ReScape: transforming coral-reefscape images for quantitative analysis

Ever since the first image of a coral reef was captured in 1885, people worldwide have been accumulating images of coral reefscapes that document the historic conditions of reefs. However, these innumerable reefscape images suffer from perspective distortion, which reduces the apparent size of distant taxa, rendering the images unusable for quantitative analysis of reef conditions. Here we solve this century-long distortion problem by developing a novel computer-vision algorithm, ReScape, which removes the perspective distortion from reefscape images by transforming them into top-down views, making them usable for quantitative analysis of reef conditions. In doing so, we demonstrate the first-ever ecological application and extension of inverse-perspective mapping-a foundational technique used in the autonomous-driving industry. The ReScape algorithm is composed of seven functions that (1) calibrate the camera lens, (2) remove the inherent lens-induced image distortions, (3) detect the scene's horizon line, (4) remove the camera-roll angle, (5) detect the transformable reef area, (6) detect the scene's perspective geometry, and (7) apply brute-force inverse-perspective mapping. The performance of the ReScape algorithm was evaluated by transforming the perspective of 125 reefscape images. Eighty-five percent of the images had no processing errors and of those, 95% were successfully transformed into top-down views. ReScape was validated by demonstrating that same-length transects, placed increasingly further from the camera, became the same length after transformation. The mission of the ReScape algorithm is to (i) unlock historical information about coral-reef conditions from previously unquantified periods and localities, (ii) enable citizen scientists and recreational photographers to contribute reefscape images to the scientific process, and (iii) provide a new survey technique that can rigorously assess relatively large areas of coral reefs, and other marine and even terrestrial ecosystems, worldwide. To facilitate this mission, we compiled the ReScape algorithm into a free, user-friendly App that does not require any coding experience. Equipped with the ReScape App, scientists can improve the management and prediction of the future of coral reefs by uncovering historical information from reefscape-image archives and by using reefscape images as a new, rapid survey method, opening a new era of coral-reef monitoring.

Evidence-based pharmacological prophylaxis recommendations for venous thromboembolism in hospitalized acutely ill medical patients: a systematic review of clinical practice guidelines

Venous thromboembolism is a complex multifactorial disease considered the most common cause of preventable deaths in hospitalized patients. Recommendations about pharmacological venous thromboembolism prophylaxis in adult hospitalized patients are available in clinical practice guidelines for optimization of healthcare delivery and improvement of patient outcomes. We conducted a systematic review of clinical practice guidelines using ADAPTE to synthesize recommendations for pharmacological prophylaxis of venous thromboembolism in hospitalized medical patients at a medium complexity university hospital. Recommendations for pharmacological prophylaxis were extracted from seven clinical practice guidelines considered of high quality after assessment with the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. These recommendations will support discussion with specialists and implementation of practices in the setting of the hospital studied.

Factors associated with higher quality of clinical practice guidelines and their recommendations for the pharmacological treatment of depression: a systematic review

OBJECTIVE

The objective of this study was to assess the quality of clinical practice guidelines (CPGs) for the pharmacological treatment of depression along with their recommendations and factors associated with higher quality.

DESIGN

We conducted a systematic review that included CPGs for the pharmacological treatment of depression in adults.

DATA SOURCES

We searched for publications from 1 January 2011 to 31 December 2021, in MEDLINE, Cochrane Library, Embase, PsycINFO, BVS and 12 other databases and guideline repositories.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included CPGs containing recommendations for the pharmacological treatment of depression in adults at outpatient care setting, regardless of whether it met the U.S. National Academy of Medicine criteria, or not. If a CPG included recommendations for both children and adults, they were considered. No language restriction was applied.

DATA EXTRACTION AND SYNTHESIS

Data extraction was also conducted independently and in duplicate, a process that was validated in a previous project. The quality of the CPGs and their recommendations were assessed by three independent reviewers using Appraisal of Guidelines for Research and Evaluation (AGREE II) and Appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX). A CPG was considered to be of high quality if AGREE II Domain 3 was ≥60%; while their recommendations were considered high if AGREE-REX Domain 1 was ≥60%.

RESULTS

Seventeen out of 63 (27%) CPGs were classified as high quality, while 7 (11.1%) had high-quality recommendations. The factors associated with higher-scoring CPGs and recommendations in the multiple linear regression analyses were 'Handling of conflicts of interest', 'Multiprofessional team' and 'Type of institution'. 'Inclusion of patient representative in the team' was also associated with higher-quality recommendations.

CONCLUSIONS

The involvement of professionals from diverse backgrounds, the handling of conflicts of interest, and the inclusion of patients' perspectives should be prioritised by developers aiming for high-quality CPGs for the treatment of depression.

Guidelines' recommendations for the treatment-resistant depression: A systematic review of their quality

INTRODUCTION

Depression is a serious and widespread mental health disorder. A significant proportion of patients with depression fail to remit after two antidepressant treatment trials, a condition named treatment-resistant depression (TRD). Clinical practice guidelines (CPGs) are instruments aimed to improve diagnosis and treatment. This study objective is to systematically appraise the quality and elaborate a comparison of high-quality CPGs with high-quality recommendations aimed at TRD.

METHODS AND ANALYSIS

We searched several specialized databases and organizations that develop CPGs. Independent researchers assessed the quality of the CPGs and their recommendations using AGREE II and AGREE-REX instruments, respectively. We selected only high-quality CPGs that included definition and recommendations for TRD. We investigated their divergencies and convergencies as well as weak and strong points.

RESULTS

Among seven high-quality CPGs with high-quality recommendations only two (Germany's Nationale Versorgungs Leitlinie-NVL and US Department of Veterans Affairs and Department of Defense-VA/DoD) included specific TRD definition and were selected. We found no convergent therapeutic strategy among these two CPGs. Electroconvulsive therapy is recommended by the NVL but not by the VA/DoD, while repetitive transcranial magnetic stimulation is recommended by the VA/DoD but not by the NVL. While the NVL recommends the use of lithium, and a non-routine use of thyroid or other hormones, psychostimulants, and dopaminergic agents the VA/DoD does not even include these drugs among augmentation strategies. Instead, the VA/DoD recommends ketamine or esketamine as augmentation strategies, while the NVL does not mention these drugs. Other differences between these CPGs include antidepressant combination, psychotherapy as a therapeutic augmentation, and evaluation of the need for hospitalization all of which are only recommended by the NVL.

CONCLUSIONS

High-quality CPGs for the treatment of depression diverge regarding the definition and use of the term TRD. There is also no convergent approach to TRD from currently high-quality CPGs.

Recommendations for the pharmacological treatment of treatment-resistant depression: A systematic review protocol

INTRODUCTION

Depression is a serious and widespread mental health disorder. Although effective treatment does exist, a significant proportion of patients with depression fail to respond to antidepressant treatment trials, a condition named treatment-resistant depression. Efficient approach should be given this condition in order to revert the burden caused by depression. Clinical practice guidelines (CPGs) are evidence-based health promotion instruments to improve diagnosis and treatment. CPGs recommendations for treatment-resistant depression must be trustworthy. The objective of the proposed study is to systematically identify, appraise the quality of CPGs for the treatment of depression and elaborate a synthesis of recommendations for treatment-resistant depression of CPGs considered to be of high quality and with high quality recommendations.

METHODS AND ANALYSIS

We will search the databases of organizations, such as PubMed, Embase, Cochrane Library, PsycInfo, and the Virtual Health Library, and organizations that develop CPGs. Three independent researchers will assess the quality of the CPGs and their recommendations using the AGREE II and AGREE-REX instruments, respectively. Given the identification of divergences and convergences as well as weak and strong points among high quality CPGs, our work may help developers, clinicians and eventually patients.

ETHICS AND DISSEMINATION

No ethical approval is required for a systematic review, as no patient data will be used. The research results will be disseminated in conferences and submitted to a peer reviewed journal.

Quality of clinical practice guidelines for inadequate response to first-line treatment for depression according to AGREE II checklist and comparison of recommendations: a systematic review

OBJECTIVE

To assess similarities and differences in the recommended sequence of strategies among the most relevant clinical practice guidelines (CPGs) for the treatment of depression in adults with inadequate response to first-line treatment.

DATA SOURCES

We performed a systematic review of the literature spanning January 2011 to August 2020 in Medline, Embase, Cochrane Library and 12 databases recognised as CPGs repositories. CPGs quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

STUDY SELECTION

The eligibility criteria were CPGs that described pharmacological recommendations for treating depression for individuals aged 18 years or older in outpatient care setting. We included CPGs considered of high-quality (≥80% in domain 3 of AGREE II) or recognised as clinically relevant.

DATA EXTRACTION

Two independent researchers extracted recommendations for patients who did not respond to first-line pharmacological treatment from the selected CPGs.

RESULTS

We included 46 CPGs and selected 8, of which 5 were considered high quality (≥80% in domain 3 of AGREE II) and 3 were recognised as clinically relevant. Three CPGs did not define inadequate response to treatment and 3 did not establish a clear sequence of strategies. The duration of treatment needed to determine that a patient had not responded was not explicit in 3 CPGs and was discordant in 5 CPGs. Most CPGs agree in reassessing the diagnosis, assessing the presence of comorbidities, adherence to treatment, and increase dosage as first steps. All CPGs recommend psychotherapy, switching antidepressants, and considering augmentation/combining antidepressants.

CONCLUSION

Relevant CPGs present shortcomings in recommendations for non-responders to first-line antidepressant treatment including absence and divergencies in definition of inadequate response and sequence of recommended strategies. Overall, most relevant CPGs recommend reassessing the diagnosis, evaluate comorbidities, adherence to treatment, increase dosage of antidepressants, and psychotherapy as first steps.

PROSPERO REGISTRATION NUMBER

CRD42016043364.

Association of Cognitive Performance with Frailty in Older Individuals with Cognitive Complaints

OBJECTIVES

Frailty is a risk factor for poor cognitive performance in older adults. However, few studies have evaluated the association of cognitive performance with frailty in a low- to middle-income country (LMIC). This study aimed to investigate an association between cognitive performance and frailty in older adults with memory complaints in Brazil. Secondarily, we aim to assess an association of cognitive performance with gait speed and grip strength.

DESIGN

Cross-sectional study.

SETTING

Outpatient service from a LMIC.

PARTICIPANTS

Older adults with memory complaints reported by the participants, their proxies, or their physicians.

MEASUREMENTS

Frailty was evaluated using the Cardiovascular Health Study criteria. A neuropsychological battery evaluated memory, attention, language, visuospatial function, executive function. Linear regression analysis with adjustment for age, sex, and education was used. We also evaluated the interaction of education with frailty, grip strength, and gait speed.

RESULTS

Prefrailty was associated with poor performance in the memory domain, as well as slower gait speed was associated with worse performance in memory, attention, language, and executive function. Frailty and grip strength were not associated with cognitive performance. Interactions of education with gait speed were significant for global performance, as well as for attention and visuospatial ability.

CONCLUSION

In elderly patients with memory complaints, prefrailty was associated with poor memory performance. Slowness was associated with poorer performance in some cognitive domains, mainly in participants with low education.

ATIVIDADE INIBITÓRIA DE PESTICIDAS PIRETROIDES SOBRE A GLUTATIONA S-TRANSFERASE

INHIBITORY ACTIVITY OF PYRETHROID PESTICIDES ON GLUTATHIONE S-TRANSFERASE. Glutathione S-transferase (GST) is one of the enzymes used to evaluate the effects caused by environmental contaminants. The aim of this work was to study the effects of four pyrethroid compounds (allethrin, cypermethrin, deltamethrin and fenpropathrin) on the catalytic activity of GST and to estimate the potential for environmental contamination in silico of these insecticides. Spectrophotometric analyses showed that the activity of the GST enzyme was inhibited by the four pesticides, with the values for the inhibition constant (Ki) varying from 0.12 to 20 µmol L-1, with the following order of inhibition from the highest to the lowest Ki value: deltamethrin > cypermethrin > allethrin > fenpropathrin. They presented a competitive and non-competitive inhibition mechanism depending on the compound. The IC50 values (concentration that inhibits 50% of the enzyme activity) showed the insecticide deltamethrin with greater inhibitory capacity, since it reduced the activity of the GST enzyme by half, even though it was in a lower concentration in relation to the other analyzed compounds. The in silico evaluation indicated the possibility of most of the insecticides contaminating the surface waters (rivers and lakes) adhered to the suspended sediment, but did not show any potential for contamination of groundwater through leaching.

Guidelines for hypertension management in primary care: is local adaptation possible?

OBJECTIVE

Hypertension affects more than one billion people worldwide. There has been much discussion about clinical practice guidelines (CPGs) following the proposal of lower thresholds for starting pharmacological treatment. Some smaller groups or institutions could benefit from adapting CPGs to their local context, a process that requires high-quality CPGs with few points of conflict in their recommendations. To address this issue, we have compared high-quality hypertension CPGs and highlighted conflicting recommendations.

METHODS

CPGs were searched in MEDLINE, Embase, the Cochrane Library, as well as specific websites. Only CPGs published between 2016 and 2019 were included. We defined CPGs as high-quality if the 'rigor of development' and 'editorial independence' AGREE II domains were scored at least 60%. We compared recommendations made by high-quality CPGs and highlighted areas of conflict (defined as disagreements between more than two CPGs).

RESULTS

Nineteen CPGs were identified. The highest scoring domain was 'scope and purpose' (74.3%) and the lowest scoring was 'applicability' (40.0%). Eight CPGs were rated as high quality. Most CPG recommendations on the management of hypertension were consistent. Conflicting recommendations were regarding blood pressure (BP) levels to initiate pharmacotherapy and therapeutic goals, particularly in patients with low cardiovascular risk and older patients.

CONCLUSION

It is possible to adapt hypertension CPGs once high-quality documents have been identified with agreement between most recommendations. Guideline developers can focus on the adaption process and concentrate efforts on implementation.

Conhecimento inadequado sobre medicamentos prescritos e seus preditores em pacientes muito idosos e seus cuidadores

Resumo Objetivo Identificar preditores do conhecimento inadequado sobre medicamentos prescritos a pacientes ambulatoriais muito idosos e seus cuidadores. Método O conhecimento sobre os medicamentos prescritos para 80 pacientes com 80 anos ou mais de idade foi avaliado por meio de um questionário validado, em uma entrevista realizada com os pacientes ou seus cuidadores (quando os pacientes apresentavam dificuldades de comunicação, demência ou qualquer necessidade de assistência para ajudá-los a usar medicamentos). Dois modelos de regressão logística hierárquica avaliaram a associação entre conhecimento inadequado sobre medicamentos e variáveis sociodemográficas e medicamentosas. Resultados Trinta e nove (48,8%) entrevistados eram cuidadores. Conhecimento inadequado foi encontrado em 81,5% (404/496) dos medicamentos prescritos. Forma de administração, Dose, Frequência e Duração do Tratamento foram os aspectos de maior conhecimento, enquanto Reações Adversas, Precauções, Interações e Contraindicações, os de menor. No primeiro modelo, o conhecimento inadequado foi associado à escolaridade do ensino fundamental completo ao médio incompleto (Razão de Chances (RC):0,12; p=0,018), do médio ao superior incompleto (RC:0,12; p<0,001), superior completo (RC:0,13; p<0,001), agentes que atuam no sistema renina-angiotensina (SRA) (RC:0,30; p=0,001), diuréticos (RC:0,31; p=0,013) e antitrombóticos (RC:12,59; p=0,027). No segundo modelo, os preditores foram cuidadores (RC:0,17; p<0,001), agentes que atuam no SRA (RC:0,33; p=0,002), diuréticos (RC:0,35; p=0,024) e antitrombóticos (RC:12,57; p=0,026). Conclusão A maioria dos medicamentos prescritos para pessoas muito idosas é pouco conhecida. Além disso, o aconselhamento acerca de informações sobre medicamentos deve ser mais intensivo para os pacientes do que para seus cuidadores, com foco em informações de segurança e ser direcionado a antitrombóticos.

Comparison of the methodological quality and transparency of Brazilian practice guidelines

This study aims to compare the differences between clinical practice guidelines (CPGs) of the Ministry of Health (MoH) and those of other Brazilian health institutions. A systematic review of Brazilian CPGs was carried out. CPGs with recommendations for the pharmacological treatment of non-communicable disease (NCDs) were included. CPG methodological quality and transparency was independently assessed by 2 reviewers using the AGREE II. CPGs were rated as high, moderate, and low quality (ranging from A to C). Twenty-six CPGs were assessed for quality. MoH CPGs were published more recently, and were of better quality than the others: 6/6 (100%) were rated as Moderate-A. Although CPGs presented a wide range of methodological quality and transparency, MoH CPGs presented better consistency in the preparation method. To avoid confusion and to improve the quality of care within finite resources in Brazil, and to avoid potential bias, conflicts of interest, national CPGs used within SUS should be developed by Conitec with partners who have no conflict of interest.

[Validation of the "Conocimiento del Paciente sobre sus Medicamentos" (CPM-ES-ES) questionnaire]

This work cross-culturally adapted the Spanish questionnaire `Patients' knowledge about their medications ("Conocimiento del Paciente sobre sus Medicamentos" - CPM-ES-ES) for use in Brazil. It measures the level of medication knowledge by means of 11 questions. Eighty patients ≥ 80 years were investigated and in 39 cases the caregivers were interviewed. The evaluation of conceptual and item equivalences considered the concept of knowledge and the questions that assess it as pertinent. Semantic equivalence was obtained by the correspondence in the denotative and connotative meaning of items. The study of measurement equivalence included factorial analysis and the calculation of validity and reliability estimates. As with the original questionnaire, principal component analysis identified 4 components, however, in 2 of them there were differences regarding included items. One question was removed from this analysis due to its sample inadequacy. Medication knowledge was correlated with medication regimen complexity r = -.22, p = .046. Medication knowledge of antihypertensives was correlated with their adherence r = .70, p < .001, and blood pressure control rb = .46, p = .029. The adapted version revealed functional equivalence, therefore it can be used in the Brazilian context.

Factors Associated With High-Quality Guidelines for the Pharmacologic Management of Chronic Diseases in Primary Care: A Systematic Review

IMPORTANCE

As the rate of publication of new and sometimes conflicting medical research increases, clinicians rely heavily on clinical practice guidelines (CPGs) to inform practice. However, CPGs are of widely variable quality, and there are no existing objective measures to rate the quality of CPGs.

OBJECTIVE

To systematically assess 421 CPGs for the management of common noncommunicable diseases in primary care using the validated Appraisal of Guidelines for Research and Evaluation Instrument, version II (AGREE-II) tool and elucidate the factors associated with quality of CPGs.

EVIDENCE REVIEW

MEDLINE, Embase, the Cochrane Library, and 12 websites for CPGs were searched for CPGs for the management of common noncommunicable diseases in primary care published between January 1, 2011, and August 30, 2017. The assessment of the quality of CPGs was performed by 3 appraisers using the 6 domains of the AGREE-II instrument. A multiple logistic regression was performed to identify factors associated with quality of CPGs.

FINDINGS

Of the 421 CPGs reviewed, 23.5% (99) were classified as high quality. Among included guidelines, clarity of presentation (70%) and scope and purpose (61%) had the highest median AGREE-II scores. The domains with the lowest median scores were applicability (22%) and rigor of development (33%). Factors associated with high-quality CPGs included having more than 20 authors (odds ratio, 9.08; 95% CI, 3.35-24.62), development at governmental institutions (odds ratio, 10.38; 95% CI, 2.72-39.60), and reporting funding (odds ratio, 10.34; 95% CI, 4.77-22.39). Year of publication, region, guideline version, and scope were not associated with quality among included CPGs.

CONCLUSIONS AND RELEVANCE

Primary care professionals and policymakers should be aware that CPGs in primary care are of widely variable quality, with less than 25% of included CPGs rated as high quality. High-quality CPGs were associated with a higher number of authors, governmental institutions, and the report of funding. Region of origin was not associated with quality of CPGs, which suggests that the improvement of the quality of CPGs should be an international concern.

Anxiolytic- and Antidepressant-Like Effects of Fish Oil-Enriched Diet in Brain-Derived Neurotrophic Factor Deficient Mice

Despite significant advances in the understanding of the therapeutic activity of antidepressant drugs, treatment-resistant depression is a public health issue prompting research to identify new therapeutic strategies. Evidence strongly suggests that nutrition might exert a significant impact on the onset, the duration and the severity of major depression. Accordingly, preclinical and clinical investigations demonstrated the beneficial effects of omega-3 fatty acids in anxiety and mood disorders. Although the neurobiological substrates of its action remain poorly documented, basic research has shown that omega-3 increases brain-derived neurotrophic factor (BDNF) levels in brain regions associated with depression, as antidepressant drugs do. In contrast, low BDNF levels and hippocampal atrophy were observed in animal models of depression. In this context, the present study compared the effects of long-lasting fish oil-enriched diet, an important source of omega-3 fatty acids, between heterozygous BDNF^+/- mice and their wild-type littermates. Our results demonstrated lower activation of Erk in BDNF^+/- mice whereas this deficit was rescued by fish oil-enriched diet. In parallel, BDNF^+/- mice displayed elevated hippocampal extracellular 5-HT levels in relation with a local decreased serotonin transporter protein level. Fish oil-enriched diet restored normal serotonergic tone by increasing the protein levels of serotonin transporter. At the cellular level, fish oil-enriched diet increased the pool of immature neurons in the dentate gyrus of BDNF^+/- mice and the latter observations coincide with its ability to promote anxiolytic- and antidepressant-like response in these mutants. Collectively, our results demonstrate that the beneficial effects of long-term exposure to fish oil-enriched diet in behavioral paradigms known to recapitulate diverse abnormalities related to the depressive state specifically in mice with a partial loss of BDNF. These findings contrast with the mechanism of action of currently available antidepressant drugs for which the full manifestation of their therapeutic activity depends on the enhancement of serotoninergic and BDNF signaling. Further studies are warranted to determine whether fish oil supplementation could be used as an add-on strategy to conventional pharmacological interventions in treatment-resistant patients and relevant animal models.

Algorithms for monitoring warfarin use: Results from Delphi Method

Warfarin stands as the most prescribed oral anticoagulant. New oral anticoagulants have been approved recently; however, their use is limited and the reversibility techniques of the anticoagulation effect are little known. Thus, our study's purpose was to develop algorithms for therapeutic monitoring of patients taking warfarin based on the opinion of physicians who prescribe this medicine in their clinical practice. The development of the algorithm was performed in two stages, namely: (i) literature review and (ii) algorithm evaluation by physicians using a Delphi Method. Based on the articles analyzed, two algorithms were developed: "Recommendations for the use of warfarin in anticoagulation therapy" and "Recommendations for the use of warfarin in anticoagulation therapy: dose adjustment and bleeding control." Later, these algorithms were analyzed by 19 medical doctors that responded to the invitation and agreed to participate in the study. Of these, 16 responded to the first round, 11 to the second and eight to the third round. A 70% consensus or higher was reached for most issues and at least 50% for six questions. We were able to develop algorithms to monitor the use of warfarin by physicians using a Delphi Method. The proposed method is inexpensive and involves the participation of specialists, and it has proved adequate for the intended purpose. Further studies are needed to validate these algorithms, enabling them to be used in clinical practice.

Training of pharmacy technicians for dispensing drugs in Primary Health Care

Few Brazilian articles discuss the importance of pharmacy technicians who offer direct assistance to patients. This paper describes an experience of the training of pharmacy technicians in drug dispensing. A descriptive, cross-sectional study was conducted in the primary healthcare setting. The technicians were trained by the pharmacist to advise patients at the time of drug dispensing and to screen cases that needed pharmaceutical consultation. Problems were identified by verifying the prescription and return date for dispensing the medication as well as through direct questioning of the patients. Flowcharts for problem identification and intervention were created for use by the technicians. After training, pharmacy technicians identified 3944 problems, the most common of which were the use of a lower dosage than that prescribed (26%) and non-adherence to pharmacological treatment. The findings of the present study demonstrate the importance of training pharmacy technicians with regard to dispensing drugs so that they can assist pharmacists in the process of identifying and solving drug-related problems, thereby making them active members of the care process in the public health system.

Non-Communicable Disease Clinical Practice Guidelines in Brazil: A Systematic Assessment of Methodological Quality and Transparency

BACKGROUND

Annually, non-communicable diseases (NCDs) kill 38 million people worldwide, with low and middle-income countries accounting for three-quarters of these deaths. High-quality clinical practice guidelines (CPGs) are fundamental to improving NCD management. The present study evaluated the methodological rigor and transparency of Brazilian CPGs that recommend pharmacological treatment for the most prevalent NCDs.

METHODS

We conducted a systematic search for CPGs of the following NCDs: asthma, atrial fibrillation, benign prostatic hyperplasia, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease and/or stable angina, dementia, depression, diabetes, gastroesophageal reflux disease, hypercholesterolemia, hypertension, osteoarthritis, and osteoporosis. CPGs comprising pharmacological treatment recommendations were included. No language or year restrictions were applied. CPGs were excluded if they were merely for local use and referred to NCDs not listed above. CPG quality was independently assessed by two reviewers using the Appraisal of Guidelines Research and Evaluation instrument, version II (AGREE II).

MAIN FINDINGS

"Scope and purpose" and "clarity and presentation" domains received the highest scores. Sixteen of 26 CPGs were classified as low quality, and none were classified as high overall quality. No CPG was recommended without modification (77% were not recommended at all). After 2009, 2 domain scores ("rigor of development" and "clarity and presentation") increased (61% and 73%, respectively). However, "rigor of development" was still rated < 30%.

CONCLUSION

Brazilian healthcare professionals should be concerned with CPG quality for the treatment of selected NCDs. Features that undermined AGREE II scores included the lack of a multidisciplinary team for the development group, no consideration of patients' preferences, insufficient information regarding literature searches, lack of selection criteria, formulating recommendations, authors' conflict of interest disclosures, and funding body influence.

Polypharmacy among the elderly in the city of São Paulo, Brazil - SABE Study

Polypharmacy for the elderly and associated factors were assessed. A cross-sectional study was conducted using data from the SABE Study (Health, Well-being and Aging), 2006. 1,115 individuals representing 422,377 elderly aged 65 or more, living in São Paulo City, were interviewed. Polypharmacy was defined as the use of five or more medications. A multivariate regression logistics was used. Polypharmacy prevalence was 36%. Female (OR = 1.7; IC 95%: 1.0; 2.9), age over 75 years (OR = 1.9; CI 95%: 1.3; 2.7), higher income (OR = 1.8; CI 95%: 1.2; 2.8), working (OR = 1.8; CI 95%: 1.1; 2.9), regular self assessed health (OR = 1.6; CI 95%: 1.1; 2.3) or poor (OR = 2.6; CI 95%: 1.4; 4.9), hypertension (OR = 2.0; CI 95%: 1.4; 2.9), diabetes (OR = 4.1; CI 95%: 2.2; 7.5), rheumatic diseases (OR = 2.3; CI 95%: 1.5; 3.6) and cardiac problems (OR = 2.9; CI 95%: 1.9; 4.5) were associated positively with polypharmacy. Using only the public health system (OR = 0.5, 95% CI: 0.3; 0.7) was inversely associated with polypharmacy. Medicines for the cardiovascular system and for the alimentary tract and metabolism were the most used. The knowledge of factors associated with polypharmacy, such as those identified in this study, may be useful to alert health professionals about the importance of identifying and monitoring the elderly groups most vulnerable to polypharmacy.