A cloroquina e o paraquedas: uma fábula da era COVID19

O cenário atual da COVID-19 tem gerado muitas angústias. É natural que a sociedade anseie por respostas rápidas. Entretanto, o conhecimento gerado por estudos científicos demanda alto investimento, rigidez metodológica e árduo trabalho para que dados coletados sejam confiáveis e gerem resultados robustos e, assim, possam ser aplicados diretamente à população adoecida. Passos científicos importantes têm sido “pulados” para se tentar dar celeridade às respostas exigidas pelo momento atual. De forma mais preocupante, estudos de baixa qualidade metodológica estão sendo publicados e conclusões inapropriadas têm ganhado as páginas dos jornais e posts pouco racionais nas mídias. Baseado em heurística, preceitos científicos e nos dados até aqui divulgados sobre cloroquina e hidroxicloroquina, este texto trata de forma narrativa, metafórica e algo sarcástica o tema através de uma fábula aplicável ao cenário atual, traçando um paralelo liberal entre o paradigma do paraquedas e as recomendações de hidroxicloroquina para tratamento da COVID-19

Evaluation of evening versus morning levothyroxine intake in elderly (MONIALE)

Background: The aging population is associated with increased multimorbidity and polypharmacy. Older adults are at a higher risk of adverse events and reduced therapeutic response. This phenomenon is partially explained by drug interactions and treatment adherence. Most randomized clinical trials have found no significant differences between morning and evening levothyroxine (LT4) administration in young adults, but there is little evidence regarding alternative LT4 regimens in older populations. Thus, the MONIALE trial aims to test an alternative schedule for LT4 administration in older adults. Methods/design: This randomized crossover clinical trial will include participants aged 60 years or older with primary hypothyroidism. The trial groups will consist of morning LT4 intake (60 min before breakfast) or evening LT4 intake (60 min after supper). The primary outcome will be variation in serum thyrotropin (TSH) levels after 24 weeks of the LT4 protocol. The secondary outcomes will be the prevalence of drugs that potentially interact with LT4 and hypothyroidism control according to interaction status. The sample size was calculated to detect a minimum mean difference of 1 mUI/L in serum TSH level between the groups with 80% power and a 5% probability of type I error, resulting in 91 patients per group. The project was approved by the Hospital de Clínicas de Porto Alegre Ethics Committee. Discussion: Considering the aging population, the increased prevalence of multimorbidity and polypharmacy, as well as potential drug interactions and treatment adherence difficulties, an alternative LT4 protocol could be useful for hypothyroidism treatment in the elderly. Prior studies comparing alternative LT4 administration protocols have mainly included young adult populations and have not addressed potential drug interactions

Effects of physical exercise programs on sarcopenia management, dynapenia, and physical performance in the elderly : a systematic review of randomized clinical trials

Introduction. Sarcopenia is a prevalent condition in the elderly population, imposing a significant impact over their functional ability as well as their quality of life. Furthermore, it is associated with greater incidence of major geriatric outcomes, as reduced mobility, falls, loss of independence, cognitive impairment, and all-cause mortality. Physical Exercise Programs directed to improve muscle mass and its function may be key to reduce sarcopenia consequences. However, a significant heterogeneity is found in clinical trials, especially as a consequence of different exercise protocols applied to research subjects. Objectives. To access the effects of physical exercise programs compared to no exercise interventions to improve sarcopenia components and its determinants in sarcopenic elder individuals. Methods. A systematic review was conducted in the Pubmed database to identify randomized clinical trials (RCTs) which tested the effects of physical exercise programs to manage sarcopenia components in sarcopenic elder individuals. Two independent reviewers assessed the studies’ eligibility according to specified inclusion criteria in a four-step strategy. Data regarding population characteristics, muscle mass, muscle quality, muscle strength, and muscle function were extracted from each one of the included studies. Assessment of quality and individual studies risk of bias were assessed through Cochrane Risk of Bias Tool®. Assuming theoretical expected heterogeneity among studies, especially regarding different physical exercise programs and different outcome measurements, authors decided to be conservative and present study results in descriptive tables. Results. Search strategy retrieved 298 papers on PubMed database. )ree more were identified through manual search, being 301 studies revised for inclusion. 278 were excluded during title/abstract review. After further evaluation of 23 fulltexts, 5 RCTs were included. All 5 trials tested the efficacy of isolated exercise programs to improve sarcopenia components in the elderly compared to no physical intervention. Resistance training was the main intervention component in all included trials compared to inactive control groups (health education mainly). Physical training improved muscle strength, muscle quality, and muscle function compared to inactive control groups. Considering muscle mass, no differences were demonstrated. Data metaanalysis was not possible to be performed due to high heterogeneity among trials and small number of studies for each outcome comparison. Conclusion. Heterogeneity among trials and small number of RCTs limited robust conclusions and data metaanalysis. However, resistance training protocols can improve muscle strength and physical performance in elders previously diagnosed with sarcopenia, although its effect size and clinical impact are barely relevant

Bedside Ultrasound of Quadriceps to Predict Rehospitalization and Functional Decline in Hospitalized Elders

ObjectiveTo evaluate the capacity of total anterior thigh thickness, quadriceps muscle thickness, and quadriceps contractile index, all measured by bedside ultrasound, to predict rehospitalization, functional decline, and death in elderly patients 3 months after hospital discharge. To evaluate intra and interobserver reproducibility of the dominant thigh evaluation method by point of care ultrasound.MethodsCohort study of patients aged 65 years or more admitted to a medium complexity unit in a teaching hospital in southern Brazil. Comprehensive geriatric assessment and ultrasound evaluation of the dominant thigh of each participant were performed. After 3 months of hospital discharge, telephone contact was made to evaluate the outcomes of rehospitalization or death and functional decline—assessed by the 100 points Barthel scale and defined as a decrease of five or more points.Results100 participants were included. There was no statistically significant difference between intraobserver measurements in the GEE method analysis (p > 0.05), and the mean bias obtained in Bland–Altman plots was close to zero in all four analyses performed, suggesting good intra and interobserver agreement. There was a significant correlation between the echographic measurements (quadriceps thickness and contractile index) and gait speed, timed up and go, and handgrip tests. There was a significant association between contractile index (quadriceps thickness over total anterior thigh thickness multiplied by 100) lower than 60% and functional decline (relative risk 1.35; CI 95% 1.10–1.65; p = 0.003) as well as between the thickness of the quadriceps and rehospitalization or death, in both individuals with preserved walking capacity and in bedridden elders (relative risk 1.34; CI 95% 1.02–1.75; p = 0.04).ConclusionThe ultrasonographic method to evaluate thigh thickness was easily applicable and reproducible. The thickness of the quadriceps could predict rehospitalization or death, even in those patients without walking capacity—unable to perform gait speed and timed up and go tests. Additionally, the contractile index was associated with functional decline after 3 months of hospital discharge. This is a promising result, which highlights the bedside ultrasound of the quadriceps as a potential tool for the prognosis evaluation of bedridden hospitalized elderly patients

Evaluation of providing military service organizations economic performance by executive dashboards

The subject of this article is to explore what are the possibilities and limitations of the use of a computerized system of executive dashboards to evaluate the providing military service organizations economic performance. This research is classified as qualitative, non-experimental, exploratory, bibliographic, documentary and case study. The main findings are associated with the fact that the use panel indicators allowed for more accurate monitoring, and in the shortest time, the performance of these organizations; viewing the most current and critical of their economic situation, allowing the identification and timely recommendations corrections; integration of information in a data platform safer; creating historical series for the preparation of studies and works with applications in Brazilian Navy and academia, and finally, facilitating the reading of the indicators for the use of new graphics and images in metrics representation

Dilemas contábeis e orçamentários em organizações militares prestadoras de serviço na Marinha do Brasil

O presente estudo tem como objetivo principal investigar como o estilo de tomada de decisão influencia no controle orçamentário e gerencial dos custos e despesas fixas, em uma Base Militar eleita a partir de uma experiência-piloto. Em termos metodológicos, o estudo pode ser classificado como pesquisa qualitativa, exploratória, bibliográfica, documental e estudo de caso. A experiência-piloto com a Base Militar advoga o recebimento de recursos de funcionamento e manutenção por aquela Organização Militar Prestadora de Serviço via Sistema do Plano Diretor, ao invés de cobrar taxas e índices das Organizações Militares Clientes como forma de obter orçamento suficiente para cobrir seus custos indiretos e despesas administrativas. A cargo dos clientes ficariam unicamente os custos diretos envolvidos nos serviços prestados. Sugerem-se alterações na apresentação dos orçamentos por parte das Organizações Militares Prestadoras de Serviço e modificações na indicação dos recursos para pagamento dos serviços prestados por parte das Organizações Militares Clientes. Tal alteração compreende a evidenciação e segregação entre a parcela de recursos destinada ao pagamento dos custos diretos e a parcela de recursos destinada a fazer face aos custos indiretos e despesas administrativas, bem como confere maior transparência aos processos decorrentes

A phase III, randomized, non-inferiority study comparing the efficacy and safety of biosimilar filgrastim versus originator filgrastim for chemotherapy-induced neutropenia in breast cancer patients

OBJECTIVES: To compare the efficacy and safety of two filgrastim formulations for controlling chemotherapy-induced neutropenia and to evaluate the non-inferiority of the test drug relative to the originator. METHODS: This phase III non-inferiority study had a randomized, multicenter, and open-label design. The patients were randomized at a ratio of 1:1 with a follow-up period of 6 weeks for each patient. In both study arms, filgrastim was administered subcutaneously at a daily dose of 5 mg/kg body weight. The primary endpoint was the rate of grade 4 neutropenia in the first treatment cycle. The secondary endpoints were the duration of grade 4 neutropenia, the generation of anti-filgrastim antibodies, and the rates of adverse events, laboratory abnormalities, febrile neutropenia, and neutropenia of any grade. RESULTS: The primary efficacy analysis demonstrated the non-inferiority of the test drug compared with the originator drug; the upper limit of the 90% confidence interval (CI) for the rate of neutropenia between the two groups (12.61%) was lower than the established margin of non-inferiority. The two treatments were similar with respect to the secondary endpoints and safety. CONCLUSION: The efficacy and safety profile of the test drug were similar to those of the originator product based on the rate of grade 4 neutropenia in the first treatment cycle. This study supports Anvisa’s approval of the first biosimilar drug manufactured by the Brazilian industry (Fiprima¯)