Infecções parasitárias em pacientes transplantados de órgãos sólidos : o caso da doença de chagas

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Ciências da Saúde, Programa de Pós-Graduação em Saúde Coletiva, 2014.Introdução: Existe uma tendência de aumento na incidência de infecções parasitárias em pacientes transplantados e o risco de infecção é determinado por fatores relacionados à exposição epidemiológica do indivíduo, ao tipo de órgão transplantado, ao estado de imunossupressão e às complicações cirúrgicas. Neste contexto, dentre as infecções parasitárias, as doenças tropicais negligenciadas têm despertado preocupação. Conhecer a incidência e entender os mecanismos de infecção e as complicações decorrentes destas se fazem necessárias para a mudança da conduta clínica. Procurou-se neste trabalho, começar o estudo pela doença de Chagas considerando o grande volume de informações e particularidades que cada doença parasitária tem no processo de infecção em transplantes. Objetivo: Sintetizar e avaliar, por meio de uma revisão sistemática (RS) da literatura, as evidências disponíveis sobre a doença de Chagas em transplantes de órgãos sólidos. Métodos: Foi realizada uma busca sistemática nas bases de dados MEDLINE (via Pubmed), EMBASE, The Cochrane Library, Centre for Reviews and Dissemination (CRD), Cumulative Index to Nursingand Allied Health Literature (CINAHL), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus e Web of Science com o objetivo de encontrar estudos que avaliassem a ocorrência de infecções parasitárias em pacientes após o transplante de órgão sólido. Como recorte, para esta RS, foram incluídos estudos que relataram a ocorrência de doença de Chagas em receptores de órgãos sólidos por reativação da doença nos receptores ou por transmissão de doadores infectados. A última busca foi concluída em março de 2014. Resultados: Foram recuperados 4633 artigos e, após triagem por título e resumo por dois revisores independentes, 478 estudos que tratavam das infecções parasitárias foram considerados elegíveis. Desses, 109 artigos que abordavam a doença de Chagas foram separados para leitura de texto completo. Ao final, foram incluídos 74 estudos, dos quais 31 tratavam de estudos observacionais e 43 eram relatos de casos. A incidência de reativação da infecção por T. cruzi foi de 43,0 % (IC95% 34,0 – 52,0; I2 = 67,4%). Dentre os pacientes que receberam órgãos infectados (principalmente coração, fígado e rim), a incidência de infecção foi de 25,0% (IC95% 14,0 – 41,0; I2 = 43,6%). A sorologia foi o método mais utilizado para triagem pré-transplante tanto de doadores quanto de receptores, destacando-se as técnicas de Imunofluorescência Indireta, Hemaglutinação, Reação de Fixação de Complemento e ELISA. Na fase pós-transplante, observou-se a predominância da utilização de métodos parasitológicos diretos e indiretos e biópsias dos tecidos, com destaque para xenodiagnóstico, exame direto no sangue, hemocultura, biópsia endomiocárdica e de lesões da pele e PCR. Conclusão: A incidência de reativação e nova infecção por T. cruzi em receptores de órgãos sólidos é elevada nos países da América Latina, especialmente no Brasil e há maior necessidade de desenvolvimento de novas plataformas de diagnóstico que possibilite a detecção rápida de doadores infectados, seja para evitar a transmissão da doença de Chagas, bem como para monitorar a resposta à terapia na ocorrência de transmissão ou reativação.Background: There is a trend of increased incidence of parasitic infections in transplant patients and the risk of infection is determined by factors related to the epidemiological exposure of the individual, the type of transplanted organ, the state of immunosuppression and surgical complications. In this context, among parasitic infections, neglected tropical diseases have aroused concern. Knowing the incidence and understand the mechanisms of infection and complications of these are necessary to change the clinical management. This work began the study by Chagas disease considering the large volume of information and circumstances that each parasitic disease is in the process of infection in transplantation. Objective: To summarize and evaluate, through a systematic review (SR) of literature, the available evidence on Chagas disease in solid organ transplantation. Methods: A systematic search was performed in databases MEDLINE (via PubMed), EMBASE, The Cochrane Library, Centre for Reviews and Dissemination (CRD), Cumulative Index to Nursingand Allied Health Literature (CINAHL), Latin American and Caribbean Health Sciences (LILACS), Scopus and Web of Science with the aim of finding studies that assessed the occurrence of parasitic infections in patients after solid organ transplantation. Specifically for this SR were included studies that reported the occurrence of Chagas disease in solid organ recipients by reactivation of the disease in recipient or by transmission from infected donors. The last search was completed in March 2014. Results: 4633 articles were recovered and after sorting by title and abstract by two independent reviewers, 478 studies dealing with the parasitic infections were eligible. Of these, 109 articles that addressed Chagas disease were separated for full-text reading. In the end, 74 studies, 31 of which these were observational studies and 43 were case reports were included. The incidence of reactivation of T. cruzi infection was 43.0% (95% CI 34.0 to 52.0; I2 = 67.4%). Among patients who received infected organs (mainly heart, liver and kidney), the incidence of infection was 25.0% (95% CI 14.0 to 41.0; I2 = 43.6%). Serology was the most used method for pre-transplant screening of donors and recipients, highlighting the techniques of indirect immunofluorescence, hemagglutination, complement fixation reaction and ELISA. In the post-transplant phase, there was a predominance of the use of direct and indirect parasitological methods and biopsies of tissue, especially xenodiagnosis, direct examination in the blood, blood culture, and endomyocardial biopsy of skin lesions and PCR. Conclusion: The incidence of reactivation and new T. cruzi infection in solid organ recipients is high in Latin America, especially in Brazil and there is greater need for development of new diagnostics platforms that enables the rapid detection of infected donors whether to prevent the transmission of Chagas disease and for to monitor response to therapy in the event of transmission or reactivation

Pubertal timing in girls and depression: A systematic review

Background: Because the incidence of depression increases after puberty, it is possible that pubertal timing in girls influences the onset of depression. Our objective was to assess the effect of early and late puberty in girls on the incidence of depression. Methods: We systematically searched relevant databases for controlled studies that assessed the impact of pubertal timing in girls on the incidence of depression or depressive symptoms. The last search was completed in August 2013. Two authors selected the studies, extracted the data, and assessed the quality of the evidence. Meta-analyses of the adjusted and unadjusted results were calculated using random effects. Results: Four cohort studies were included (n=8055 participants). Early puberty significantly increased the risk of new cases of depression in the unadjusted meta-analysis (RR=1.33; CI 95%: 1.02, 1.73) but not in the adjusted estimate of two of the included studies (RR=1.48; CI 95%: 0.69, 2.28). For late puberty, no significant associations were found (unadjusted RR=1.28; CI 95%: 0.87, 1.88). Two studies assessed the effect of early puberty on depressive symptoms and found positive associations. The quality of the available evidence was rated as very low. Limitations: The polled results had wide confidence intervals, and the available evidence was of very low quality. Conclusions: The available evidence supports little confidence regarding the impact of pubertal timing on the onset of depression in girls but suggests that early puberty in girls may increase the risk of depression. Further higher quality studies are needed to clarify the association between pubertal timing and the incidence of depression in girls and women

The Assessment for Disinvestment of Intramuscular Interferon Beta for Relapsing-Remitting Multiple Sclerosis in Brazil

In Brazil, inclusion and exclusion of health technologies within the Unified Health System (SUS) is the responsibility of the National Committee for Health Technology Incorporation (CONITEC). A recent Cochrane systematic review demonstrated that intramuscular interferon beta 1a (IFN-beta-1a-IM) was inferior to the other beta interferons (IFN-beta s) for multiple sclerosis (MS). As a result, CONITEC commissioned an analysis to review possible disinvestment within SUS. The objective of this paper is to describe the disinvestment process for IFN-beta-1a-IM in Brazil. The first assessment comprised a literature review and mixed treatment comparison meta-analysis. The outcome of interest was the proportion of relapse-free patients in 2 years. This analysis confirmed the inferiority of IFN-beta-1a-IM. Following this, CONITEC recommended disinvestment, with the decision sent for public consultation. More than 3000 contributions were made on CONITEC's webpage, most of them against the preliminary decision. As a result, CONITEC commissioned a study to assess the effectiveness of IFN-beta-1a-IM among Brazilian patients in routine clinical care. The second assessment involved an 11-year follow-up of a non-concurrent cohort of 12,154 MS patients developed by deterministic-probabilistic linkage of SUS administrative databases. The real-world assessment further demonstrated that IFN-beta-1a-IM users had a statistically higher risk of treatment failure, defined as treatment switching or relapse treatment or death, with the assessment showing that IFN-beta-1a-IM was inferior to the other IFN-beta s and to glatiramer acetate in both direct and indirect analysis. In the drug ranking with 40,000 simulations, IFN-beta-1a-IM was the worst option, with a success rate of only 152/40,000. Following this, CONITEC decided to exclude the intramuscular presentation of IFN-beta from the current MS treatment guidelines, giving patients who are currently on this treatment the option of continuing until treatment failure. In conclusion, we believe this is the first example of this new disinvestment process in action, providing an exemplar for other treatments in Brazil as well as other countries.Ministry of Health of BrazilUniv Fed Minas Gerais, Fac Farm, SUS Collaborating Ctr Technol Assessment & Excell, Sala 1042,Ave Presidente Antonio Carlos 6627, BR-31270901 Belo Horizonte, MG, BrazilUniv Fed Minas Gerais, Fac Med, Programa Posgrad Saude Publ, Sala 533,Ave Porf Alfredo Balena 190,Campus Saude, BR-30130100 Belo Horizonte, MG, BrazilUniv Fed Minas Gerais, Fac Farm, Programa Posgrad Medicamentos & Assistencia Farma, Sala 1023,Ave Presidente Antonio Carlos 6627, BR-31270901 Belo Horizonte, MG, BrazilInst Nacl Cardiol, Nucleo Avaliacao Tecnol Saude, R Laranjeiras 374, BR-22240006 Rio De Janeiro, RJ, BrazilMinist Saude, Dept Gestao & Inc Tecnol Saude, Secretaria Ciencia Tecnol & Insumos Estrateg, Esplanada Minist Bloco G, BR-70058900 Brasilia, DF, BrazilUniv Fed Sao Paulo, Programa Posgrad Saude Baseada Evidencias, Rua Botucatu 740,3 Andar, BR-04023900 Sao Paulo, SP, BrazilKarolinska Inst, Karolinska Univ Hosp Huddinge, Div Clin Pharmacol, S-14186 Stockholm, SwedenUniv Strathclyde, Strathclyde Inst Pharm & Biomed Sci, 161 Cathedral St, Glasgow G4 0RE, Lanark, ScotlandUniv Liverpool, Sch Management, Ctr Hlth Econ, Liverpool, Merseyside, EnglandUniv Fed Sao Paulo, Programa Posgrad Saude Baseada Evidencias, Rua Botucatu 740,3 Andar, BR-04023900 Sao Paulo, SP, BrazilMinistry of Health of Brazil: TED 78/2015, BR/LOA 1500033.001Web of Scienc

Assessment intelligence network: consensus building in Health Technology Assessment

Health Technology Assessment (HTA) is a multidisciplinary field of study which seeks to analyze health technologies development, diffusion and use and their clinical, social, economic and ethical implications. The defining process of HTA methodological guidelines requires consensus building among a broad range of experts and decision makers in the elaboration of a scientific robust document. In Brazil, since the creation of the Brazilian Network for Health Technology Assessment (REBRATS) in 2008, the elaboration of HTA guidelines has been performed through a collaborative process between network members. This process has contributed not only to the HTA methodological standardization, but also to structure an assessment intelligence network in Brazil. This article aims to discuss the structure and dynamics of this evaluative intelligence and how it has improved over time

Evaluation of the effectiveness of prevention programs for obesity in adolescents: systematic review and metanalysis

Submitted by Jaqueline Ferreira de Souza ([email protected]) on 2020-03-16T13:37:04Z No. of bitstreams: 1 ve_Marina_Freitas_etal.pdf: 241034 bytes, checksum: f0c47990617b2d21ddd08b9771087879 (MD5)Approved for entry into archive by Jaqueline Ferreira de Souza ([email protected]) on 2020-03-18T11:51:10Z (GMT) No. of bitstreams: 1 ve_Marina_Freitas_etal.pdf: 241034 bytes, checksum: f0c47990617b2d21ddd08b9771087879 (MD5)Made available in DSpace on 2020-03-18T11:51:10Z (GMT). No. of bitstreams: 1 ve_Marina_Freitas_etal.pdf: 241034 bytes, checksum: f0c47990617b2d21ddd08b9771087879 (MD5) Previous issue date: 2017Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brasil.Universidade de Brasília. Faculdade de Ciências da Saúde. Brasília, DF, Brasil.Fundação Oswaldo Cruz. Fiocruz Brasília. Brasília, DF, Brasil.Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brasil.Objetivos: Identificar, descrever e avaliar a efetividade dos programas de prevenção da obesidade para adolescentes. Métodos: Revisão sistemática, com busca estruturada em nove bases de dados. Foram considerados elegíveis ensaios clínicos randomizados (ECR) e estudos quase-experimentais que relataram a experiência desses programas quando comparado a um controle, sendo o tempo de acompanhamento de no mínimo um ano. Os desfechos dos estudos deveriam incluir medidas relativas à obesidade, a partir das quais metanálises foram realizadas. Foi realizada descrição dos componentes dos programas. Resultados: Dentre 1.614 estudos identificados, 13 atenderam aos critérios de inclusão. As metanálises realizadas para a diferença de média dos desfechos escore Z do IMC, IMC e prevalência de sobrepeso e obesidade foram -0,01, 0,01 e -0,01, respectivamente. A descrição dos programas revelou elementos motivacionais, de educação, de incentivo à alimentação saudável e atividade física e de envolvimento da família. A metanálise realizada mostrou redução do percentual de gordura corporal (diferença média: -2,18). Conclusões: Observou-se relevância no desfecho percentual de gordura corporal. A descrição mostrou que os programas avaliados possuem amplo leque de intervenções.Objectives: To identify, describe and evaluate the effectiveness of obesity prevention programs for adolescents. Methods: Systematic review with structured search in nine databases. Randomized controlled trials (RCT) and quasi-experimental studies that reported the experience of these programs when compared to a control were eligible, and the follow-up of at least one year. The studies’ outcomes should include measures relating to obesity, from which meta-analyzes would be carried out. It was performed description of programs. Results: Of 1614 identified studies, 13 met the inclusion criteria. Metaanalyzes performed for the mean difference of the Z score outcomes of BMI, BMI and the prevalence of overweight and obesity were -0.01, 0.01 and -0.01, respectively. The description of the programs revealed elements, such as: motivational, education, to encourage healthy eating and physical activity and family involvement. The meta-analysis showed a reduction in body fat percentage (mean difference: -2.18). Conclusions: There was significance in the outcome percentage of body fat. The description showed that the evaluated programs have wide range of interventions

Los valores sociales sobre la incorporación de tecnologías: lo que piensan los participantes del SUS

Submitted by Jaqueline Ferreira de Souza ([email protected]) on 2020-03-17T13:24:43Z No. of bitstreams: 1 ve_Flavia_Elias_etal.pdf: 271055 bytes, checksum: 4bbdce005d3fd5a525072d58fed154f0 (MD5)Approved for entry into archive by Jaqueline Ferreira de Souza ([email protected]) on 2020-03-18T13:28:05Z (GMT) No. of bitstreams: 1 ve_Flavia_Elias_etal.pdf: 271055 bytes, checksum: 4bbdce005d3fd5a525072d58fed154f0 (MD5)Made available in DSpace on 2020-03-18T13:28:05Z (GMT). No. of bitstreams: 1 ve_Flavia_Elias_etal.pdf: 271055 bytes, checksum: 4bbdce005d3fd5a525072d58fed154f0 (MD5) Previous issue date: 2015Fundação Oswaldo Cruz. Fiocruz Brasília. Brasília, DF, Brasil.Ministério da Saúde. Brasília, DF, Brasil.Conselho Nacional de Desenvolvimento Científico e Tecnológico. Brasília, DF, Brasil.Universidade Nova de Lisboa. Lisboa, Portugal.Universidade Federal do Amazonas. Manaus, AM, Brasil.O trabalho teve como objetivo conhecer a opinião dos delegados da 14ª Conferência Nacional de Saúde, ocorrida no período de 1º a 4 de dezembro de 2011, sobre os critérios de avaliação para incorporação de tecnologia para o sistema público de saúde no Brasil (SUS). Foi aplicado questionário para autopreenchimento aos visitantes do stand do Ministério da Saúde durante o evento. Um total de 11,5% dos participantes respondeu a pesquisa. Destes, 43,6% representaram cidadãos ou pacientes; 33,6% dos profissionais de saúde, 13,1% tomadores de decisão; 3,8% prestadores de serviços e 5,9% outros. A maioria já havia participado do controle social do SUS, há mais de cinco anos. Os critérios pré-definidos para a avaliação das tecnologias no questionário foram colocados em uma ordem hierárquica: a melhoria da qualidade de vida e sobrevida dos pacientes (60%); evidências sobre os efeitos previstos na prevenção, diagnóstico, tratamento ou reabilitação (49%); evidências sobre a segurança para o paciente / usuário / consumidor (46%); impacto sobre a saúde da população (43%); relação entre benefícios / efeitos da tecnologia e os custos (40%). Os «custos para o sistema de saúde» e «critérios de custos para os doentes» estavam em penúltimo e último lugar, respectivamente. As perspectivas dos doentes / cidadãos e profissionais de saúde devem ser estimulados a fim de apoiar a aplicação da Lei 12.401 / 2011, que estabelece critérios para Incorporação de Tecnologias da Saúde.The survey had the objective to become aware of the opinion of the delegates from the 14th National Health Conference during the period of the 1st to the 4th of December, 2011. About the technology assessment criteria for the public health system in Brazil (SUS). A self-questionnaire survey was applied to all visitors at a Ministry of Health booth in the event. About 11.5% (502/4370) participants were covered by the survey. Of these, 43.6% represented citizens/patients; 33.6 % health professionals, 13.1% policymakers; 3.8% service providers and5.9% others. The majority of them have participated in SUS social control for more than five years. Eleven of the pre-defined criteria for technology assessment on the questionnaire were put in a hierarchical order in the following manner: improved quality of life and patient survival (60%); evidence on the anticipated effects in prevention, diagnostics, treatment or rehabilitation (49%); evidence regarding safety for patient/user/consumer (46%); impact on the population’s health (43%); relationship between benefits/effects of the technology and the costs (40%). The criteria “costs for the health system” and “costs for patients” were in second to last and last place, respectively. The perspectives of patients/citizens and health professionals should be stimulated in order to support the application of the Law 12,401/2011, which establishes criteria for Incorporation of Health Technologies.La investigación tuvo el objectivo de conocer la opinión de los delegados de la 14ª Conferencia Nacional de Salud, durante la duración del 1 al 04 diciembre de 2011,.en los criterios de evaluación para la incorporación de la tecnología en el sistema de salud pública en Brasil (SUS). Fue submetido a los visitantes del stand del Ministério de la Salud un auto-cuestionario. Al menos 11,5% (502/4370) de los participantes estaban cubiertos por la encuesta. De estos, el 43,6% representado ciudadanos o pacientes; 33,6% de los profesionales de la salud, 13,1% de los que toman las decisiones; 3,8% los proveedores de servicios y 5,9% otros. La mayoría de ellos han participado en el control social del SUS por más de cinco años. Once de los criterios predefinidos para la evaluación de las tecnologías en el cuestionario fueron colocados en un orden jerárquico de la siguiente manera: la mejora de la calidad de vida y la supervivencia de los pacientes (60%); pruebas para los fines establecidos en la prevención, diagnóstico, tratamiento o rehabilitación (49%); evidencia sobre la seguridad para el paciente / usuario / consumidor (46%); impacto en la salud de la población (43%); beneficios de relación / efectos de la tecnología y el costo (40%). El «costo para el sistema de salud» y «criterios de costo para los pacientes» fueron penúltimo y último, respectivamente. La perspectiva de los pacientes / ciudadanos y profesionales de la salud deben ser alentados a apoyar la aplicación de la Ley 12.401 / 2011 que establecen criterios para la Incorporación de tecnologias sanitarias

Effectiveness of nirmatrelvir-ritonavir for the treatment of patients with mild to moderate COVID-19 and at high risk of hospitalization: Systematic review and meta-analyses of observational studies.

ObjectiveTo assess the effectiveness of nirmatrelvir-ritonavir in the treatment of outpatients with mild to moderate COVID-19 who are at higher risk of developing severe illness, through a systematic review with meta-analyses of observational studies.MethodsA systematic search was performed, in accordance with the Cochrane search methods, to identify observational studies that met the inclusion criteria. The outcomes of mortality and hospitalization were analyzed. Search was conducted on PubMed, EMBASE, and The Cochrane Library. Two reviewers independently screened references, selected the studies, extracted the data, assessed the risk of bias using ROBINS-I tool and evaluated the quality of evidence using the GRADE tool. This study followed the PRISMA reporting guideline.ResultsA total of 16 observational studies were finally included. The results of the meta-analysis showed that in comparison to standard treatment without antivirals, nirmatrelvir-ritonavir reduced the risk of death by 59% (OR = 0.41; 95% CI: 0.35-0.52; moderate certainty of evidence). In addition, a 53% reduction in the risk of hospital admission was observed (OR = 0.47; 95% CI: 0.36-0.60, with very low certainty of evidence). For the composite outcome of hospitalization and/or mortality, there was a 56% risk reduction (OR = 0.44; 95% CI: 0.31-0.64, moderate certainty of evidence).ConclusionThe results suggest that nirmatrelvir-ritonavir could be effective in reducing mortality and hospitalization. The results were valid in vaccinated or unvaccinated high-risk individuals with COVID-19. Data from ongoing and future trials may further advance our understanding of the effectiveness and safety of nirmatrelvir-ritonavir and help improve treatment guidelines for COVID-19

Fig 7 -

A: Forest plot of hospitalization or mortality outcome within 35 days by vaccination status subgroup. B: Forest plot of hospitalization or mortality by subgroup of age group.</p