A model to optimize public health care and downstage breast cancer in limited-resource populations in southern Brazil. (Porto Alegre Breast Health Intervention Cohort).

BACKGROUND: Breast cancer (BC) is a major public health problem, with rising incidence in many regions of the globe. Although mortality has recently dropped in developed countries, death rates are still increasing in some developing countries, as seen in Brazil. Among the reasons for this phenomenon are the lack of structured screening programs, a long waiting period between diagnosis and treatment, and lack of access to health services for a large proportion of the Brazilian population. METHODS AND DESIGN: Since 2004, an intervention study in a cohort of women in Southern Brazil, denominated Porto Alegre Breast Health Intervention Cohort, is being conducted in order to test the effectiveness and cost-effectiveness of a model for BC early detection and treatment. In this study, over 4,000 women from underserved communities aged 40 to 69 years are being screened annually with mammography and clinical breast examination performed by a multidisciplinary team, which also involves nutritional counseling and genetic cancer risk assessment. Risk factors for BC development are also being evaluated. Active search of participants by lay community health workers is one of the major features of our program. The accrual of new participants was concluded in 2006 and the study will last for 10 years. The main goal of the study is to demonstrate significant downstaging of BC in an underserved population through proper screening, attaining a higher rate of early-stage BC diagnoses than usually seen in women diagnosed in the Brazilian Public Health System. Preliminary results show a very high BC incidence in this population (117 cases per 100,000 women per year), despite a low prevalence of classical risk factors. DISCUSSION: This study will allow us to test a model of BC early diagnosis and treatment and evaluate its cost-effectiveness in a developing country where the mortality associated with this disease is very high. Also, it might contribute to the evaluation of risk factors in a population with a different ethnic background from that studied in developed countries. If our model is proven effective, it may be replicated in other parts of the globe where BC is also a major public health problem.

Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean.

Stroke is a major health problem in Latin American and Caribbean countries. In this paper, we review the epidemiology, aetiology, and management of stroke in the region based on a systematic search of articles published in Spanish, Portuguese, and English. Stroke mortality is higher than in developed countries but rates are declining. Population-based studies show variations in incidence of strokes: lower rates of ischaemic stroke and similar rates of intracranial haemorrhages, compared with other regions. A significant proportion of strokes in these populations can be attributed to a few preventable risk factors. Some countries have published national clinical guidelines, although much needs to be done in the organisation of care and rehabilitation. Even though the burden of stroke is high, there is a paucity of information for implementing evidence-based management. The Global Stroke Initiative, the WHO STEPS Stroke surveillance, and WHO-PREMISE projects provide opportunities for surveillance at institutional and community levels.

Endovascular thrombectomy for the treatment of acute ischemic stroke.

UNLABELLED: Few patients benefit from the current standard treatment for acute ischemic stroke (AIS), encouraging the development of new treatments. OBJECTIVE: To systematically review the literature on the efficacy and/or safety of endovascular thrombectomy in AIS compared to standard treatment and to identify ongoing randomized controlled trials (RCTs). METHOD: Searches for RCTs were performed in Medline/Embase, and for ongoing trials: International Clinical Trial Registry Platform, Clinicaltrials.gov and ISRCTN registry (to June 15th, 2015). RESULTS: From the eight published RCTs, five showed the superiority of treatment that includes thrombectomy compared to standard care alone. From the 13 ongoing RCTs, 3 have been halted, one has not started, one has unknown status and eight will end between 2016 - 2020. CONCLUSION: Evidence favours a combination of the standard therapy with endovascular thrombectomy. The selection criteria however limit the number of people who can benefit. Further studies are needed to prove its cost-effectiveness.

Is there evidence for recommending specific intravenous immunoglobulin formulations? A systematic review of head-to-head randomized controlled trials.

Intravenous immunoglobulins (IVIG) have been used for several licensed and off-label indications. Each IVIG product is a unique formulation of IgG and excipients, making them distinct products. How these differences impact on individual IVIG product efficacy and safety are not well established but can be investigated by head-to-head randomized controlled trials (RCT). A systematic review of head-to-head RCT comparing different formulations of IVIG, regardless of the target condition and outcomes investigated. Two reviewers screened 4084 citations retrieved from MEDLINE, Embase, Cochrane and LILACS, and 23 citations were fully-text evaluated. Eight trials were included. The clinical conditions, outcomes and risk of bias were assessed. Of the eight trials included only two investigated products that are currently on the market. One evaluated two Grifols brands used in patients with primary immunodeficiency and another evaluated two Baxter brands used in patients with chronic inflammatory demyelinating polyradiculoneuropathy. There were no differences between the formulations for the outcomes evaluated. In the other trials, either the manufacturers were acquired by other companies or the formulation was withdrawn from the market. As consequence, evidence concerning these products could not be considered. The quality of the studies was low, showing high risk of bias. Direct evidence about the different IVIGs is scarce and, at present, there is no scientific evidence that can be applied for a specific brand or formulation. Further comparative effectiveness studies are highly desirable for a better understanding of the differences in safety and efficacy of IVIGs.

Robotically assisted coronary artery bypass grafting: a systematic review and meta-analysis.

BACKGROUND: It remains uncertain as to whether robotically assisted coronary bypass surgery (RACBS) is superior to non-robotic procedures. METHODS: Literature searches were conducted using MEDLINE, EMBASE and LILACS. Two review authors independently screened citations, assessed trial quality and performed data extraction. RESULTS: Three trials met the inclusion criteria. None was randomized. Compared with non-robotic approaches, RACBS was associated with longer surgical times, shorter intensive care unit and hospital stays, higher extubation rates and lower odds for atrial fibrillation as well as myocardial infarction. There were no differences for the odds of stroke and mortality between the interventions. CONCLUSIONS: Although robotic-assisted coronary bypass appears to be promising, the study designs were not adequate and may have a high risk of selection bias. There is a need for randomized trials to corroborate the findings and to determine the long-term benefits of RACBS compared with traditional surgical approaches.

Endovascular thrombectomy for the treatment of acute ischemic stroke / Tratamento endovascular do acidente vascular isquêmico agudo

ABSTRACT Few patients benefit from the current standard treatment for acute ischemic stroke (AIS), encouraging the development of new treatments. Objective To systematically review the literature on the efficacy and/or safety of endovascular thrombectomy in AIS compared to standard treatment and to identify ongoing randomized controlled trials (RCTs). Method Searches for RCTs were performed in Medline/Embase, and for ongoing trials: International Clinical Trial Registry Platform, Clinicaltrials.gov and ISRCTN registry (to June 15th, 2015). Results From the eight published RCTs, five showed the superiority of treatment that includes thrombectomy compared to standard care alone. From the 13 ongoing RCTs, 3 have been halted, one has not started, one has unknown status and eight will end between 2016 - 2020. Conclusion Evidence favours a combination of the standard therapy with endovascular thrombectomy. The selection criteria however limit the number of people who can benefit. Further studies are needed to prove its cost-effectiveness.

RESUMO Poucos pacientes se beneficiam do atual tratamento para o acidente vascular cerebral isquêmico agudo (AVCIA), incentivando o desenvolvimento de novos tratamentos. Objetivo Revisão sistemática da literatura sobre a eficácia e/ou segurança da trombectomia endovascular (TE) em AVCIA comparado com tratamento padrão (TP) e identificar ensaios clínicos randomizados controlados (ECR) atualmente em andamento. Método Buscas por ECRs foram conduzidas no Medline,Embase, International Clinical Trial Registry Platform, Clinicaltrials.gov e no ISRCTN registry (to June 15th, 2015). Resultados Oito ECRs publicados foram identificados, dos quais cinco mostraram superioridade do tratamento com trombectomia comparado ao TP. Dos 13 ERCs registrados, 3 foram suspensos, um não iniciou, um temstatus desconhecido e oito encerrarão recrutamento entre 2016 e 2020. Conclusão A evidência favorece a combinação do TP com a TE em relação ao TP somente. Os critérios de inclusão limitam o número daqueles que poderiam se beneficiar. Mais estudos são necessários para demonstrar o custo-efetividade desta intervenção.

Epidemiologia das doenças cerebrovasculares / Epidemiology of cerebrovascular diseases

O processo de transiçäo epidemiológica em que se encontra o Brasil está determinado progressivo aumento no número de idosos e, com isto, aumento das doenças crônico-degenerativas. Entre elas, as doenças cerebrovasculares säo das mais importantes. Suas taxas de prevalência aumentam com a idade e variam geograficamente, podendo chegar, em nosso meio, até a 4,5%, a partir dos 60 anos. A incidência também apresenta estas variaçöes e dados nacionais mostram letalidade alta e demasiadamente precoce. As taxas de mortalidade colocam as doenças cerebrovasculares como a terceira causa de morte em várias cidades brasileiras, com valores que variam de 63 a 112/100.000 hab/ano. Em Porto Alegre, assim como no exterior, tem-se observado uma diminuiçäo progressiva destas taxas. O controle dos fatores de risco parece estar implicado nestas tendências de declínio. Por sua importância epidemiológica, as doenças cerebrovasculares necessitam de açöes visando prevençäo, melhor tratamento e melhores cuidados reabilitacionais

Orientaçöes para a prevençäo primária da epilepsia / Orientate for the primary prevention of epilepsy

Este artigo refere-se a recentes publicaçöes da Organizaçäo Mundial da Saúde sobre a prevençäo primária de transtornos mentais, neurológicos e psicosociais e aborda a epilepsia. Cerca de 50 milhöes de pessoas no mundo têm epilepsia e aproximadamente 2 milhöes desenvolvem epilepsia a cada ano. A implementaçäo da estratégia de cuidados primários à saúde é fundamental para a prevençäo e para os cuidados às pessoas com epilepsia. Entre as causa identificáveis mais comuns de epilepsia estäo as infecçöes, a febre e o traumatismo crânioencefálico. As etapas básicas para a prevençäo da epilepsia compreendem: cuidados pré-natais, parto seguro, controle das doenças infecciosas e parasitárias, reduçäo da lesäo cerebral por traumatismo crânioencefálico e acidentes vasculares cerebrais, controle da febre em crianças e aconselhamento genético