Recommendations for the development of Clinical Practice Guidelines / Recomendações para o desenvolvimento de Diretrizes de Prática Clínica

Clinical practice guidelines are statements that include recommendations intended to optimize patient care, are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options, and ensure that the best available clinical knowledge is used to provide effective and quality care. They can reduce inappropriate care and variability in clinical practice and can support the translation of new research knowledge into clinical practice. Recommendations from clinical practice guidelines can support health professionals by facilitating the decision-making process, empowering them to make more informed health care choices, clarifying which interventions should be priorities based on a favorable tradeoff, and discouraging the use of those that have proven ineffective, dangerous, or wasteful. This review aims to summarize the key components of high-quality and trustworthy guidelines. Articles were retrieved from various libraries, databases, and search engines using free-text term searches adapted for different databases, and selected according to author discretion. Clinical practice guidelines in geriatrics can have a major impact on prevention, diagnosis, treatment, rehabilitation, health care, and the management of diseases and conditions, but they should only be implemented when they have high-quality, rigorous, and unbiased methodologies that consider older adult priorities and provide valid recommendations.

As diretrizes de prática clínica são declarações que incluem recomendações destinadas a otimizar o atendimento ao paciente, informadas por uma revisão sistemática de evidências e uma avaliação dos benefícios e malefícios de opções alternativas de atendimento, garantindo que o melhor conhecimento clínico disponível seja usado para fornecer atendimento eficaz e de qualidade. Elas contribuem reduzindo os cuidados inadequados e a variabilidade na prática clínica e podem apoiar a tradução de novos conhecimentos de pesquisa. As recomendações dessas diretrizes podem apoiar os profissionais de saúde, facilitando o processo de tomada de decisão, capacitando-os a fazer escolhas de cuidados de saúde mais informadas, esclarecendo quais intervenções devem ser prioritárias com base em um trade-off favorável e desencorajando o uso daquelas comprovadamente ineficazes, perigosas ou que consistam em desperdício. Esta revisão visa resumir os principais componentes de diretrizes confiáveis e de alta qualidade. Os artigos foram recuperados de várias bibliotecas, bancos de dados e mecanismos de busca por meio de buscas de termos de texto livre adaptados para diferentes bancos de dados e selecionados de acordo com o critério do autor. As diretrizes de prática clínica em geriatria podem ter grande impacto na prevenção, diagnóstico, tratamento, reabilitação, assistência à saúde e manejo de doenças e condições, mas só devem ser implementadas quando tiverem metodologias de alta qualidade, rigorosas e imparciais, que considerem as prioridades da pessoa idosa e forneçam recomendações válidas.

Evidence and decision-making in times of pandemic / Evidencias y decisiones en tiempos de pandemia

In December 2019, an outbreak of a respiratory desease caused by a new coronavirus strain was detected in Wuhan, China. The disease spread rapidly around the world and was recognized as a pandemic by the World Health Organization in March 2020. From the very beginning of the pandemic, society was faced with a scenario fraught with uncertainty: a new disease with severe effects on some patients and no specific treatment. The medical community reacted promptly and undertook the quest for treatment options, some based on prior experiences with diseases caused by other coronavirus strains or related viruses, and other approaches based on potential pathophysiological mechanisms promising at the time but without any supporting scientific evidence.

En diciembre de 2019, se detectó en Wuhan (China) un brote de una enfermedad respiratoria causada por una nueva cepa de coronavirus. La enfermedad se extendió rápidamente por todo el mundo y fue reconocida como pandemia por la Organización Mundial de la Salud en marzo de 2020. Desde el principio de la pandemia, la sociedad se enfrentó a un escenario cargado de incertidumbre: una nueva enfermedad con graves efectos en algunos pacientes y sin tratamiento específico. La comunidad médica reaccionó rápidamente y emprendió la búsqueda de opciones de tratamiento, algunas basadas en experiencias previas con enfermedades causadas por otras cepas de coronavirus o virus relacionados, y otras aproximaciones basadas en posibles mecanismos fisiopatológicos prometedores en ese momento pero sin ninguna evidencia científica que los respaldara.

Relación médico-industria y los conflictos de interés: aspectos históricos y normativos, impactos negativos y propuestas / Physician-industry relationship and conflicts of interest: Historical, normative aspects, negative impact and proposals

RESUMEN El presente artículo revisa de manera narrativa y general la relación entre los médicos y la industria (RMI); se incluye a la industria farmacéutica, de dispositivos, de suplementos y los conflictos de intereses que surgen de dicha relación. Se aborda el tema mediante algunas definiciones y un breve recuento histórico de cómo la RMI se ha convertido en un problema importante en el ejercicio médico y los sistemas de salud. El artículo expone los diversos roles dentro de los escenarios más comunes en los que ocurre la RMI: en la investigación biomédica, las guías de práctica clínica, la educación médica continua, la visita médica, los líderes de opinión, así como en la interacción directa, la exposición indirecta y la que denominamos exposición temprana. Se mencionan, posteriormente, algunas técnicas que utiliza la industria para modificar los hábitos de prescripción basadas en elementos de psicología social, así como el papel que ejercen los obsequios y otras estrategias de mercadeo. Se revisó la literatura que muestra el impacto y el efecto que estas técnicas tienen en el ejercicio médico. Finalmente, se plantean algunas propuestas que se han desarrollado desde la normatividad y recomendaciones para afrontar el problema que podrían contribuir a mitigar los efectos negativos de una RMI muy estrecha. Estas propuestas son prohibir el contacto de los. estudiantes con la industria, la inclusión del tema de conflictos de intereses (CI) en los currículos de medicina, financiación alternativa de la educación continua, declaración de conflictos como norma, campañas de concientización, uso de evidencia sintetizada y analizada transparente e independientemente, entre otras.

SUMMARY This article presents a narrative review of the relationship between physicians and industry (RPI), which includes pharmaceutical, devices and supplements' industries and the conflicts of interest that arise from this relationship. It introduces the problem through some definitions and a brief history review of how RPI has become a major problem in medical practice and health systems. The article discusses the different roles within the most common scenarios in which RPI occurs: biomedical research, clinical practice guidelines, continuing medical education, medical visits, opinion leaders, as well as in direct interaction, indirect exposure, and what we call, an early exposure. Some techniques used by industry to modify prescription habits based on elements of social psychology, are described, as well as the role of gifts and other marketing techniques on prescriptions. We review literature that shows the impact and effect these techniques have on medical practice. Finally, some initiatives, codes and recommendations that have been developed to address the problem and which could contribute to mitigate the negative effects of a very close RPI. The possible actions are: banning any contact between industry and students, inclusion of conflict of interests into the medical curricula, alternative financial support to continuous education, making the disclosure of conflicts of interests mandatory, launching awareness campaings among physicians, and the use of synthesized evidence that have been transparently and independently assessed, among others.

Determinantes dietéticos del consumo de zinc en menores de cinco años con retardo del crecimiento en comunidades mayas de Guatemala / Dietetic Determinants of Zinc Consumption in Stunted Children Under Five in Maya Communities From Guatemala

RESUMEN El objetivo del estudio fue identificar elementos del patrón alimentario que influyen en la ingesta y biodisponibilidad de zinc en niños con retardo del crecimiento (RC) entre 1-5 años en comunidades maya de la localidad de Huehuetenango, Guatemala. Estudio descriptivo, transversal aplicado en 138 niños de entre 1-5 años con RC. Se realizó un inventario de disponibilidad alimentaria de fuentes de zinc, se construyó un cuestionario frecuencia de consumo de alimentos, un cuestionario de condiciones de vida, prácticas alimentarias, antropometría, y se recolectó información acerca de enfermedades infecciosas. Hubo disponibilidad de 28 alimentos fuentes de zinc (54% de baja y 7% de alta biodisponibilidad). El consumo de alimentos de alta biodisponibilidad fue bajo y el de alimentos antagonistas, alto. Los niños consumían 3 mg de zinc al día (IC95% 2,65-3,35). Solo el 14,5% alcanzaba los requerimientos de zinc, y el 2,9% alcanzaba la recomendación diaria. La ocurrencia de diarrea e infecciones, en los quince días previos, fue del 29,71 y 45,65%, respectivamente. Concluimos que la mayoría de niños con RC tuvo un bajo consumo de fuentes de zinc, alto consumo de alimentos antagonistas.

ABSTRACT The objective of the study was to identify the elements from feeding patterns that influence the intake and bioavailability of zinc in stunted children (SC) 1-5 years from Maya communities living in Huehuetenango, Guatemala. This descriptive, cross-sectional study was performed in 138 stunted children aged 1-5 years. It was applied: an inventory of zinc food sources availability, a Food Frequency Questionnaire, a questionnaire about living conditions. anthropometrics measurements and information on food intake habits, and information about disease prevalence. Twenty-eight food sources of zinc were available for consumption (54% low and 7% high zinc bioavailability). The consumption of foods with high bioavailability was low, while the antagonistic foods were high. On average the daily zinc consumption in diet 3 mg (95% CI: 2.65-3.35). Only 14.5% of the children met the zinc requirements, and 2.9% reached the daily recommendation. Episodes of diarrhea and respiratory infections were observed 15 days before the visit, in 29.71% and 45.6% of children, respectively. Most of children have a diet that does not cover the daily requirement.

Costos de la rehidratación oral y nasogástrica comparadas con la rehidratación endovenosa en niños con diarrea en Colombia / Costs of oral and nasogastric rehydration compared to intravenous rehydration in children under 5 years of age with diarrhea in Colombia

RESUMEN Objetivo Evaluar los costos de las terapias de rehidratación oral (TRO) y de rehidratación nasogástrica (TRN) comparadas con la terapia de rehidratación endovenosa (TRE) para corregir la deshidratación por diarrea en niños. Metodología Análisis de minimización de costos desde la perspectiva del Sistema de Salud colombiano comparando TRO (seguida de TRN ante falla de la TRO), con la TRE. El horizonte temporal fue la duración de la rehidratación. La medida de efectividad se extrajo de una revisión sistemática de literatura. Para determinar costos, se construyó un caso típico y un árbol de decisiones, a partir de revisión de guías e historias clínicas, validado con expertos. Los costos unitarios se obtuvieron de bases de datos colombianas. Costos fueron calculados en pesos colombianos (COP) y dólares americanos (USD). Se realizaron análisis de sensibilidad de una y dos vías. Resultados La TRO y la TRE son similares en efectividad para prevenir hospitalización y lograr rehidratación. En el caso base, el costo de la TRO fue $91,221COP (40.5 USD) y para TRE $112,944COP (50.14USD), es decir, un ahorro de $21,723 COP (9.64 USD). En los análisis de sensibilidad por regímenes de aseguramiento y complejidad del hospital, la TRO suele ser la estrategia menos costosa. Discusión Ambas intervenciones son similares en efectividad, pero la TRO, seguida de TRN ante falla de la primera resulta menos costosa que la TRE. La TRO es recomendable como primera opción para corregir la deshidratación. Deberían continuarse esfuerzos por implementar TRO y TRN en los servicios de salud en Colombia.(AU)

ABSTRACT Objective To evaluate the costs of oral rehydration therapy (ORT) and nasogastric rehydration therapy (NRT) compared with intravenous rehydration therapy (IRT) to treat dehydration in children under 5 years of age with diarrhea. Methodology Cost-minimization analysis from the perspective of the Colombian Health System, comparing ORT, (followed by NRT when ORT fails), with IRT. The time horizon was the duration of rehydration. The effectiveness measure was obtained from a systematic review of the literature. To determine costs, a typical case was created based on current guidelines and medical records; this case was validated by experts. Unit costs were obtained from Colombian databases and were provided in Colombian pesos (COP) and US dollars (USD) for 2010. One- and two-way sensitivity analyzes were performed. Results ORT and ERT are similarly effective to prevent hospitalization and to achieve rehydration. In the base case, the expected cost of ORT was $91,221 COP (40.5 USD) and for IRT was $112,944 COP ($50.14 USD), saving $21,723 COP ($9.64 USD) per case. In the sensitivity analyzes by health insurance and hospital level, ORT is often the least costly strategy. Discussion Both interventions are similarly effective, but ORT, followed by NRT when ORT fails, is less costly than IRT. ORT is recommended as the first option to treat dehydration since it is effective and less expensive. Efforts should be continued to implement TRO and NRT in the health services of Colombia.(AU)

Guías de práctica clínica en el Perú: evaluación de su calidad usando el instrumento AGREE II / Clinical practice guidelines in Peru: evaluation of its quality using the AGREE II instrument

RESUMEN Con el fin de evaluar la calidad metodológica de las guías de práctica clínica (GPC) desarrolladas por el Ministerio de Salud (MINSA) de Perú, se evaluaron 17 GPC del MINSA publicadas entre 2009-2014, por tres expertos metodológicos, de forma independiente, usando el instrumento AGREE II. La puntuación de los dominios del AGREE II fue baja y muy baja en todas las GPC: alcance y propósito (mediana, 44%), claridad de la presentación (mediana, 47%), participación de decisores (mediana, 8%), rigor metodológico (mediana 5%), aplicabilidad (mediana, 5%), e independencia editorial (mediana, 8%). Se concluye que la calidad metodológica de las GPC del MINSA es baja. Como consecuencia, no es posible recomendar su uso. Urge la incorporación de metodología estandarizada para el desarrollo de GPC de calidad en el Perú.

ABSTRACT To evaluate the methodological quality of clinical practice guidelines (CPGs) put into practice by the Peruvian Ministry of Health (MINSA), 17 CPGs from the ministry, published between 2009 and 2014, were independently evaluated by three methodologic experts using the AGREE II instrument. The score of AGREE II domains was low and very low in all CPGs: scope and purpose (medium, 44%), clarity of presentation (medium, 47%), participation of decision-makers (medium, 8%), methodological rigor (medium, 5%), applicability (medium, 5%), and editorial independence (medium, 8%). In conclusion, the methodological quality of CPGs implemented by the MINSA is low. Consequently, its use could not be recommended. The implementation of the methodology for the development of CPGs described in the recentlypublished CPG methodological preparation manual in Peru is a pressing need.

Cost effectiveness of Zinc Supplementation for the Treatment of Acute Diarrhoea in Children under 5 Years in Colombia.

Objectives: To determine the relative cost-effectiveness of zinc supplementation for the treatment of acute diarrhoea in children under five years in Colombia. Methods: Cost-effectiveness analysis from the perspective of the Colombian Health System. We evaluated standard treatment with addition of zinc versus standard treatment without zinc supplement for children from birth to five years. The time horizon was the duration of the diarrhoea. Effectiveness information was extracted from a Cochrane systematic review and Colombian databases and observational studies. Identification and measurement of resource use was based in clinical guidelines, protocols and expert opinion. Unit costs were obtained from Colombian tariff manuals. We performed deterministic sensitivity analysis to assess the impact of changes in the cost and effectiveness of the strategies on the results of the model. Results: The average treatment cost of one diarrhoea episode in Colombia is USD $40.77 using standard treatment, and USD $32.96 with zinc supplementation, a reduction of $7.81 USD. Additionally, zinc supplementation is more effective than standard treatment without zinc: it reduces diarrhoea-related mortality and incidence of persistent diarrhoea. The results are sensitive to changes in the probability of hospitalization and persistent diarrhoea, but conclusions do not change substantially. Conclusions: Zinc for the treatment of acute diarrhoea is a highly cost-effective strategy from the perspective of the Colombian Health System. It is more cost-effective in children with higher risk of persistent diarrhoea and hospitalization.

Correlación entre la fiebre y la frecuencia respiratoria en menores de 5 años / Correlation between fever and respiratory rate in children under 5 years of age

Introducción: Entre los efectos de la fiebre está el incremento de la frecuencia respiratoria (FR) hasta alcanzar rangos de generar taquipnea. El diagnóstico de neumonía según la OMS basado en la presencia de taquipnea puede sobreestimarse durante la fiebre. El objetivo de este estudio fue determinar la correlación entre fiebre y FR en niños febriles menores de 5 años. Pacientes y Método: Estudio prospectivo de correlación en niños entre 2 y 60 meses. Se midió FR y temperatura corporal al ingreso a Servicio de Urgencia y luego de recibir acetaminofén. Se calculó la correlación entre el cambio de temperatura y el cambio en la FR. Se determinó la frecuencia de taquipnea al ingreso y al normalizar la temperatura. Resultados: 362 pacientes fueron incluidos, media 23,7 meses (DE 16,1). La FR en menores de un año disminuyó 12,9 respiraciones por minuto (DE 6,7) al normalizar temperatura; en mayores, disminuyó 10,7 respiraciones por minuto (DE 5,2). El coeficiente r² entre temperatura y FR fue 0,08 para menores de un año y 0,11 para mayores. De los niños que estaban taquipneicos, 57 por ciento no lo estaban al normalizar la temperatura. Conclusiones: Se recomienda reevaluar la FR de todo niño febril luego de normalizar su temperatura antes de definir taquipnea.

Introduction: Increased body temperature results in raised respiratory rate (RR) leading to tachypnea. According to World Health Organization (WHO), the diagnosis of pneumonia based on the presence of tachypnea can be overestimated during fever. The aim of this study is to determine the correlation between fever and RR in febrile children under five years of age. Patients and Method: A prospective study of correlation in children between 2 and 60 months was performed. RR and body temperature were measured on Emergency Room admission and after receiving acetaminophen. The correlation between the temperature change and the change in the RR was calculated. The frequency of tachypnea at admission and after normalizing the temperature was determined. Results: 362 patients were included, mean age 23.7 months old. RR in children under one year of age decreased 12.9 breaths per minute after normalizing the temperature, in older than one year of age, it decreased 10.7 breaths per minute. The r² coefficient between temperature and RR was 0.08 for children under one year and 0.11 for older. Among the children who were tachypneic, 57 percent did not present this condition after normalizing the temperature. Conclusions: It is recommended to reevaluate RR in all febrile children after normalizing the temperature and before diagnosing tachypnea.