DIAGNÓSTICO SITUACIONAL MEDIANTE MONITORAMENTO DA LINHA DE CUIDADO DAS PESSOAS VIVENDO COM HIV/AIDS: UM ESTUDO TRANSVERSAL

Introdução Desigualdades de acesso ao tratamento do HIV foram aprofundadas pela pandemia;entretanto, os benefícios de continuar a fornecer serviços de HIV superam o risco de mortes adicionais relacionadas à COVID-19. Na última década, Porto Alegre-RS está no topo do ranking do HIV, sendo necessário reconhecer as fragilidades da Linha de Cuidado(LC) das pessoas vivendo com HIV/AIDS (PVHA), em especial, as populações-chave. Objetivo Monitorar a LC das PVHA que acessaram os serviços do Consultório na Rua (CR) e da Unidade de Saúde (US) tradicional em Porto Alegre durante a pandemia do COVID-19. Métodos Estudo transversal, com dados do monitoramento 121 PVHA por 1 ano desde abril de 2020 nos serviços de CR e US, situados no mesmo estabelecimento. Resultados No CR, com 5332 pessoas cadastradas, 67 (1,2%) foram atendidos pelo HIV, sendo 22 (32,8%) pretos e pardos, 11 (16,4%) com 50 anos ou mais e 56 (83,6%) homens cis, enquanto na US, com 140000 cadastrados, atendeu-se 54 (0,38%), sendo 16 (29,6%) pretos e pardos, 23 (42,5%) com 50 anos ou mais e 21 (38,9%) mulher cis e 2 (3,7%) mulher trans. Em relação a adesão ao TARV, na US 35 (64,8%) retirando a medicação nos últimos 90 dias, e no CR 38(56,7%). Estão com a CV indetectável para o HIV na US 37 (68,5%) e no CR 28 (41,7%). O CD4<350 na última coleta, verificou-se 13 (24%) pacientes na US versus 25 (37,3%) no CR. Na US, 20 (37%) estão em uso de Dolutegravir-Tenofovir-Lamivudina, no CR, 19 (28,8%) estão em uso do mesmo esquema. Estão em uso de Tenofovir-Lamivudina-Efavirenz, 14 (25,9%) dos usuários da US e 22 (33,3%) dos usuários do CR, assim 34 (50,7%) e 41 (75,9%) estão em esquema de primeira linha nos serviços do CR e US, respectivamente. Os encaminhamentos para a especialidade de Infectologia foram na US 31 (57,4%) e no CR 38 (56,7%). O histórico de tuberculose está presente na US, 8 (14%) e no CR 14 (20,8%). Conclusões A Atenção Primária à Saúde (APS) pode colaborar na LC das PVHA, em especial as em situação de rua, em conjunto com serviços de Infectologia como garantia de acesso e direcionamento dos casos previstos de AIDS ou co-infecção. O monitoramento por tabela de Excel organizadas pelos valores de CD4 auxiliam a APS a promover a adesão na LC, agiliza o acolhimento das demandas e proporciona planejamento das buscas ativas para a retomada dos tratamentos pelas suas equipes de assistência multiprofissional. A otimização dos esquemas antirretrovirais para primeira linha facilita o papel da APS para atingir a Meta 90-90-90.

Risk of bias and certainty of evidence on the association between obesity and mortality in patients with SARS-COV-2: An umbrella review of meta-analyses.

BACKGROUND & AIMS: This umbrella review of systematic reviews with meta-analysis (SR-MAs) aimed to evaluate the risk of bias and the certainty of the evidence of SR-MAs on the association between obesity and mortality in patients with SARS-CoV-2. METHODS: We conducted a comprehensive literature search until April 22, 2022, in several databases and assessed the risk of bias of SR-MAs according to AMSTAR-2 and the certainty of evidence using the GRADE approach. The degree of overlap between meta-analyses was based on the corrected covered area (CCA) index. The results of each MA [relative risk (RR), hazard ratio (HR), or odds ratio (OR)] were extracted to evaluate the magnitude of the association between obesity and mortality. RESULTS: A total of 24 SR-MAs were eligible, and the association between obesity and mortality was not statistically significant in eight (33.3%) of them, while the OR/HR/RR ranged from 1.14 to 3.52 in the other SR-MAs. The overlap was slight (CCA = 4.82%). The majority of SR-MAs presented critically low quality according to AMSTAR-2 (66.7%), and the certainty of the evidence for most of them (83.4%) was "very low". CONCLUSIONS: Obesity was associated with an increased risk of death in patients with SARS-CoV-2 infection in most SR-MAs; however, a critical appraisal pointed to a high risk of bias, and the certainty of their evidence was not well graded. The dissemination of poor SR-MAs may limit the interpretation of findings, and we should always aspire to trustworthy scientific evidence. PROSPERO: PROSPERO 2021 CRD42021253142.

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.

Adult patients admitted to a tertiary hospital for COVID-19 and risk factors associated with severity: a retrospective cohort study.

COVID-19 is a disease whose knowledge is still under construction, high transmissibility, with no consensual treatment available to everyone. Therefore, the identification of patients at higher risk of evolving to the critical form of the disease is fundamental. The study aimed to determine risk factors associated with the severity of COVID-19 in adults patients. This is an observational, retrospective study from a cohort of adult patients with COVID-19 admitted to a public hospital from March to August 2020, whose medical records were evaluated. For the association of possible severity predictors, a Poisson regression was used. The primary outcome was the critical form of the disease (need for admission to the Intensive Care Unit and/or invasive mechanical ventilation). We included 565 patients: mostly men; 55.5% of those who progressed to the critical form of the disease were over sixty years old. Hypertension, diabetes mellitus and obesity were the most frequent comorbidities. There were 39.8% of patients who progressed to the critical form of the disease. The hospital mortality rate was 22.1%, and that of critical patients was 46.7%. The independent factors associated with the severity of the disease were obesity [RR = 1.33 (95% CI 1.07 to 1.66; p = 0.011)], SpO2/FiO2 ratio ≤ 315 [RR = 2.20 (95% CI 1.79 to 2.71; p = 0.000)], C-reactive protein > 100 mg/L [RR = 1.65 (95% CI 1.33 to 2.06; p = 0.000)], and lymphocytes < 1,000/µL [RR = 1.44 (95% CI 1.18 to 1.75; p = 0.000)]. Advanced age and comorbidities were dependent factors strongly associated with the critical form of the disease.

Evaluation of the initial response in clinical trial efforts for COVID-19 in Brazil. / Avaliação da resposta inicial de desenvolvimento de ensaios clínicos para COVID-19 no Brasil.

OBJECTIVE: To describe the methodological characteristics and good research practices of COVID-19 interventional studies developed in Brazil in the first months of the pandemic. METHODS: We reviewed the bulletin of the National Research Ethics Committee - Coronavirus Special Edition (Comissão Nacional de Ética em Pesquisa - CONEP-COVID) (May 28, 2020) and the databases of the International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and Brazilian Clinical Trials Registry (Registro Brasileiro de Ensaios Clínicos - ReBEC) to identify interventional studies registered in Brazil that assessed drug type, biological therapy, or vaccines. We described their methodological characteristics and calculated their power for different effect magnitudes. RESULTS: A total of 62 studies were included, 55 retrieved from the CONEP website, and 7 from registry databases. The most tested pharmacological interventions in these studies were: chloroquine/hydroxychloroquine, azithromycin, convalescent plasma, tocilizumab, sarilumab, eculizumab, vaccine, corticosteroids, anticoagulants, n-acetylcysteine, nitazoxanide, ivermectin, and lopinavir/ritonavir. Out of 22 protocols published on registry databases until May 2020, 18 (82%) were randomized clinical trials, and 13 (59%) had an appropriate control group. However, 9 (41%) of them were masked, and only 5 (24%) included patients diagnosed with a specific laboratory test (for example, reverse transcription polymerase chain reaction - RT-PCR). Most of these studies had power > 80% only to identify large effect sizes. In the prospective follow-up, 60% of the studies available at CONEP until May 2020 had not been published on any registry platform (ICTRP/ReBEC/ClinicalTrials) by July 21, 2020. CONCLUSION: The interventions evaluated during the Brazilian research response reflect those of international initiatives, but with a different distribution and a large number of studies assessing hydroxychloroquine/chloroquine. Limitations in methodological design and sample planning represent challenges that could affect the research outreach.

OBJETIVO: Descrever as características metodológicas e de boas práticas em pesquisa dos estudos de intervenção para COVID-19 desenvolvidos no Brasil nos primeiros meses da pandemia. MÉTODOS: Revisamos o boletim da Comissão Nacional de Ética em Pesquisa - edição especial Coronavírus (CONEP-COVID) (28 de maio de 2020) e as bases International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov e Registro Brasileiro de Ensaios Clínicos (ReBEC) para identificar estudos registrados no Brasil que avaliassem intervenções de tipo de medicamento, terapia biológica ou vacinas. Descrevemos as características metodológicas e calculamos o poder para diferentes magnitudes de efeito. RESULTADOS: Foram incluídos 62 estudos, 55 identificados no site da CONEP e mais sete nas bases de registro. As intervenções medicamentosas mais frequentemente testadas nesses estudos foram: cloroquina/hidroxicloroquina, azitromicina, plasma convalescente, tocilizumabe, sarilumabe, eculizumabe, vacina, corticoides, anticoagulantes, n-acetilcisteína, nitazoxanida, ivermectina e lopinavir/ritonavir. De 22 protocolos publicados até maio de 2020 nas bases de registro, 18 (82%) eram ensaios clínicos randomizados e 13 (59%) tinham grupo controle adequado. Entretanto, nove (41%) eram mascarados e somente cinco (24%) incluíam pacientes diagnosticados com teste de laboratório específico (por exemplo, transcrição reversa seguida de reação em cadeia da polimerase - RT-PCR). A maioria desses trabalhos teria poder > 80% apenas para identificar grandes tamanhos de efeito. Em seguimento prospectivo, observamos que 60% dos estudos disponíveis na CONEP até maio de 2020 não estavam em nenhuma das plataformas de registro (ICTRP/ReBEC/ClinicalTrials) até o dia 21 de julho de 2020. CONCLUSÃO: As intervenções avaliadas durante a resposta brasileira em pesquisa refletem iniciativas internacionais, porém com distribuição diferente, tendo número elevado de estudos que avaliam hidroxicloroquina/cloroquina. Limitações no delineamento metodológico e planejamento amostral representam desafios que podem afetar o alcance dos trabalhos.

The COVID-19 Pandemic and Planetary Health. A Critical Review of Epidemiology, Prevention, Clinical Characteristics and Treatments for Oral, Head and Neck Health Professionals. Do We Have a Roadmap?

Introduction Coronavirus disease 19 (COVID-19) is potentially the greatest global public health crisis of this century. This disease emerged as an outbreak of pneumonia of unknown cause in Wuhan, the capital city of the Hubei province in China, in December 2019. Otolaryngologists, head and neck surgeons and dentists are at an increased risk of occupational disease. Objective The present review summarizes currently published evidence of Covid-19 epidemiology, clinical characteristics, treatment and prevention. No proven effective treatments for this disease currently exist. Data Synthesis COVID-19 started from a zoonotic transmission event associated with a large seafood market that also traded in live wild animals, and it soon became clear that efficient person-to-person transmission was also occurring. Symptoms are varied, and not all patients develop all of them. Conclusion Social distancing seems to have been successful in several places in the world. However, this recommendation alone is not enough to contain the disease, and it is not a long-term solution. Large-scale testing by health professionals of representative samples of the population may give an estimate of the progression of the disease. Different treatments are under test and bring hope of a cure to the population. However, no current treatments (April 27, 2020) have been proven to be the key to success in the treatment of patients with COVID-19. Planetary health is a useful concept to understand the current drivers of this pandemic and to draw a roadmap for science and healthcare that may guide actions to fight economic depression and ensure a healthy recovery.

The COVID-19 Pandemic and Planetary Health. A Critical Review of Epidemiology, Prevention, Clinical Characteristics and Treatments for Oral, Head and Neck Health Professionals. Do We Have a Roadmap?

Introduction Coronavirus disease 19 (COVID-19) is potentially the greatest global public health crisis of this century. This disease emerged as an outbreak of pneumonia of unknown cause in Wuhan, the capital city of the Hubei province in China, in December 2019. Otolaryngologists, head and neck surgeons and dentists are at an increased risk of occupational disease. Objective The present review summarizes currently published evidence of Covid-19 epidemiology, clinical characteristics, treatment and prevention. No proven effective treatments for this disease currently exist. Data Synthesis COVID-19 started from a zoonotic transmission event associated with a large seafood market that also traded in live wild animals, and it soon became clear that efficient person-to-person transmission was also occurring. Symptoms are varied, and not all patients develop all of them. Conclusion Social distancing seems to have been successful in several places in the world. However, this recommendation alone is not enough to contain the disease, and it is not a long-term solution. Large-scale testing by health professionals of representative samples of the population may give an estimate of the progression of the disease. Different treatments are under test and bring hope of a cure to the population. However, no current treatments (April 27, 2020) have been proven to be the key to success in the treatment of patients with COVID-19. Planetary health is a useful concept to understand the current drivers of this pandemic and to draw a roadmap for science and healthcare that may guide actions to fight economic depression and ensure a healthy recovery.