston General Hospital, Kingston, ON, Canada
| | - S Vanner
- GIDRU, Queen’s University, Kingston, ON, Canada
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Migliavaca CB, Stein C, Colpani V, Barker TH, Ziegelmann PK, Munn Z, Falavigna M. Meta-analysis of prevalence: I 2 statistic and how to deal with heterogeneity. Res Synth Methods 2022; 13:363-367. [PMID: 35088937 DOI: 10.1002/jrsm.1547] [Citation(s) in RCA: 85] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 01/18/2022] [Accepted: 01/24/2022] [Indexed: 11/06/2022]
Abstract
Over the last decade there has been a ten-fold increase in the number of published systematic reviews of prevalence. In meta-analyses of prevalence, the summary estimate represents an average prevalence from included studies. This estimate is truly informative only if there is no substantial heterogeneity among the different contexts being pooled. In systematic reviews, heterogeneity is usually explored with I-squared statistic (I2 ), but this statistic does not directly inform us about the distribution of effects and frequently systematic reviewers and readers misinterpret this result. In a sample of 134 meta-analyses of prevalence, the median I2 was 96.9% (IQR 90.5 to 98.7). We observed larger I2 in meta-analysis with higher number of studies and extreme pooled estimates (defined as <10% or > 90%). Studies with high I2 values were more likely to have conducted a sensitivity analysis, including subgroup analysis. Only 3 (2%) systematic reviews reported prediction intervals. Meta-analyses of prevalence often present high I2 values. However, the number of studies included in the meta-analysis and the point estimate can be associated with the I2 value, and a high I2 value is not always synonymous with high heterogeneity. In meta-analyses of prevalence, I2 statistics may not be discriminative and should be interpreted with caution, avoiding arbitrary thresholds. To discuss heterogeneity, reviewers should focus on the description of the expected range of estimates, which can be done using prediction intervals and planned sensitivity analysis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Celina Borges Migliavaca
- National Institute of Science and Technology for Health Technology Assessment (INCT / IATS), Clinical Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | | | | | - Timothy Hugh Barker
- JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Australia
| | - Patricia Klarmann Ziegelmann
- National Institute of Science and Technology for Health Technology Assessment (INCT / IATS), Clinical Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Zachary Munn
- JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Australia
| | - Maicon Falavigna
- National Institute of Science and Technology for Health Technology Assessment (INCT / IATS), Clinical Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Hospital Moinhos de Vento, Porto Alegre, Brazil.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Falavigna M, Stein C, do Amaral JLG, de Azevedo LCP, Belli KC, Colpani V, da Cunha CA, Dal-Pizzol F, Dias MBS, Ferreira JC, Freitas APDR, Gräf DD, Guimarães HP, Lobo SMA, Monteiro JT, Nunes MS, de Oliveira MS, Prado CCL, Santos VCC, da Silva RM, Sobreira ML, Veiga VC, Vidal ÁT, Xavier RM, Zavascki AP, Machado FR, de Carvalho CRR. Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19. Rev Bras Ter Intensiva 2022. [PMID: 35674525 PMCID: PMC9345589 DOI: 10.5935/0103-507x.20220001-en] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective Several therapies are being used or proposed for COVID-19, and many lack appropriate evaluations of their effectiveness and safety. The purpose of this document is to develop recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. Methods A group of 27 experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. Results Sixteen recommendations were generated. They include strong recommendations for the use of corticosteroids in patients using supplemental oxygen, the use of anticoagulants at prophylactic doses to prevent thromboembolism and the nonuse of antibiotics in patients without suspected bacterial infection. It was not possible to make a recommendation regarding the use of tocilizumab in patients hospitalized with COVID-19 using oxygen due to uncertainties regarding the availability of and access to the drug. Strong recommendations against the use of hydroxychloroquine, convalescent plasma, colchicine, lopinavir + ritonavir and antibiotics in patients without suspected bacterial infection and also conditional recommendations against the use of casirivimab + imdevimab, ivermectin and rendesivir were made. Conclusion To date, few therapies have proven effective in the treatment of hospitalized patients with COVID-19, and only corticosteroids and prophylaxis for thromboembolism are recommended. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and promote economical resource use.
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Affiliation(s)
- Maicon Falavigna
- Institute for the Evaluation of Health Technology, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brazil
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
- Corresponding author: Maicon Falavigna, Núcleo de Apoio à Pesquisa Hospital Moinhos de Vento Rua Ramiro Barcelos, 630/916, Zip code: 90035-001 - Porto Alegre (RS), Brazil E-mail:
| | - Cinara Stein
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
| | | | - Luciano Cesar Pontes de Azevedo
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brazil
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
| | | | | | - Clóvis Arns da Cunha
- Sociedade Brasileira de Infectologia - São Paulo (SP), Brazil
- Universidade Federal do Paraná - Curitiba (PR), Brazil
| | - Felipe Dal-Pizzol
- Experimental Pathophysiology Laboratory, Posgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense - Criciúma (SC), Brazil
| | - Maria Beatriz Souza Dias
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
| | - Juliana Carvalho Ferreira
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brazil
- Sociedade Brasileira de Pneumologia e Tisiologia - São Paulo (SP), Brazil
- Heart Institute, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
| | - Ana Paula da Rocha Freitas
- Associação Brasileira de Medicina de Emergência - São Paulo (SP), Brazil
- Hospital de Pronto-Socorro de Porto Alegre - Porto Alegre (RS), Brazil
| | | | | | - Suzana Margareth Ajeje Lobo
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brazil
- Faculdade de Medicina de São José do Rio Preto - São José do Rio Preto (SP), Brazil
| | | | - Michelle Silva Nunes
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brazil
- Empresa Brasileira de Serviços Hospitalares - São Paulo (SP), Brazil
| | | | - Clementina Corah Lucas Prado
- Department of Management and Incorporation of Technologies and Innovation in Health, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministério da Saúde - Brasília (DF), Brazil
| | - Vania Cristina Canuto Santos
- Department of Management and Incorporation of Technologies and Innovation in Health, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministério da Saúde - Brasília (DF), Brazil
| | | | - Marcone Lima Sobreira
- Sociedade Brasileira de Angiologia e Cirurgia Vascular - São Paulo (SP), Brazil
- Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - Botucatu (SP), Brazil
| | - Viviane Cordeiro Veiga
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brazil
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil
| | - Ávila Teixeira Vidal
- Department of Management and Incorporation of Technologies and Innovation in Health, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministério da Saúde - Brasília (DF), Brazil
| | | | | | - Flávia Ribeiro Machado
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brazil
- Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brazil
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Falavigna M, Stein C, Amaral JLGD, Azevedo LCPD, Belli KC, Colpani V, Cunha CAD, Dal-Pizzol F, Dias MBS, Ferreira JC, Freitas APDR, Gräf DD, Guimarães HP, Lobo SMA, Monteiro JT, Nunes MS, Oliveira MSD, Prado CCL, Santos VCC, Silva RMD, Sobreira ML, Veiga VC, Vidal ÁT, Xavier RM, Zavascki AP, Machado FR, Carvalho CRRD. Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19: Joint guideline of Associação Brasileira de Medicina de Emergência, Associação de Medicina Intensiva Brasileira, Associação Médica Brasileira, Sociedade Brasileira de Angiologia e Cirurgia Vascular, Sociedade Brasileira de Infectologia, Sociedade Brasileira de Pneumologia e Tisiologia, Sociedade Brasileira de Reumatologia. Rev Bras Ter Intensiva 2022; 34:1-12. [PMID: 35674525 DOI: 10.5935/0103-507x.20220001-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/10/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Several therapies are being used or proposed for COVID-19, and many lack appropriate evaluations of their effectiveness and safety. The purpose of this document is to develop recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. METHODS A group of 27 experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. RESULTS Sixteen recommendations were generated. They include strong recommendations for the use of corticosteroids in patients using supplemental oxygen, the use of anticoagulants at prophylactic doses to prevent thromboembolism and the nonuse of antibiotics in patients without suspected bacterial infection. It was not possible to make a recommendation regarding the use of tocilizumab in patients hospitalized with COVID-19 using oxygen due to uncertainties regarding the availability of and access to the drug. Strong recommendations against the use of hydroxychloroquine, convalescent plasma, colchicine, lopinavir + ritonavir and antibiotics in patients without suspected bacterial infection and also conditional recommendations against the use of casirivimab + imdevimab, ivermectin and rendesivir were made. CONCLUSION To date, few therapies have proven effective in the treatment of hospitalized patients with COVID-19, and only corticosteroids and prophylaxis for thromboembolism are recommended. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and promote economical resource use.
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Affiliation(s)
- Maicon Falavigna
- Instituto de Avaliação de Tecnologia em Saúde, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | - Cinara Stein
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | | | - Luciano Cesar Pontes de Azevedo
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brasil.,Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | | | - Clóvis Arns da Cunha
- Sociedade Brasileira de Infectologia - São Paulo (SP), Brasil.,Universidade Federal do Paraná - Curitiba (PR), Brasil
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de PósGraduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense - Criciúma (SC), Brasil
| | - Maria Beatriz Souza Dias
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Juliana Carvalho Ferreira
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brasil.,Sociedade Brasileira de Pneumologia e Tisiologia - São Paulo (SP), Brasil.,Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Ana Paula da Rocha Freitas
- Associação Brasileira de Medicina de Emergência - São Paulo (SP), Brasil.,Hospital de Pronto Socorro de Porto Alegre - Porto Alegre (RS), Brasil
| | | | | | - Suzana Margareth Ajeje Lobo
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brasil.,Faculdade de Medicina de São José do Rio Preto - São José do Rio Preto (SP), Brasil
| | | | - Michelle Silva Nunes
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brasil.,Empresa Brasileira de Serviços Hospitalares - São Paulo (SP), Brasil
| | | | - Clementina Corah Lucas Prado
- Departamento de Gestão e Incorporação de Tecnologias e Inovação em Saúde, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministério da Saúde - Brasília (DF), Brasil
| | - Vania Cristina Canuto Santos
- Departamento de Gestão e Incorporação de Tecnologias e Inovação em Saúde, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministério da Saúde - Brasília (DF), Brasil
| | | | - Marcone Lima Sobreira
- Sociedade Brasileira de Angiologia e Cirurgia Vascular - São Paulo (SP), Brasil.,Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - Botucatu (SP), Brasil
| | - Viviane Cordeiro Veiga
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brasil.,BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | - Ávila Teixeira Vidal
- Departamento de Gestão e Incorporação de Tecnologias e Inovação em Saúde, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministério da Saúde - Brasília (DF), Brasil
| | | | | | - Flávia Ribeiro Machado
- Associação de Medicina Intensiva Brasileira - São Paulo (SP), Brasil.,Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
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11
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Falavigna M, Stein C, Amaral JLGD, Azevedo LCPD, Belli KC, Colpani V, Cunha CAD, Dal-Pizzol F, Dias MBS, Ferreira JC, Freitas APDR, Gräf DD, Guimarães HP, Lobo SMA, Monteiro JT, Nunes MS, Oliveira MSD, Prado CCL, Santos NCC, Silva RMD, Sobreira ML, Veiga VC, Vidal ÁT, Xavier RM, Zavascki AP, Machado FR, Carvalho CRRD. Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19. Rev Bras Ter Intensiva 2022. [DOI: 10.5935/0103-507x.20220001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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12
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van der Schans J, Stein C. Patient journey as tool for measuring effectiveness and cost-effectiveness of community health interventions. Eur J Public Health 2021. [DOI: 10.1093/eurpub/ckab164.629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Myanmar, Vietnam, and Indonesia aim for a stronger interlinkage between primary and secondary health care as well as between health facilities and communities. The possibility to combine community-based facilities with primary health care will help to reduce costs and provide synergistic effects to interventions that are currently functioning on a standalone level. However, the evidence on (cost-) effectiveness of prevention and treatment targeted at NCDs, such as diabetes and hypertension, is scarce in Southeast Asia. Outside Southeast Asia multiple studies have shown the (cost-) effectiveness and efficiency in LMICs of service delivery of healthcare interventions (e.g., shifting the point of care), improvement of the health workforce (e.g., capacity building of healthcare workers), improvement of health information (e.g., monitoring of patients and people at risk), and health financing (e.g., community-based insurance system). This indicates the potential of adjusting existing interventions or tailoring new interventions to its local context within the field of NCD related supply of prevention and treatment. Matching the chronic care pathway (patient journey) of the country specific demand with possible improvements of the supply side of the health care system in place could help improve the (cost-) effectiveness and efficiency. To get more insight into the demand, services and outcomes of NCDs in Southeast Asia we identified the patient journeys and related methodology to evaluate (cost-)effective interventions for identifying individuals with high risks for developing NCDs, early treatment and lifestyle interventions, which fit in local cultures and health systems.
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Affiliation(s)
| | - C Stein
- SUNI-SEA Office, HelpAge, Yangon, Myanmar
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13
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Barker TH, Migliavaca CB, Stein C, Colpani V, Falavigna M, Aromataris E, Munn Z. Conducting proportional meta-analysis in different types of systematic reviews: a guide for synthesisers of evidence. BMC Med Res Methodol 2021; 21:189. [PMID: 34544368 PMCID: PMC8451728 DOI: 10.1186/s12874-021-01381-z] [Citation(s) in RCA: 185] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/31/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Single group data present unique challenges for synthesises of evidence. Proportional meta-analysis is becoming an increasingly common technique employed for the synthesis of single group data. Proportional meta-analysis shares many similarities with the conduct and reporting of comparative, or pairwise, meta-analysis. While robust and comprehensive methods exist detailing how researchers can conduct a meta-analysis that compares two (or more) groups against a common intervention, there is a scarcity of methodological guidance available to assist synthesisers of evidence in the conduct, interpretation, and importance of proportional meta-analysis in systematic reviews. MAIN BODY This paper presents an overview targeted to synthesisers of evidence and systematic review authors that details the methods, importance, and interpretation of a proportional meta-analysis. We provide worked examples of how proportional meta-analyses have been conducted in research syntheses previously and consider the methods, statistical considerations, and presentation of this technique. CONCLUSION This overview is designed to serve as practical guidance for synthesisers of evidence in the conduct of proportional meta-analyses.
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Affiliation(s)
- Timothy Hugh Barker
- JBI, The University of Adelaide, 55 King William Rd, North Adelaide, SA, 5006, Australia.
| | - Celina Borges Migliavaca
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Maicon Falavigna
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Edoardo Aromataris
- JBI, The University of Adelaide, 55 King William Rd, North Adelaide, SA, 5006, Australia
| | - Zachary Munn
- JBI, The University of Adelaide, 55 King William Rd, North Adelaide, SA, 5006, Australia
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14
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Nicolodi GV, Della Méa Plentz R, Righi NC, Stein C. Effects of aerobic exercise on patients with pre-dialysis chronic kidney disease: a systematic review of randomized controlled trials. Disabil Rehabil 2021; 44:4179-4188. [PMID: 34033723 DOI: 10.1080/09638288.2021.1900929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Reviewing systematically the randomized controlled trials (RCTs) that evaluated aerobic exercisealone vs. usual care in exercise tolerance, functional capacity, and quality of life (QoL) in patients withpre-dialysis. METHODS Searches in the MEDLINE, Cochrane CENTRAL, EMBASE, PEDro, and LILACS databases untilFebruary 2021 included RCTs that evaluated the effects of aerobic exercise on peak VO2, functional capacity,lower limb muscle strength, and QoL. The random effect meta-analysis model was used andreported as mean difference (MD) and 95% confidence interval (CI), risk of bias through RoB2.0 and thequality of evidence by GRADE. RESULTS 10 RCTs, with 365 patients. Aerobic exercise increased 2.07 ml/kg/min (95% CI = 1.16 to 2.98; I2= 24%, QoE moderate) at peak VO2; 77.78m (95% CI= 33.27 to 122.30; I2= 44.5%, QoE moderate) in the 6MWT and 7.65 repetitions (95% CI= 5.73 to 9.58; I2= 0 %; QoE moderate) in STS-30 versus usual care. In QoL, studies reported improvements in the questionnaire scores. Eu.2 = 24%, QoE moderado) no pico de VO2; 77,78 m (IC95% = 33,27-122,30; Eu.2 = 44,5%, QoE moderado) nas repetições 6MWT e 7,65 (IC95% = 5,73-9,58; Eu.2 = 0%; QoE moderado) em STS-30". CONCLUSION Aerobic exercise increases VO2 peak, functional capacity and lower limb muscle strength in patients with pre-dialysis. Effects on QoL appear to be beneficial.IMPLICATIONS FOR REHABILITATIONAerobic exercise should be encouraged in the rehabilitation of patients at any stage of chronic kidney disease.Aerobic exercise promotes improved exercise tolerance, functional capacity, and muscle strength of the lower limbs.There is some evidence to show it is beneficial to improve the quality of life.
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Affiliation(s)
- Graziela Valle Nicolodi
- Physiotherapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brasil.,Physiotherapy Department, Universidade de Cruz Alta (UNICRUZ), Cruz Alta, Brasil
| | - Rodrigo Della Méa Plentz
- Physiotherapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brasil
| | - Natiele Camponogara Righi
- Physiotherapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brasil
| | - Cinara Stein
- Physiotherapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brasil
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15
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Piccoli GF, Mesquita LA, Stein C, Aziz MM, Zoldan M, Degobi NAH, Spiazzi BF, Junior GLL, Colpani V, Gerchman F. Do GLP-1 Receptor Agonists Increase the Risk of Breast Cancer? A Systematic Review and Meta-Analysis. J Endocr Soc 2021. [PMCID: PMC8089886 DOI: 10.1210/jendso/bvab048.718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Risk of cancer is a major concern in the development of drugs for the treatment of obesity and diabetes. In randomized controlled trials (RCTs) of the liraglutide development program, a glucagon-like peptide-1 receptor agonist (GLP-1RA), subjects treated with the active drug had a higher absolute number of breast cancer events. Aim: To assess whether patients treated with GLP-1RAs had a higher risk of breast neoplasms. Methods: We searched MEDLINE, Embase, Web of Science, and CENTRAL from inception to February 8, 2020. Three pairs of reviewers examined and retrieved abstractsand full-text articles for RCTs of GLP-1RAs versus non-GLP-1RA controls(active or placebo) in adults with overweight, obesity, prediabetes, or diabetes,with a minimum follow-up period of 24 weeks and which reported at least oneevent of breast cancer or benign breast neoplasm. Divergences were dealt withby consensus. Researchers extracted study-level data and assessed within-study risk of bias with the RoB 2.0 tool and quality of evidence with GRADE. This study follows PRISMA reporting guidelines. Results: We included 52 trials, of which 50 reported breast cancer events and 11 reported benign breast neoplasms. Overall methodological quality was high. Among 48267 subjects treated with GLP-1RAs, 130 developed breast cancer compared to 107 of 40755 controls (relative risk [RR], 0.98; 95% confidence interval [CI], 0.76 to 1.26). Subset analyses according to follow-up, participant/investigator blinding, and type of GLP-1RA did not reveal any differences. The risk of benign breast neoplasms also did not differ between groups (RR, 0.99; 95% CI, 0.48 to 2.01). Trial sequential analysis provided evidence that the sample size was sufficient to avoid missing alternative results. Conclusion: Treatment with GLP-1RAs for obesity and diabetes does not increase the risk of breast neoplasms. Register: This systematic review was preregistered in PROSPERO (CRD42019132704).
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Affiliation(s)
| | | | | | | | - Maira Zoldan
- HOSPITAL DE CLINIC DE PORTO ALEGRE, Porto Alegre, Brazil
| | | | | | | | | | - Fernando Gerchman
- Federal University of Rio Grande do Sul - School of Medicine, Porto Alegre, Brazil
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16
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Piccoli GF, Mesquita LA, Stein C, Aziz M, Zoldan M, Degobi NAH, Spiazzi BF, Lopes Junior GL, Colpani V, Gerchman F. Do GLP-1 Receptor Agonists Increase the Risk of Breast Cancer? A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2021; 106:912-921. [PMID: 33248445 DOI: 10.1210/clinem/dgaa891] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Risk of cancer is a major concern in the development of drugs for the treatment of obesity and diabetes. In randomized controlled trials (RCTs) of the Liraglutide Clinical Development Program, subjects treated with a glucagon-like peptide-1 receptor agonist (GLP-1RA) had a higher absolute number of breast cancer events. OBJECTIVE To assess whether patients treated with GLP-1RAs had a higher risk of breast neoplasms. DATA SOURCES We searched MEDLINE, Embase, Web of Science, and CENTRAL from July 31, 2019 to February 8, 2020. STUDY SELECTION Reviewers assessed abstracts and full-text articles for RCTs of GLP-1RAs in adults with excessive weight and/or diabetes and a minimum follow-up of 24 weeks. DATA EXTRACTION Researchers extracted study-level data and assessed within-study risk of bias with the RoB 2.0 tool and quality of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE). DATA SYNTHESIS We included 52 trials, of which 50 reported breast cancer events and 11 reported benign breast neoplasms. Overall methodological quality was high. Among 48 267 subjects treated with GLP-1RAs, 130 developed breast cancer compared with 107 of 40 755 controls (relative risk [RR], 0.98; 95% confidence interval [CI], 0.76-1.26). Subset analyses according to follow-up, participant/investigator blinding, and type of GLP-1RA did not reveal any differences. The risk of benign breast neoplasms also did not differ between groups (RR, 0.99; 95% CI, 0.48-2.01). Trial sequential analysis provided evidence that the sample size was sufficient to avoid missing alternative results. CONCLUSIONS Treatment with GLP-1RAs for obesity and diabetes does not increase the risk of breast neoplasms.
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Affiliation(s)
- Giovana F Piccoli
- Endocrine and Metabolism Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Leonardo A Mesquita
- Graduate Program in Medical Sciences (Endocrinology), Department of Internal Medicine, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Cinara Stein
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Marina Aziz
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Maira Zoldan
- Endocrine and Metabolism Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Nathália A H Degobi
- Endocrine and Metabolism Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Bernardo F Spiazzi
- Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Verônica Colpani
- Endocrine and Metabolism Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Fernando Gerchman
- Endocrine and Metabolism Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Medical Sciences (Endocrinology), Department of Internal Medicine, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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17
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Yu Y, Jiménez-Vargas NN, Tsang QK, Lopez Lopez C, Jaramillo Polanco J, Stein C, Lomax AE, Reed DE, Bunnett N, Vanner S. A45 A NOVEL PH-SENSITIVE OPIOID ANALGESIC THAT SELECTIVELY INHIBITS NOCICEPTION IN DSS-INDUCED COLITIS. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Opioid drugs are used to treat pain in inflammatory bowel disease (IBD) but their side effects can cause serious morbidity. Therefore, we tested a novel opioid analgesic, ±)-N-(3-fluoro-1-phenethylpiperidine-4-yl)-N-phenylpropionamide (NFEPP) which selectively activates peripheral µ-opioid receptors at acidic pH, as occurs in inflamed tissue.
Aims
Evaluate whether NFEPP causes analgesia in the inflamed colon of DSS-colitis mice using both in vitro and in vivo techniques.
Methods
To measure the visceral motor reflex (VMR) in response to colorectal distention, EMG electrodes connected to a telemetric transmitter were implanted in mice (c57BL/6), after 10 days recovery acute dextran sodium sulfate (DSS) colitis was induced (5 days 2.5% DSS, 2 days water). VMR was measured 30 min after s.c. injection of vehicle or 0.2 mg/kg of NFEPP or fentanyl. Motility was assessed by fecal pellet count 1 hour after NFEPP. Colonic tissue pH was evaluated using the SNARF-4F-5 carboxylic acid probe. Excitability of mouse dorsal root ganglia (DRG) neurons was measured by recording the rheobase (minimum input current to fire an action potential) after superfusion of NFEPP (300 nM, 10 min) or vehicle at pH 6.5 or 7.4. Colonic afferent nerve responses to probing with a von Frey filament (1 gm) were examined before and after exposure to NFEPP (300 nM, 5 min superfusion) at pH 6.5 and 7.4 respectively. The data was analyzed with Welch’s t-test, 1- or 2-way ANOVA with post hoc Dunnett or Bonferroni or Tukey’s test.
Results
NFEPP significantly inhibited the VMR in response to distension in mice with colitis compared to vehicle (decreased response by 65%, P<0.001). NFEPP had no effect in control mice. Conversely, fentanyl caused a similar decreased response in both groups (DSS 79% and control 67%, P<0.001). Pelleting was not affected by NFEPP injection in either group compared to vehicle. The pH measurement revealed a more acidic environment in DSS colonic tissue (ΔpH0.37±0.14, P<0.05) compared to controls. In patch-clamp studies, NFEPP decreased DRG excitability at pH 6.5 compared to the baseline and vehicle (increased rheobase 53.84%, P<0.01 and 36.36%, P<0.05 respectively) but had no effect at pH 7.4. In colonic afferent nerve recordings, NFEPP significantly attenuated afferent responses (28.9% P<0.01) to probing at pH 6.5 but also had no effect at pH 7.4.
Conclusions
This pH-selective opioid agonist significantly inhibits pain at the site of inflammation where the tissue pH is acidic but has no effect in tissues where the pH is in the physiological range. Thus, NFEPP could be an effective opioid analgesic in IBD while being devoid of any unwanted side effects.
Funding Agencies
CCC
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Affiliation(s)
- Y Yu
- Queen’s University, Kingston, ON, Canada
| | | | - Q K Tsang
- Medicine, Queen’s University, Kingston, ON, Canada
| | - C Lopez Lopez
- Gastrointestinal Diseases Research Unit, Queen’s University, Kingston, ON, Canada
| | - J Jaramillo Polanco
- Gastrointestinal Diseases Research Unit, Queen’s University, Kingston, ON, Canada
| | - C Stein
- Freie Universitat Berlin, Berlin, Berlin, Germany
| | - A E Lomax
- Queen’s University, Kingston, ON, Canada
| | - D E Reed
- Queen’s University, Kingston, ON, Canada
| | | | - S Vanner
- Queen’s University, Kingston, ON, Canada
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18
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Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
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Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
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Migliavaca CB, Stein C, Colpani V, Eibel B, Bgeginski R, Simões MV, Rohde LE, Falavigna M. High-dose versus low-dose angiotensin converting enzyme inhibitors in heart failure: systematic review and meta-analysis. Open Heart 2020; 7:openhrt-2019-001228. [PMID: 32820054 PMCID: PMC7443275 DOI: 10.1136/openhrt-2019-001228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/07/2020] [Accepted: 07/13/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To systematically review evidence comparing the effect of low-dose versus high-dose ACE inhibitors (ACEIs) on all-cause and cardiovascular mortality and hospitalisation, functional capacity and side effects in patients with heart failure (HF). METHODS We searched PubMed, Embase, Cochrane CENTRAL and LILACS up to January 2019. We included randomised controlled trials (RCTs) comparing low-dose versus high-dose ACEIs in adults with HF with reduced left ventricular ejection fraction (HFrEF). Study selection and data extraction were performed by two independent reviewers. Risk of bias was assessed with RoB 2.0, and quality of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE). We conducted random effects meta-analysis and trial sequential analysis. RESULTS We included eight RCTs (5829 patients with HF). In comparison with low-dose ACEIs, high-dose ACEIs showed a non-significant effect on all-cause mortality (8 RCTs, n=5828, relative risk (RR) 0.95, 95% CI 0.88 to 1.02; moderate quality of evidence), cardiovascular mortality (6 RCTs, n=4048, RR 0.93, 95% CI 0.85 to 1.01; moderate quality of evidence), all-cause hospitalisation (5 RCTs, n=5394, RR 0.95, 95% CI 0.82 to 1.10; moderate quality of evidence) and cardiovascular hospitalisation (4 RCTs, n=5242, RR 0.98, 95% CI 0.83 to 1.17; low quality of evidence). High-dose ACEI increased functional capacity (4 studies, n=555, standardised mean difference 0.38, 95% CI 0.20 to 0.55; low quality of evidence) and the risk of hypotension (4 RCTs, n=3783, RR 1.64, 95% CI 1.30 to 2.05; moderate quality of evidence). High-dose ACEI had no effect on dizziness (3 RCTs, n=4994, RR 1.37, 95% CI 0.97 to 1.93; low quality of evidence), but decreased the risk of cough (4 RCTs, n=5146, RR 0.85, 95% CI 0.73 to 0.98; moderate quality of evidence). CONCLUSIONS The magnitude of benefit of using high dose versus low to intermediate doses of ACEIs might be less than traditionally suggested in clinical guidelines. These findings might help clinicians address the complex task of HF management in a more rational and timely fashion, saving efforts to implement strategies with the greatest net clinical benefit.
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Affiliation(s)
- Celina Borges Migliavaca
- Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil .,Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Cinara Stein
- Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| | - Verônica Colpani
- Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| | - Bruna Eibel
- Post Graduate Program in Health Sciences: Cardiology, Instituto de Cardiologia/Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS, Brazil.,Fisioterapia, Centro Universitário da Serra Gaúcha, Caxias do Sul, RS, Brazil
| | - Roberta Bgeginski
- School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | | | - Luiz Eduardo Rohde
- Cardiovascular Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Maicon Falavigna
- Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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20
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Migliavaca CB, Stein C, Colpani V, Munn Z, Falavigna M. Quality assessment of prevalence studies: a systematic review. J Clin Epidemiol 2020; 127:59-68. [PMID: 32679313 DOI: 10.1016/j.jclinepi.2020.06.039] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 05/19/2020] [Accepted: 06/30/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The objective of the study is to identify items and domains applicable for the quality assessment of prevalence studies. STUDY DESIGN AND SETTING We searched databases and the gray literature to identify tools or guides about the quality assessment of prevalence studies. After study selection, we abstracted questions applicable for prevalence studies and classified into at least one of the following domains: 'population and setting', 'condition measurement', 'statistics', and 'other'. PROSPERO registration:CRD42018088437. RESULTS We included 30 tools: eight (26.7%) specifically designed to appraise prevalence studies and 22 (73.3%) adaptable for this purpose. We identified 12 unique items in the domain "population and setting", 16 in the domain "condition measurement", and 14 in the domain "statistics". Of those, 25 (59.5%) were identified in the eight specific tools. Regarding the domain "other", we identified 77 unique items, mainly related to manuscript writing and reporting (n = 48, 62.3%); of those, 24 (31.2%) were identified in the eight specific tools and 53 (68.8%) in the additional 22 nonspecific tools. CONCLUSION We provide a comprehensive set of items classified by domains that can guide the appraisal of prevalence studies, conduction of primary prevalence studies, and update or development of tools to evaluate prevalence studies.
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Affiliation(s)
- Celina Borges Migliavaca
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, CEP 90035-003, Santa Cecília, Porto Alegre, Rio Grande do Sul, Brazil; Hospital Moinhos de Vento, Porto Alegre, Rua Ramiro Barcelos, 910, CEP 90035-001, Floresta, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Cinara Stein
- Hospital Moinhos de Vento, Porto Alegre, Rua Ramiro Barcelos, 910, CEP 90035-001, Floresta, Porto Alegre, Rio Grande do Sul, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento, Porto Alegre, Rua Ramiro Barcelos, 910, CEP 90035-001, Floresta, Porto Alegre, Rio Grande do Sul, Brazil
| | - Zachary Munn
- Joanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Maicon Falavigna
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, CEP 90035-003, Santa Cecília, Porto Alegre, Rio Grande do Sul, Brazil; Hospital Moinhos de Vento, Porto Alegre, Rua Ramiro Barcelos, 910, CEP 90035-001, Floresta, Porto Alegre, Rio Grande do Sul, Brazil
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Falavigna M, Colpani V, Stein C, Azevedo LCP, Bagattini AM, de Brito GV, Chatkin JM, Cimerman S, Corradi MDFDB, da Cunha CA, de Medeiros FC, de Oliveira Junior HA, Fritscher LG, Gazzana MB, Gräf DD, Marra LP, Matuoka JY, Nunes MS, Pachito DV, Pagano CGM, Parreira PDCS, Riera R, Silva Júnior A, Tavares BDM, Zavascki AP, Rosa RG, Dal-Pizzol F. Guidelines for the pharmacological treatment of COVID-19. The task-force/consensus guideline of the Brazilian Association of Intensive Care Medicine, the Brazilian Society of Infectious Diseases and the Brazilian Society of Pulmonology and Tisiology. Rev Bras Ter Intensiva 2020; 32:166-196. [PMID: 32667444 PMCID: PMC7405746 DOI: 10.5935/0103-507x.20200039] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Different therapies are currently used, considered, or proposed for the treatment of COVID-19; for many of those therapies, no appropriate assessment of effectiveness and safety was performed. This document aims to provide scientifically available evidence-based information in a transparent interpretation, to subsidize decisions related to the pharmacological therapy of COVID-19 in Brazil. METHODS A group of 27 experts and methodologists integrated a task-force formed by professionals from the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB), the Brazilian Society of Infectious Diseases (Sociedad Brasileira de Infectologia - SBI) and the Brazilian Society of Pulmonology and Tisiology (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT). Rapid systematic reviews, updated on April 28, 2020, were conducted. The assessment of the quality of evidence and the development of recommendations followed the GRADE system. The recommendations were written on May 5, 8, and 13, 2020. RESULTS Eleven recommendations were issued based on low or very-low level evidence. We do not recommend the routine use of hydroxychloroquine, chloroquine, azithromycin, lopinavir/ritonavir, corticosteroids, or tocilizumab for the treatment of COVID-19. Prophylactic heparin should be used in hospitalized patients, however, no anticoagulation should be provided for patients without a specific clinical indication. Antibiotics and oseltamivir should only be considered for patients with suspected bacterial or influenza coinfection, respectively. CONCLUSION So far no pharmacological intervention was proven effective and safe to warrant its use in the routine treatment of COVID-19 patients; therefore such patients should ideally be treated in the context of clinical trials. The recommendations herein provided will be revised continuously aiming to capture newly generated evidence.
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Affiliation(s)
- Maicon Falavigna
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Instituto para Avaliação de Tecnologia em Saúde, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
- Department of Health Research Methods, Evidence, and Impact, McMaster University - Hamilton, Canadá
| | - Verônica Colpani
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Programa de Pós-Graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Cinara Stein
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | - Luciano Cesar Pontes Azevedo
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Disciplina de Emergências Clínicas, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Angela Maria Bagattini
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Programa de Pós-Graduação em Medicina Tropical e Saúde Pública, Universidade Federal de Goiás - Goiânia (GO), Brasil
| | | | - José Miguel Chatkin
- Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
- Sociedade Brasileira de Pneumologia e Tisiologia - Brasília (DF), Brasil
| | - Sergio Cimerman
- Instituto de Infectologia Emílio Ribas - São Paulo (SP), Brasil
- Sociedade Brasileira de Infectologia - São Paulo (SP), Brasil
| | | | - Clovis Arns da Cunha
- Sociedade Brasileira de Infectologia - São Paulo (SP), Brasil
- Universidade Federal do Paraná - Curitiba (PR), Brasil
| | | | | | - Leandro Genehr Fritscher
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Marcelo Basso Gazzana
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
- Serviço de Pneumologia e Cirurgia Torácica, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | | | - Lays Pires Marra
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brasil
| | - Jessica Yumi Matuoka
- Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | - Daniela Vianna Pachito
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Fundação Getúlio Vargas - São Paulo (SP), Brasil
| | | | | | - Rachel Riera
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | | | | | - Alexandre Prehn Zavascki
- Serviço de Infectologia e Controle de Infecção, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Departamento de Medicina Interna, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense - Criciúma (SC), Brasil
- Serviço de Medicina Intensiva, Hospital São José - Criciúma (SC), Brasil
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Borges Migliavaca C, Stein C, Colpani V, Barker TH, Munn Z, Falavigna M. How are systematic reviews of prevalence conducted? A methodological study. BMC Med Res Methodol 2020; 20:96. [PMID: 32336279 PMCID: PMC7184711 DOI: 10.1186/s12874-020-00975-3] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/12/2020] [Indexed: 12/17/2022] Open
Abstract
Background There is a notable lack of methodological and reporting guidance for systematic reviews of prevalence data. This information void has the potential to result in reviews that are inconsistent and inadequate to inform healthcare policy and decision making. The aim of this meta-epidemiological study is to describe the methodology of recently published prevalence systematic reviews. Methods We searched MEDLINE (via PubMed) from February 2017 to February 2018 for systematic reviews of prevalence studies. We included systematic reviews assessing the prevalence of any clinical condition using patients as the unit of measurement and we summarized data related to reporting and methodology of the reviews. Results A total of 235 systematic reviews of prevalence were analyzed. The median number of authors was 5 (interquartile range [IQR] 4–7), the median number of databases searched was 4 (3–6) and the median number of studies included in each review was 24 (IQR 15–41.5). Search strategies were presented for 68% of reviews. Forty five percent of reviews received external funding, and 24% did not provide funding information. Twenty three percent of included reviews had published or registered the systematic review protocol. Reporting guidelines were used in 72% of reviews. The quality of included studies was assessed in 80% of reviews. Nine reviews assessed the overall quality of evidence (4 using GRADE). Meta-analysis was conducted in 65% of reviews; 1% used Bayesian methods. Random effect meta-analysis was used in 94% of reviews; among them, 75% did not report the variance estimator used. Among the reviews with meta-analysis, 70% did not report how data was transformed; 59% percent conducted subgroup analysis, 38% conducted meta-regression and 2% estimated prediction interval; I2 was estimated in 95% of analysis. Publication bias was examined in 48%. The most common software used was STATA (55%). Conclusions Our results indicate that there are significant inconsistencies regarding how these reviews are conducted. Many of these differences arose in the assessment of methodological quality and the formal synthesis of comparable data. This variability indicates the need for clearer reporting standards and consensus on methodological guidance for systematic reviews of prevalence data.
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Affiliation(s)
- Celina Borges Migliavaca
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil. .,Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Cinara Stein
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Timothy Hugh Barker
- JBI, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Zachary Munn
- JBI, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Maicon Falavigna
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Bernabe E, Marcenes W, Hernandez C, Bailey J, Abreu L, Alipour V, Amini S, Arabloo J, Arefi Z, Arora A, Ayanore M, Bärnighausen T, Bijani A, Cho D, Chu D, Crowe C, Demoz G, Demsie D, Dibaji Forooshani Z, Du M, El Tantawi M, Fischer F, Folayan M, Futran N, Geramo Y, Haj-Mirzaian A, Hariyani N, Hasanzadeh A, Hassanipour S, Hay S, Hole M, Hostiuc S, Ilic M, James S, Kalhor R, Kemmer L, Keramati M, Khader Y, Kisa S, Kisa A, Koyanagi A, Lalloo R, Le Nguyen Q, London S, Manohar N, Massenburg B, Mathur M, Meles H, Mestrovic T, Mohammadian-Hafshejani A, Mohammadpourhodki R, Mokdad A, Morrison S, Nazari J, Nguyen T, Nguyen C, Nixon M, Olagunju T, Pakshir K, Pathak M, Rabiee N, Rafiei A, Ramezanzadeh K, Rios-Blancas M, Roro E, Sabour S, Samy A, Sawhney M, Schwendicke F, Shaahmadi F, Shaikh M, Stein C, Tovani-Palone M, Tran B, Unnikrishnan B, Vu G, Vukovic A, Warouw T, Zaidi Z, Zhang Z, Kassebaum N. Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study. J Dent Res 2020; 99:362-373. [PMID: 32122215 PMCID: PMC7088322 DOI: 10.1177/0022034520908533] [Citation(s) in RCA: 551] [Impact Index Per Article: 137.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank’s classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.
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Affiliation(s)
| | - E. Bernabe
- E. Bernabe, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, Bessemer Road, London, SE5 9RS, UK.
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24
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Stein C, Jourde-Chiche N, Burtey S, Jacques Grob J, Monestier S, Richard MA, Gaudy C, Brunet P. Effets secondaires rénaux chez les patients traités par immunothérapie anti-PD1 pour un mélanome métastatique : analyse d’une cohorte de 239 patients. Ann Dermatol Venereol 2019. [DOI: 10.1016/j.annder.2019.09.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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25
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Antoniak K, Stein C, Deierlein A. Associations between maternal serum and urinary metal concentrations and birthweight. Ann Epidemiol 2019. [DOI: 10.1016/j.annepidem.2019.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Nicholson B, De Vries S, Stein C, Mould-Millman NK. 168 Developing a Standardized Basic Life Support Curriculum for Emergency Medical Services Providers in Africa: A Modified Delphi Expert Consensus Process. Ann Emerg Med 2019. [DOI: 10.1016/j.annemergmed.2019.08.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Opioids are the oldest and most potent drugs for the treatment of severe pain but they are burdened by detrimental side effects, such as respiratory depression, addiction potential, sedation, nausea and constipation. Their clinical application is undisputed in the treatment of acute (e.g. perioperative) and cancer pain but their long-term use in chronic pain has met increasing criticism and has contributed to the current "opioid crisis". OBJECTIVES This article reviews the pharmacological principles and new research strategies aiming at novel opioids with reduced side effects. The basic mechanisms underlying pain and opioid analgesia and other effects of opioids are outlined. To illustrate the clinical situation and medical problems, the plasticity of opioid receptors, intracellular signaling pathways, endogenous and exogenous opioid receptor ligands, central and peripheral sites of analgesic and side effects are discussed. CONCLUSION The epidemic of opioid misuse has shown that there is a lack of fundamental knowledge about the characteristics and management of chronic pain, that conflicts of interest and validity of models must be more intensively considered in the context of drug development and that novel analgesics with less addictive potential are urgently needed. Currently, the most promising perspectives appear to be augmenting endogenous opioid actions and the selective activation of peripheral opioid receptors.
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Affiliation(s)
- C Stein
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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do Amaral Sartori S, Stein C, Coronel CC, Macagnan FE, Plentz RDM. Effects of Transcutaneous Electrical Nerve Stimulation in Autonomic Nervous System of Hypertensive Patients: A Randomized Controlled Trial. Curr Hypertens Rev 2019; 14:66-71. [PMID: 29658440 DOI: 10.2174/1573402114666180416155528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with hypertension have altered autonomic nervous system function, which are increased sympathetic activity. Transcutaneous Electrical Nerve Stimulation (TENS) is a useful modality for pain control and has also been shown to be effective in the reduction of sympathetic activity in healthy subjects and individuals with cardiovascular diseases. OBJECTIVE The aim of this study was to verify the effects of transcutaneous electrical nerve stimulation by the evaluation of heart rate variability (HRV) in patients with essential hypertension. METHOD Twenty-eight patients received an application of low-frequency TENS(4 Hz) n=8, highfrequency TENS (100 Hz) n=10 or placebo TENS n=10 in paravertebral ganglionar region during thirty minutes. RESULTS After 4 Hz TENS, there was a decrease in the low-frequency (LFn.u.) component (57.71±9.46 vs 45.58±13.51, p<0.026) and an increase in the high-frequency (HFn.u.) component (33.03±13.83 vs 45.83±20.19, p <0.05) of HRV. After 100 Hz TENS and placebo, there were no changes in the LF and HF components. No significant differences were found in systolic blood pressure with low-frequency TENS (129.37± 15.48 vs 126.69 ± 15.21, p<0.490). There was an increase, although not significant, with high-frequency TENS (131.00 ± 15.97 vs 138.75 ± 25.79, p<0.121) and placebo (133.80 ± 29.85 vs 134.80 ± 29.72, p< 0.800). No differences were found in the diastolic blood pressure with low-frequency TENS and placebo, but there was a significant increase in high-frequency TENS (81.00 ± 11.78 vs 85.65 ± 13.68, p< 0.018). CONCLUSION Low-frequency TENS decreases sympathetic nervous system activity and increases parasympathetic nervous system activity and high-frequency TENS increases diastolic blood pressure, when applied on the paravertebral ganglionar region in the hypertensive patients.
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Affiliation(s)
| | - Cinara Stein
- Universidade Federal de Ciencias da Saude de Porto Alegre-UFCSPA, Porto Alegre-RS, Brazil
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Klose H, Chin K, Ewert R, Gall H, Parambil J, Poch D, Seyfarth H, Axelsen L, Schmitz SH, Stein C, Preston I. Safety, Tolerability and Pharmacokinetics Study in Patients with Pulmonary Arterial Hypertension (PAH) Temporarily Switching from Oral to IV Selexipag. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.1247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Pinto C, Salazar AP, Marchese RR, Stein C, Pagnussat AS. The Effects of Hydrotherapy on Balance, Functional Mobility, Motor Status, and Quality of Life in Patients with Parkinson Disease: A Systematic Review and Meta‐analysis. PM R 2019; 11:278-291. [DOI: 10.1016/j.pmrj.2018.09.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/10/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Camila Pinto
- Movement Analysis and Neurological Rehabilitation LaboratoryUniversidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) Porto Alegre Brazil
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Ana Paula Salazar
- Movement Analysis and Neurological Rehabilitation LaboratoryUniversidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) Porto Alegre Brazil
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Ritchele R Marchese
- Movement Analysis and Neurological Rehabilitation LaboratoryUniversidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) Porto Alegre Brazil
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Cinara Stein
- Health Sciences Graduate ProgramUniversidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) Porto Alegre Brazil
| | - Aline S Pagnussat
- Movement Analysis and Neurological Rehabilitation LaboratoryUniversidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) Porto Alegre Brazil
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
- Health Sciences Graduate ProgramUniversidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) Porto Alegre Brazil
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Vaz PG, Salazar APDS, Stein C, Marchese RR, Lukrafka JL, Plentz RDM, Pagnussat AS. Noninvasive brain stimulation combined with other therapies improves gait speed after stroke: a systematic review and meta-analysis. Top Stroke Rehabil 2019; 26:201-213. [PMID: 30735104 DOI: 10.1080/10749357.2019.1565696] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive brain stimulation (NIBS) techniques able to modulate cortical excitability. OBJECTIVE To determine the effects of NIBS combined with other therapies on gait speed after stroke. METHODS Electronic databases searched were PUBMED, EMBASE, COCHRANE, SCOPUS, SCIELO and PEDro. Eligibility criteria were randomized controlled trials that reported the effects of tDCS and rTMS combined with other therapies for improving gait speed, walking cadence, functional ambulation category (FAC) and motricity index (MI-LE) after stroke. Risk of bias was assessed by Cochrane risk of bias assessment tool. Mean differences (MD) and 95% confidence intervals were calculated. Quality of evidence was assessed by Grades of Researches, Assessment, Development and Evaluation approach. RESULTS Ten studies (226 subjects) were included in the meta-analysis. NIBS combined with other therapies was effective for improving gait speed (MD 0.09 m/s [95% CI, 0.05 to 0.13; I2 0%, p < 0.0001]). Gait speed improved in both acute/subacute (MD 0.08 m/s [95% CI, 0.02 to 0.14]) and chronic phases (MD 0.08 m/s [95% CI, 0.03 to 0.13]). Furthermore, inhibitory (MD 0.09 m/s [95% CI, 0.04 to 0.14]) and excitatory (MD 0.07 m/s [95% CI, 0.02 to 0.12]) protocols were effective to improve gait speed. NIBS was also effective to improve walking cadence but was unable to modify other outcomes (FAC and MI-LE). CONCLUSIONS This systematic review with meta-analysis synthesizes moderate-quality evidence that NIBS combined with other therapies are effective to improve gait speed after stroke. Systematic Review registration number: PROSPERO registration number CDR42015024237.
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Affiliation(s)
- Patricia Graef Vaz
- a Health Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil.,b Department of Physiotherapy , Centro Universitário Ritter dos Reis (UniRitter) - Laureate International Universities , Porto Alegre , Brazil.,c Movement Analysis and Neurological Rehabilitation Laboratory , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil
| | - Ana Paula da Silva Salazar
- c Movement Analysis and Neurological Rehabilitation Laboratory , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil.,d Rehabilitation Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil
| | - Cinara Stein
- a Health Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil
| | - Ritchele Redivo Marchese
- c Movement Analysis and Neurological Rehabilitation Laboratory , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil
| | - Janice Luisa Lukrafka
- c Movement Analysis and Neurological Rehabilitation Laboratory , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil.,d Rehabilitation Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil
| | - Rodrigo Della Méa Plentz
- a Health Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil.,d Rehabilitation Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil
| | - Aline Souza Pagnussat
- a Health Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil.,c Movement Analysis and Neurological Rehabilitation Laboratory , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil.,d Rehabilitation Sciences Graduate Program , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , Brazil
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Abstract
BACKGROUND Opioids are the oldest and most potent drugs for the treatment of severe pain but they are burdened by detrimental side effects, such as respiratory depression, addiction potential, sedation, nausea and constipation. Their clinical application is undisputed in the treatment of acute (e.g. perioperative) and cancer pain but their long-term use in chronic pain has met increasing criticism and has contributed to the current "opioid crisis". OBJECTIVES This article reviews the pharmacological principles and new research strategies aiming at novel opioids with reduced side effects. The basic mechanisms underlying pain and opioid analgesia and other effects of opioids are outlined. To illustrate the clinical situation and medical problems, the plasticity of opioid receptors, intracellular signaling pathways, endogenous and exogenous opioid receptor ligands, central and peripheral sites of analgesic and side effects are discussed. CONCLUSION The epidemic of opioid misuse has shown that there is a lack of fundamental knowledge about the characteristics and management of chronic pain, that conflicts of interest and validity of models must be more intensively considered in the context of drug development and that novel analgesics with less addictive potential are urgently needed. Currently, the most promising perspectives appear to be augmenting endogenous opioid actions and the selective activation of peripheral opioid receptors.
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Affiliation(s)
- C Stein
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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Silva DV, Waclawovsky G, Kramer AB, Stein C, Eibel B, Grezzana GB, Schaun MI, Lehnen AM. Comparison of Cardiac and Vascular Parameters in Powerlifters and Long-Distance Runners: Comparative Cross-Sectional Study. Arq Bras Cardiol 2018; 111:772-781. [PMID: 30281689 PMCID: PMC6263448 DOI: 10.5935/abc.20180167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/02/2018] [Accepted: 07/02/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cardiac remodeling is a specific response to exercise training and time exposure. We hypothesized that athletes engaging for long periods in high-intensity strength training show heart and/or vascular damage. OBJECTIVE To compare cardiac characteristics (structure and function) and vascular function (flow-mediated dilation [FMD] and peripheral vascular resistance [PVR]) in powerlifters and long-distance runners. METHODS We evaluated 40 high-performance athletes (powerlifters [PG], n = 16; runners [RG], n = 24) and assessed heart structure and function (echocardiography), systolic and diastolic blood pressure (SBP/DBP), FMD, PVR, maximum force (squat, bench press, and deadlift), and maximal oxygen uptake (spirometry). A Student's t Test for independent samples and Pearson's linear correlation were used (p < 0.05). RESULTS PG showed higher SBP/DBP (p < 0.001); greater interventricular septum thickness (p < 0.001), posterior wall thickness (p < 0.001) and LV mass (p < 0.001). After adjusting LV mass by body surface area (BSA), no difference was observed. As for diastolic function, LV diastolic volume, wave E, wave e', and E/e' ratio were similar for both groups. However, LA volume (p = 0.016) and BSA-adjusted LA volume were lower in PG (p < 0.001). Systolic function (end-systolic volume and ejection fraction), and FMD were similar in both groups. However, higher PVR in PG was observed (p = 0.014). We found a correlation between the main cardiovascular changes and total weight lifted in PG. CONCLUSIONS Cardiovascular adaptations are dependent on training modality and the borderline structural cardiac changes are not accompanied by impaired function in powerlifters. However, a mild increase in blood pressure seems to be related to PVR rather than endothelial function.
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Affiliation(s)
- Diego Vidaletti Silva
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Gustavo Waclawovsky
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Ana Beatriz Kramer
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
- Faculdade Sogipa de Educação Física, Porto
Alegre, RS - Brazil
| | - Cinara Stein
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Bruna Eibel
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Guilherme Brasil Grezzana
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Maximiliano Isoppo Schaun
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Alexandre Machado Lehnen
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
- Faculdade Sogipa de Educação Física, Porto
Alegre, RS - Brazil
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Stein C. WHO’s role as knowledge broker: the WHO European Region. Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky212.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- C Stein
- Division of Information, Evidence, Research and Innovation, WHO Regional Office for Europe, Copenhagen, Denmark
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O'Donovan M, Gapp C, Stein C. Burden of disease studies in the WHO European Region—an overview. Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky212.827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M O'Donovan
- School of Medicine, National University of Ireland, Galway, Ireland
| | - C Gapp
- WHO Regional Office for Europe, Copenhagen, Denmark
| | - C Stein
- WHO Regional Office for Europe, Copenhagen, Denmark
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Marcolino MAZ, Hauck M, Stein C, Schardong J, Pagnussat ADS, Plentz RDM. Effects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: systematic review and meta-analysis of randomized controlled trials. Disabil Rehabil 2018; 42:623-635. [PMID: 30326752 DOI: 10.1080/09638288.2018.1503736] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose: To evaluate the effects and to compare transcutaneous electrical nerve stimulation protocols, alone or as additional therapy in chronic post-stroke spasticity through a systematic review and meta-analysis of randomized clinical trials.Methods: Search was conducted in MEDLINE, Cochrane Library, EMBASE and Physiotherapy Evidence Database through November 2017 (CRD42015020146). Two independent reviewers performed articles selection, data extraction and methodological quality assessment using the Cochrane Collaboration's risk of bias tool. The main outcome was spasticity assessed with Modified Ashworth Scale or other valid scale. Meta-analysis was conducted using random effects method, and pooled-effect results are mean difference with 95% confidence interval.Results: Of 6506 articles identified, 10 studies with 360 subjects were included in the review. Transcutaneous electrical nerve stimulation alone or as additional therapy is superior to placebo TENS to reduce post-stroke spasticity assessed with Modified Ashworth Scale (-0.52 [-0.74 to -0.30] p < 0.0001, 6 studies), especially in lower limbs (-0.58 [-0.82 to -0.34] p < 0.0001, 5 studies), which is in accordance with the studies that used other scales. Low frequency TENS showed a slightly larger improvement than high-frequency, but without significant difference between subgroups. Most studies present low or unclear risk of bias.Conclusion: Transcutaneous electrical nerve stimulation can provide additional reduction in chronic post-stroke spasticity, mainly as additional therapy to physical interventions. Studies with better methodological quality and larger sample are needed to increase evidence power.Implications for RehabilitationTranscutaneous electrical nerve stimulation as additional treatment to physical interventions can lead to additional reduction in chronic post-stroke spasticity.High and low frequency transcutaneous electrical nerve stimulation showed similar results, with a smaller numerical superiority of low frequency TENS.More studies are needed to substantiate the best protocol of transcutaneous electrical nerve stimulation to the treatment of spasticity.
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Affiliation(s)
- Miriam Allein Zago Marcolino
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Melina Hauck
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Cinara Stein
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Jociane Schardong
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Aline de Souza Pagnussat
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil.,Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Rodrigo Della Méa Plentz
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil.,Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
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Miozzo AP, Stein C, Marcolino MZ, Sisto IR, Hauck M, Coronel CC, Plentz RDM. Effects of High-Intensity Inspiratory Muscle Training Associated with Aerobic Exercise in Patients Undergoing CABG: Randomized Clinical Trial. Braz J Cardiovasc Surg 2018; 33:376-383. [PMID: 30184035 PMCID: PMC6122761 DOI: 10.21470/1678-9741-2018-0053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/10/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Evaluate the interaction between high-intensity inspiratory muscle training (IMT) and aerobic exercise on physical capacity, respiratory muscle strength, peripheral muscle strength, and quality of life of patients who underwent coronary artery bypass grafting (CABG). METHODS Twenty-four patients underwent CABG were randomized into two groups. During 36 sessions, one group received IMT associated with aerobic exercise and the other group received only aerobic exercise. Primary outcome was the distance in the six-minute walk distance (6MWD) test. Secondary outcomes included respiratory muscle strength, peripheral muscle strength, and quality of life. Measures were taken at the baseline, at the 12th session, the 24th session, and 36th session. RESULTS Baseline characteristics were similar between the groups. There was no statistically significant difference between the two groups in any outcome [6MWD - P=0.935; peak oxygen consumption (PeakVO2) - P=0.853; maximal inspiratory pressure (MIP) - P=0.243; maximal expiratory pressure (MEP) - P=0.268; sitting-rising test (SRT) - P=0.212], but there was interaction in MIP (P=0.000) and all outcomes improved in the two groups (6MWD - P=0.000; PeakVO2 - P=0.000; MIP - P=0.000; MEP - P=0.000; SRT - P=0.000). CONCLUSION There was an improvement of all outcomes in both groups, but IMT was not able to provide additional benefits. The use of this combination should be used with caution to not generate higher costs in the rehabilitation process of these patients.
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Affiliation(s)
- Aline Paula Miozzo
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.,Instituto de Cardiologia, Porto Alegre, RS, Brazil
| | - Cinara Stein
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.,Instituto de Cardiologia, Porto Alegre, RS, Brazil
| | - Miriam Zago Marcolino
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.,Instituto de Cardiologia, Porto Alegre, RS, Brazil
| | - Isadora Rebolho Sisto
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.,Instituto de Cardiologia, Porto Alegre, RS, Brazil
| | - Melina Hauck
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.,Instituto de Cardiologia, Porto Alegre, RS, Brazil
| | - Christian Corrêa Coronel
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.,Instituto de Cardiologia, Porto Alegre, RS, Brazil
| | - Rodrigo Della Méa Plentz
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.,Instituto de Cardiologia, Porto Alegre, RS, Brazil
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Stein C, Laforet M, Cavaille G, Brunet P, Robert T. La rhéophérèse : option thérapeutique dans la maladie des emboles de cholestérol chez le patient dialysé. Nephrol Ther 2018. [DOI: 10.1016/j.nephro.2018.07.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Borges Migliavaca C, Stein C, Colpani V, René Pinto de Sousa Miguel S, Nascimento Cruz L, Oliveira Dantas R, Falavigna M. Isosorbide and nifedipine for Chagas' megaesophagus: A systematic review and meta-analysis. PLoS Negl Trop Dis 2018; 12:e0006836. [PMID: 30265663 PMCID: PMC6179300 DOI: 10.1371/journal.pntd.0006836] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/10/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Chagas disease is a neglected tropical disease. About 6 to 8 million people are chronically infected and 10% to 15% develop irreversible gastrointestinal disorders, including megaesophagus. Treatment focuses on improving symptoms, and isosorbide and nifedipine may be used for this purpose. METHODOLOGY We conducted a systematic review to evaluate the effectiveness of pharmacological treatment for Chagas' megaesophagus. We searched MEDLINE, Embase and LILACS databases up to January 2018. We included both observational studies and RCTs evaluating the effects of isosorbide or nifedipine in adult patients with Chagas' megaesophagus. Two reviewers screened titles and abstracts, selected eligible studies and extracted data. We assessed the risk of bias using NIH 'Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group' and RoB 2.0 tool. Overall quality of evidence was assessed using GRADE. PRINCIPAL FINDINGS We included eight studies (four crossover RCTs, four before-after studies). Three studies evaluated the effect of isosorbide on lower esophageal sphincter pressure (LESP), showing a significant reduction (mean difference -10.52mmHg, 95%CI -13.57 to-7.47, very low quality of evidence). Three studies reported the effect of isosorbide on esophageal emptying, showing a decrease in esophageal retention rates (mean difference -22.16%, 95%CI -29.94 to -14.38, low quality of evidence). In one study, patients on isosorbide reported improvement in the frequency and severity of dysphagia (moderate quality of evidence). Studies evaluating nifedipine observed a decrease in LESP but no effect on esophageal emptying (very low and low quality of evidence, respectively). Isosorbide had a higher incidence of headache as a side effect than nifedipine. CONCLUSIONS Although limited, available evidence shows that both isosorbide and nifedipine are effective in reducing esophageal symptoms. Isosorbide appears to be more effective, and its use is supported by a larger number of studies; nifedipine, however, appears to have a better tolerability profile. TRIAL REGISTRATION PROSPERO CRD42017055143. ClinicalTrials.gov CRD42017055143.
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Affiliation(s)
- Celina Borges Migliavaca
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Cinara Stein
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Verônica Colpani
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Centro Universitário FADERGS, Porto Alegre, Brazil
- Faculdade Meridional–IMED, Passo Fundo, Brazil
| | - Sandro René Pinto de Sousa Miguel
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment, Post Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Luciane Nascimento Cruz
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment, Post Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Roberto Oliveira Dantas
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maicon Falavigna
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment, Post Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
- Department of Health Research Methods, Evidence and Impact, McMaster University Health Sciences Centre, Hamilton, Canada
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Scarfogliere V, Cavaille G, Laforet M, Stein C, Brunet P, Robert T. Technique d’anticoagulation régionale avec un bain de dialyse sans calcium : étude pilote en centre d’hémodialyse chronique. Nephrol Ther 2018. [DOI: 10.1016/j.nephro.2018.07.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Stein C, Migliavaca CB, Colpani V, da Rosa PR, Sganzerla D, Giordani NE, Miguel SRPDS, Cruz LN, Polanczyk CA, Ribeiro ALP, Falavigna M. Amiodarone for arrhythmia in patients with Chagas disease: A systematic review and individual patient data meta-analysis. PLoS Negl Trop Dis 2018; 12:e0006742. [PMID: 30125291 PMCID: PMC6130878 DOI: 10.1371/journal.pntd.0006742] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/10/2018] [Accepted: 08/09/2018] [Indexed: 12/15/2022] Open
Abstract
Background Chagas disease is a neglected chronic condition caused by Trypanosoma cruzi, with high prevalence and burden in Latin America. Ventricular arrhythmias are common in patients with Chagas cardiomyopathy, and amiodarone has been widely used for this purpose. The aim of our study was to assess the effect of amiodarone in patients with Chagas cardiomyopathy. Methodology We searched MEDLINE, Embase and LILACS up to January 2018. Data from randomized and observational studies evaluating amiodarone use in Chagas cardiomyopathy were included. Two reviewers selected the studies, extracted data and assessed risk of bias. Overall quality of evidence was accessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Principal findings We included 9 studies (3 before-after studies, 5 case series and 1 randomized controlled trial). Two studies with a total of 38 patients had the full dataset, allowing individual patient data (IPD) analysis. In 24-hour Holter, amiodarone reduced the number of ventricular tachycardia episodes in 99.9% (95%CI 99.8%-100%), ventricular premature beats in 93.1% (95%CI 82%-97.4%) and the incidence of ventricular couplets in 79% (RR 0.21, 95%CI 0.11–0.39). Studies not included in the IPD analysis showed a reduction of ventricular premature beats (5 studies), ventricular tachycardia (6 studies) and ventricular couplets (1 study). We pooled the incidence of adverse side effects with random effects meta-analysis; amiodarone was associated with corneal microdeposits (61.1%, 95%CI 19.0–91.3, 5 studies), gastrointestinal events (16.1%, 95%CI 6.61–34.2, 3 studies), sinus bradycardia (12.7%, 95%CI 3.71–35.5, 6 studies), dermatological events (10.6%, 95%CI 4.77–21.9, 3 studies) and drug discontinuation (7.68%, 95%CI 4.17–13.7, 5 studies). Quality of evidence ranged from moderate to very low. Conclusions Amiodarone is effective in reducing ventricular arrhythmias, but there is no evidence for hard endpoints (sudden death, hospitalization). Although our findings support the use of amiodarone, it is important to balance the potential benefits and harms at the individual level for decision-making. Chagas disease is a chronic neglected tropical disease, with high prevalence and burden in Latin America. About 30% of chronically infected patients develop Chagas cardiomyopathy. Ventricular arrhythmias are common in patients with Chagas cardiomyopathy and treatment approaches include medications, resynchronization therapy, and implantable cardioverter defibrillator. Studies published from 1980 to 1990 have evaluated the effect of amiodarone. According to our systematic review and individual patient meta-analysis, amiodarone reduced ventricular tachycardia, ventricular premature beats and incidence of ventricular couplets. Although the strong evidence of clinical benefit with arrhythmia reduction, this information should be interpreted with caution, since arrhythmia is a surrogate outcome and since its clinical impact on death and hospitalization reduction over time is not clear. Little information was identified related to hard endpoints. Regarding side effects, our systematic review observed that amiodarone was associated with corneal microdeposits, gastrointestinal events, sinus bradycardia, dermatological events, pneumonitis, hypothyroidism and drug discontinuation. The currently available evidence shows that amiodarone seems to be an effective antiarrhythmic drug for patients with Chagas disease, especially in settings where an implantable cardioverter defibrillator is not available or affordable, but that a balance between potential benefits and harms at the individual level is needed.
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Affiliation(s)
- Cinara Stein
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- * E-mail: (CS); (MF)
| | - Celina Borges Migliavaca
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Verônica Colpani
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Centro Universitário FADERGS, Porto Alegre, Brazil
- Faculdade Meridional–IMED, Passo Fundo, Brasil
| | | | - Daniel Sganzerla
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Natalia Elis Giordani
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Sandro Renê Pinto de Sousa Miguel
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment, Post-Graduate Program of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Luciane Nascimento Cruz
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment, Post-Graduate Program of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Carisi Anne Polanczyk
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment, Post-Graduate Program of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Antonio Luiz P. Ribeiro
- National Institute of Science and Technology for Health Technology Assessment, Post-Graduate Program of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
- Hospital das Clinicas and School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maicon Falavigna
- Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil
- National Institute of Science and Technology for Health Technology Assessment, Post-Graduate Program of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
- Department of Health Research Methods, Evidence and Impact, McMaster University Health Sciences Centre, Hamilton, Canada
- * E-mail: (CS); (MF)
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Schmidt J, Stein C, Poorman K, Lehman J, Mangold A, Costello C, Nelson S, DiCaudo D, Sharma A, Cappel M, Sekar S, Tassone E, Adkins J, Drenner K, Liang W, Sekulic A. 1000 Molecular mapping of necrobiosis lipoidica for identification of disease mechanisms and novel therapeutic strategies. J Invest Dermatol 2018. [DOI: 10.1016/j.jid.2018.03.1012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schaible HG, Chang HD, Grässel S, Haibel H, Hess A, Kamradt T, Radbruch A, Schett G, Stein C, Straub RH. [Research consortium Neuroimmunology and pain in the research network musculoskeletal diseases]. Z Rheumatol 2018; 77:24-30. [PMID: 29654392 DOI: 10.1007/s00393-018-0459-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The research consortium Neuroimmunology and Pain (Neuroimpa) explores the importance of the relationships between the immune system and the nervous system in musculoskeletal diseases for the generation of pain and for the course of fracture healing and arthritis. MATERIAL AND METHODS The spectrum of methods includes analyses at the single cell level, in vivo models of arthritis and fracture healing, imaging studies on brain function in animals and humans and analysis of data from patients. RESULTS Proinflammatory cytokines significantly contribute to the generation of joint pain through neuronal cytokine receptors. Immune cells release opioid peptides which activate opioid receptors at peripheral nociceptors and thereby evoke hypoalgesia. The formation of new bone after fractures is significantly supported by the nervous system. The sympathetic nervous system promotes the development of immune-mediated arthritis. The studies show a significant analgesic potential of the neutralization of proinflammatory cytokines and of opioids which selectively inhibit peripheral neurons. Furthermore, they show that the modulation of neuronal mechanisms can beneficially influence the course of musculoskeletal diseases. DISCUSSION Interventions in the interactions between the immune system and the nervous system hold a great therapeutic potential for the treatment of musculoskeletal diseases and pain.
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Affiliation(s)
- H-G Schaible
- Institut für Physiologie 1/Neurophysiologie, Universitätsklinikum Jena, Friedrich Schiller Universität Jena, Teichgraben 8, 07743, Jena, Deutschland.
| | - H-D Chang
- Deutsches Rheuma-Forschungszentrum Berlin, ein Institut der Leibniz-Gemeinschaft, Berlin, Deutschland
| | - S Grässel
- Klinik und Poliklinik für Orthopädie, Experimentelle Orthopädie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - H Haibel
- Abteilung für Rheumatologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | - A Hess
- Institut für Pharmakologie, Universitätsklinikum Erlangen-Nürnberg, Erlangen, Deutschland
| | - T Kamradt
- Institut für Immunologie, Universitätsklinikum Jena, Friedrich Schiller Universität Jena, Jena, Deutschland
| | - A Radbruch
- Deutsches Rheuma-Forschungszentrum Berlin, ein Institut der Leibniz-Gemeinschaft, Berlin, Deutschland
| | - G Schett
- Klinik für Innere Medizin, Universitätsklinikum Erlangen-Nürnberg, Erlangen, Deutschland
| | - C Stein
- Klinik für Anästhesie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | - R H Straub
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Stein C, Fernandes RO, Miozzo AP, Coronel CC, Baroni BM, Belló-Klein A, Plentz RDM. Acute Effects of Low-Level Laser Therapy on Patients' Functional Capacity in the Postoperative Period of Coronary Artery Bypass Graft Surgery: A Randomized, Crossover, Placebo-Controlled Trial. Photomed Laser Surg 2018; 36:122-129. [PMID: 29466116 DOI: 10.1089/pho.2017.4270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the acute effects of low-level laser therapy (LLLT) on the functional capacity to exercise tested by incremental shuttle walking test (ISWT) after coronary artery bypass graft (CABG) surgery. METHODS Fifteen male patients (60 ± 9 years) were crossed over during the experiment, to compare the outcomes after active LLLT and placebo LLLT treatments. LLLT (850 nm, 200 mW, 30 J to each point, resulting in a total of 240 J per quadriceps muscle), using a multidiode cluster (five spots; 6 J/spot) in eight points per leg was performed 3 min before the ISWT. We analyzed distance walked, Borg scale of perceived exertion, heart rate, and brachial arterial blood pressure. Markers of tissue damage [lactate dehydrogenase (LDH)] and oxidative stress [lipid peroxidation, total thiol levels, and antioxidant enzyme activity of superoxide dismutase (SOD) and catalase (CAT)] were also measured in peripheral blood. RESULTS Comparison of the distances walked revealed no significant differences between the LLLT and placebo LLLT groups (p = 0.779). Regarding the Borg scale (p = 0.567), heart rate (p = 0.506) as well as systolic and diastolic blood pressure (p = 0.164 and p = 0.140, respectively), no differences were observed between LLLT and placebo LLLT groups. Application of LLLT was not able to change levels of LDH (p = 0.214), oxidative lipid damage (p = 0.733), total thiol levels (p = 0.925), SOD (p = 0.202), and CAT (p = 0.825) enzyme activities. CONCLUSIONS Acute LLLT improved neither functional capacity to exercise nor the markers of oxidation after CABG. TRIAL REGISTRATION Registered as a clinical trial (NCT02688426).
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Affiliation(s)
- Cinara Stein
- 1 Physical Therapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre, RS, Brazil .,2 Instituto de Cardiologia do Rio Grande do Sul (IC), Fundação Universidade de Cardiologia (FUC) , Porto Alegre, RS, Brazil
| | - Rafael Oliveira Fernandes
- 3 Laboratory of Cardiovascular Physiology, Institute of Basic Sciences of Health (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS) , Porto Alegre, Rio Grande do Sul, Brazil
| | - Aline Paula Miozzo
- 1 Physical Therapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre, RS, Brazil .,2 Instituto de Cardiologia do Rio Grande do Sul (IC), Fundação Universidade de Cardiologia (FUC) , Porto Alegre, RS, Brazil
| | - Christian Correa Coronel
- 1 Physical Therapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre, RS, Brazil .,2 Instituto de Cardiologia do Rio Grande do Sul (IC), Fundação Universidade de Cardiologia (FUC) , Porto Alegre, RS, Brazil
| | - Bruno Manfredini Baroni
- 1 Physical Therapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre, RS, Brazil
| | - Adriane Belló-Klein
- 3 Laboratory of Cardiovascular Physiology, Institute of Basic Sciences of Health (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS) , Porto Alegre, Rio Grande do Sul, Brazil
| | - Rodrigo Della Méa Plentz
- 1 Physical Therapy Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre, RS, Brazil
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Salazar APS, Vaz PG, Marchese RR, Stein C, Pinto C, Pagnussat AS. Noninvasive Brain Stimulation Improves Hemispatial Neglect After Stroke: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2018; 99:355-366.e1. [DOI: 10.1016/j.apmr.2017.07.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/13/2017] [Accepted: 07/16/2017] [Indexed: 10/19/2022]
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Reynolds C, Stein C, Atkinson T, Hurst A, Kimberlin D. P267 XMEN disease: an unexpected presentation of a rare primary immunodeficiency. Ann Allergy Asthma Immunol 2017. [DOI: 10.1016/j.anai.2017.08.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Spahn V, Del Vecchio G, Labuz D, Rodriguez-Gaztelumendi A, Massaly N, Temp J, Durmaz V, Sabri P, Reidelbach M, Machelska H, Weber M, Stein C. A nontoxic pain killer designed by modeling of pathological receptor conformations. Science 2017; 355:966-969. [PMID: 28254944 DOI: 10.1126/science.aai8636] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/30/2017] [Indexed: 12/12/2022]
Abstract
Indiscriminate activation of opioid receptors provides pain relief but also severe central and intestinal side effects. We hypothesized that exploiting pathological (rather than physiological) conformation dynamics of opioid receptor-ligand interactions might yield ligands without adverse actions. By computer simulations at low pH, a hallmark of injured tissue, we designed an agonist that, because of its low acid dissociation constant, selectively activates peripheral μ-opioid receptors at the source of pain generation. Unlike the conventional opioid fentanyl, this agonist showed pH-sensitive binding, heterotrimeric guanine nucleotide-binding protein (G protein) subunit dissociation by fluorescence resonance energy transfer, and adenosine 3',5'-monophosphate inhibition in vitro. It produced injury-restricted analgesia in rats with different types of inflammatory pain without exhibiting respiratory depression, sedation, constipation, or addiction potential.
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Affiliation(s)
- V Spahn
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - G Del Vecchio
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - D Labuz
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - A Rodriguez-Gaztelumendi
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - N Massaly
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - J Temp
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - V Durmaz
- Computational Molecular Design, Zuse-Institut Berlin, Takustrasse 7, Berlin, 14195, Germany
| | - P Sabri
- Computational Molecular Design, Zuse-Institut Berlin, Takustrasse 7, Berlin, 14195, Germany
| | - M Reidelbach
- Computational Molecular Design, Zuse-Institut Berlin, Takustrasse 7, Berlin, 14195, Germany
| | - H Machelska
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany
| | - M Weber
- Computational Molecular Design, Zuse-Institut Berlin, Takustrasse 7, Berlin, 14195, Germany
| | - C Stein
- Department of Anesthesiology and Critical Care Medicine, Charité-Universitätsmedizin Berlin Campus Benjamin Franklin, Freie Universität Berlin, Hindenburgdamm 30, Berlin 12203, Germany.
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Kringel D, Ultsch A, Zimmermann M, Jansen JP, Ilias W, Freynhagen R, Griessinger N, Kopf A, Stein C, Doehring A, Resch E, Lötsch J. Emergent biomarker derived from next-generation sequencing to identify pain patients requiring uncommonly high opioid doses. Pharmacogenomics J 2017; 17:419-426. [PMID: 27139154 PMCID: PMC5637232 DOI: 10.1038/tpj.2016.28] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 11/05/2015] [Accepted: 11/13/2015] [Indexed: 12/14/2022]
Abstract
Next-generation sequencing (NGS) provides unrestricted access to the genome, but it produces 'big data' exceeding in amount and complexity the classical analytical approaches. We introduce a bioinformatics-based classifying biomarker that uses emergent properties in genetics to separate pain patients requiring extremely high opioid doses from controls. Following precisely calculated selection of the 34 most informative markers in the OPRM1, OPRK1, OPRD1 and SIGMAR1 genes, pattern of genotypes belonging to either patient group could be derived using a k-nearest neighbor (kNN) classifier that provided a diagnostic accuracy of 80.6±4%. This outperformed alternative classifiers such as reportedly functional opioid receptor gene variants or complex biomarkers obtained via multiple regression or decision tree analysis. The accumulation of several genetic variants with only minor functional influences may result in a qualitative consequence affecting complex phenotypes, pointing at emergent properties in genetics.
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MESH Headings
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Biomarkers, Pharmacological/analysis
- Chronic Pain/drug therapy
- Chronic Pain/genetics
- Dose-Response Relationship, Drug
- Genotype
- High-Throughput Nucleotide Sequencing
- Humans
- Pharmacogenomic Testing
- Pharmacogenomic Variants
- Receptors, Opioid/genetics
- Receptors, Opioid, delta/genetics
- Receptors, Opioid, kappa/genetics
- Receptors, Opioid, mu/genetics
- Receptors, sigma/genetics
- Sigma-1 Receptor
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Affiliation(s)
- D Kringel
- Institute of Clinical Pharmacology, Goethe-University, Frankfurt am Main, Germany
| | - A Ultsch
- DataBionics Research Group, University of Marburg, Marburg, Germany
| | - M Zimmermann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - W Ilias
- Department of Anaesthesiology and Intensive Care Medicine, Vienna, Austria
| | - R Freynhagen
- Zentrum für Anästhesiologie, Intensivmedizin, Schmerztherapie & Palliativmedizin, Benedictus Krankenhaus Tutzing, Tutzing, Germany
- Klinik für Anästhesiologie, Technische Universität München, München, Germany
| | - N Griessinger
- Department of Anesthesiology, University Hospital Erlangen, Erlangen, Germany
| | - A Kopf
- Department of Anesthesiology and Critical Care Medicine, Freie Universität Berlin–Charité, Berlin, Germany
| | - C Stein
- Department of Anesthesiology and Critical Care Medicine, Freie Universität Berlin–Charité, Berlin, Germany
| | - A Doehring
- Institute of Clinical Pharmacology, Goethe-University, Frankfurt am Main, Germany
| | - E Resch
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project Group Translational Medicine and Pharmacology TMP, Frankfurt am Main, Germany
| | - J Lötsch
- Institute of Clinical Pharmacology, Goethe-University, Frankfurt am Main, Germany
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project Group Translational Medicine and Pharmacology TMP, Frankfurt am Main, Germany
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Lorscheitter J, Stein C, Plentz RDM. Methodological Quality of Randomized Clinical Trials of Respiratory Physiotherapy in Coronary Artery Bypass Grafting Patients in the Intensive Care Unit: a Systematic Review. Braz J Cardiovasc Surg 2017; 32:318-337. [PMID: 28977205 PMCID: PMC5613714 DOI: 10.21470/1678-9741-2017-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess methodological quality of the randomized controlled trials of physiotherapy in patients undergoing coronary artery bypass grafting in the intensive care unit. METHODS The studies published until May 2015, in MEDLINE, Cochrane and PEDro were included. The primary outcome extracted was proper filling of the Cochrane Collaboration's tool's items and the secondary was suitability to the requirements of the CONSORT Statement and its extension. RESULTS From 807 studies identified, 39 were included. Most at CONSORT items showed a better adequacy after the statement's publication. Studies with positive outcomes presented better methodological quality. CONCLUSION The methodological quality of the studies has been improving over the years. However, many aspects can still be better designed.
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Affiliation(s)
- Jaqueline Lorscheitter
- Graduate Program in Health Sciences, Universidade Federal de
Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS,
Brazil
| | - Cinara Stein
- Graduate Program in Health Sciences, Universidade Federal de
Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS,
Brazil
- Laboratory of Clinical Investigation, Instituto de Cardiologia do
Rio Grande do Sul (IC), Porto Alegre, RS, Brazil
- Fundação Universidade de Cardiologia (FUC), Porto
Alegre, RS, Brazil
| | - Rodrigo Della Méa Plentz
- Graduate Program in Health Sciences, Universidade Federal de
Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS,
Brazil
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da Silva Salazar AP, Stein C, de Souza Pagnussat A. Letter to the editor on "Textured and stimulating insoles for balance and gait impairments in patients with multiple sclerosis and Parkinson's disease: A systematic review and meta-analysis" by Martin Alfuth, Gait & Posture (2017) 51, 132-141. Gait Posture 2017; 55:23-24. [PMID: 28407506 DOI: 10.1016/j.gaitpost.2017.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Ana Paula da Silva Salazar
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
| | - Cinara Stein
- Health Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Aline de Souza Pagnussat
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Health Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
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