Repetitive Transcranial Magnetic Stimulation for Fibromyalgia: Systematic Review and Meta-Analysis.

BACKGROUND: Fibromyalgia (FM) is a prevalent chronic pain syndrome with few effective therapeutic options available. Repetitive transcranial magnetic stimulation (rTMS) is an emerging therapeutic alternative for this condition; however, results have been mixed. OBJECTIVES: To evaluate the efficacy of rTMS on FM, a comprehensive systematic review and meta-analysis were performed. METHODS: Relevant published, English and Portuguese language, randomized clinical trials (RCT) comparing rTMS (irrespective of the stimulation protocol) to sham stimulation for treating FM pain intensity, depression, and/or quality of life (QoL) were identified, considering only those with low risk for bias. Trials available until April 2014 were searched through MEDLINE, EMBASE, the Cochrane Library Databases, and other 26 relevant medical databases covering from every continent. The outcomes for pain, depression, and QoL assessed closest to the 30th day after rTMS treatment were extracted, and changes from baseline were calculated to compare the effects of rTMS vs. placebo. RESULTS: One hundred and sixty-three articles were screened, and five with moderate to high quality were included. rTMS improved QoL with a moderate effect size (Pooled SMD = -0.472 95%CI = -0.80 to -0.14); it showed a trend toward reducing pain intensity (SMD = -0.64 95%CI = -0.31 to 0.017), but did not change depressive symptoms. CONCLUSION: In comparison with sham stimulation, rTMS demonstrated superior effect on the QoL of patients with FM 1 month after starting therapy. However, further studies are needed to determine optimal treatment protocols and to elucidate the mechanisms involved with this effect, which does not seem to be mediated by changes in depression, but that may involve pain modulation. Level of evidence 1b.

A 10-Year Trend Analysis of Heart Failure in the Less Developed Brazil.

BACKGROUND: Data on heart failure (HF) epidemiology in less developed areas of Brazil are scarce. OBJECTIVE: Our aim was to determine the HF morbidity and mortality in Paraiba and Brazil and its 10-year trends. METHODS: A retrospective search was conducted from 2008 to 2017 using the DATASUS database and included patients ≥ 15 years old with a primary diagnosis of HF. Data on in-hospital and population morbidity and mortality were collected and stratified by year, gender and age. Pearson correlation and linear-by-linear association test for trends were calculated, with a level of significance of 5%. RESULTS: From 2008 to 2017, HF admissions decreased 62% (p = 0.004) in Paraiba and 34% (p = 0.004) in Brazil. The in-hospital mortality rate increased in Paraiba and Brazil [65.1% (p = 0.006) and 30.1% (p = 0.003), respectively], but the absolute in-hospital mortality had a significant decrease only in Paraiba [37.5% (p = 0.013)], which was maintained after age stratification, except for groups 15-19, 60-69 and > 80 years. It was observed an increase in the hospital stay [44% (p = 0.004) in Paraiba and 12.3% (p = 0.004) in Brazil]. From 2008 to 2015, mortality rate for HF in the population decreased 10.7% (p = 0.047) in Paraiba and 7.7% (p = 0.017) in Brazil. CONCLUSIONS: Although HF mortality rate has been decreasing in Paraiba and Brazil, an increase in the in-hospital mortality rate and length of stay for HF has been observed. Hospital-based clinical studies should be performed to identify the causes for these trends of increase.

A 10-Year Trend Analysis of Heart Failure in the Less Developed Brazil / Insuficiência Cardíaca no Brasil Subdesenvolvido: Análise de Tendência de Dez Anos

Abstract Background: Data on heart failure (HF) epidemiology in less developed areas of Brazil are scarce. Objective: Our aim was to determine the HF morbidity and mortality in Paraiba and Brazil and its 10-year trends. Methods: A retrospective search was conducted from 2008 to 2017 using the DATASUS database and included patients ≥ 15 years old with a primary diagnosis of HF. Data on in-hospital and population morbidity and mortality were collected and stratified by year, gender and age. Pearson correlation and linear-by-linear association test for trends were calculated, with a level of significance of 5%. Results: From 2008 to 2017, HF admissions decreased 62% (p = 0.004) in Paraiba and 34% (p = 0.004) in Brazil. The in-hospital mortality rate increased in Paraiba and Brazil [65.1% (p = 0.006) and 30.1% (p = 0.003), respectively], but the absolute in-hospital mortality had a significant decrease only in Paraiba [37.5% (p = 0.013)], which was maintained after age stratification, except for groups 15-19, 60-69 and > 80 years. It was observed an increase in the hospital stay [44% (p = 0.004) in Paraiba and 12.3% (p = 0.004) in Brazil]. From 2008 to 2015, mortality rate for HF in the population decreased 10.7% (p = 0.047) in Paraiba and 7.7% (p = 0.017) in Brazil. Conclusions: Although HF mortality rate has been decreasing in Paraiba and Brazil, an increase in the in-hospital mortality rate and length of stay for HF has been observed. Hospital-based clinical studies should be performed to identify the causes for these trends of increase.

Resumo Fundamento: Dados sobre a epidemiologia da insuficiência cardíaca (IC) em áreas pouco desenvolvidas são escassos. Objetivos: Nosso objetivo foi determinar a morbidade e a mortalidade por IC na Paraíba e no Brasil, e sua tendência em dez anos. Métodos: Realizou-se uma busca retrospectiva de 2008 a 2017 utilizando-se o banco de dados do DATASUS incluindo pacientes com idade ≥ 15 anos, com diagnóstico primário de IC. Os dados da morbimortalidade por IC foram coletados e estratificados por ano, sexo e idade. Foram realizados correlação de Pearson e teste para tendências de Mantel-Haenzsel. Um nível de 5% foi definido como estatisticamente significativo. Resultados: De 2008 a 2017, as internações por IC diminuíram 62% (p = 0,004) na Paraíba, e 34% (p = 0,004) no Brasil. A taxa de mortalidade hospitalar aumentou na Paraíba e no Brasil [65,1% (p = 0,006) e 30,1% (p = 0,003), respectivamente], mas a mortalidade hospitalar em números absolutos apresentou uma diminuição significativa somente na Paraíba [37,5% (p = 0,013)], o que foi mantido após a estratificação por idade, exceto para os grupos 15-19, 60-69 e > 80 anos. Observou-se um aumento no período de internação [44% (p = 0,004) na Paraíba e 12,3% (p = 0,004) no Brasil]. De 2008 a 2015, a taxa de mortalidade por IC na população diminuiu 10,7% na Paraíba (p = 0,047) e 7,7% (p = 0,017) no Brasil. Conclusões: Apesar de a taxa de mortalidade por IC estar diminuindo na Paraíba e no Brasil, observou-se um aumento na taxa de mortalidade hospitalar e na duração da internação por IC. Devem ser realizados estudos clínicos em hospitais para serem identificadas as causas dessa tendência de aumento.