Periodontitis and respiratory diseases: A systematic review with meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis to evaluate the recent scientific literature addressing the association between periodontitis and asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. MATERIALS AND METHODS: The search for studies was carried out using MEDLINE/PubMed, EMBASE, Lilacs, Web of Science, Scopus, and SciELO databases, including the gray literature (ProQuest). Reference lists of selected articles were also searched. Studies having varying epidemiological designs assessing the association between periodontitis and respiratory diseases in human subjects were eligible for inclusion. Three independent reviewers performed the selection of articles and data extraction. Fixed and random effects meta-analysis were performed for the calculation of the association measurements (Odds Ratio-OR) and 95% confidence intervals (95% CI). RESULTS: A total of 3,234 records were identified in the database search, with only 13 studies meeting the eligibility criteria and 10 studies contributed data for meta-analysis. Using a random effects models periodontitis was associated with asthma: ORadjusted: 3.54 (95% CI: 2.47-5.07), I2  = 0%; with COPD: OR adjusted: 1.78 (95% CI: 1.04-3.05), I2  = 37.9%; and with pneumonia: OR adjusted: 3.21 (95% CI: 1.997-5.17), I2  = 0%. CONCLUSIONS: The main findings of this systematic review validated an association between periodontitis and asthma, COPD and pneumonia.

Maternal Active Smoking During Pregnancy and Low Birth Weight in the Americas: A Systematic Review and Meta-analysis.

INTRODUCTION: Smoking during pregnancy may negatively impact newborn birth weight. This study investigates the relationship between maternal active smoking during pregnancy and low birth weight in the Americas through systematic review and meta-analysis. METHODS: A literature search was conducted through indexed databases and the grey literature. Case-control and cohort studies published between 1984 and 2016 conducted within the Americas were included without restriction regarding publication language. The article selection process and data extraction were performed by two independent investigators. A meta-analysis of random effects was conducted, and possible causes of between-study heterogeneity were evaluated by meta-regressions and subgroup analyses. Publication bias was assessed by visual inspection of Begg's funnel plot and by Egger's regression test. RESULTS: The literature search yielded 848 articles from which 34 studies were selected for systematic review and 30 for meta-analysis. Active maternal smoking was associated with low birth weight, OR = 2.00 (95% CI: 1.77-2.26; I2 = 66.3%). The funnel plot and Egger's test (p = .14) indicated no publication bias. Meta-regression revealed that sample size, study quality, and the number of confounders in the original studies did not account for the between-study heterogeneity. Subgroup analysis indicated no significant differences when studies were compared by design, sample size, and regions of the Americas. CONCLUSION: Low birth weight is associated with maternal active smoking during pregnancy regardless of the region in the Americas or the studies' methodological aspects. IMPLICATIONS: A previous search of the major electronic databases revealed that no studies appear to have been conducted to summarize the association between maternal active smoking during pregnancy and low birth weight within the Americas. Therefore, this systematic review may help to fill the information gap. The region of the Americas contains some of the most populous countries in the world; therefore, this study may provide useful data from this massive segment of the world's population.

[Economic evaluation of health technologies: checklist for critical analysis of published articles]. / Estudos de avaliação econômica de tecnologias em saúde: roteiro para análise crítica.

OBJECTIVE: To propose a tool for critical analysis of economic evaluation studies based on a synthesis of checklists and guidelines available in the literature. METHODS: The following databases were searched: MEDLINE, Embase, Centre for Reviews and Dissemination, and International Society for Pharmacoeconomics and Outcomes Research. Two investigators independently selected the studies and extracted the data of interest. The number of questions that the checklists contained were counted on the following domains: study design, measurement of costs and health outcomes, analysis and interpretation of results, and general information. A matrix containing the items in each domain was constructed, and a tool for critical analysis was built based on that matrix. RESULTS: The literature search retrieved 406 non-duplicated articles, 19 of which were included in the study. Five hundred sixty-six questions were identified in the checklists employed in these studies: 109 (19%) dealt with health outcomes, 93 (16%) with quantification of costs, 73 (13%) with modeling, 54 (10%) with generalization of findings, and 52 (9%) with uncertainty. The resulting critical analysis checklist contains 32 questions organized into four domains: study design, measurement of costs and health outcomes, analysis and interpretation of results, and general information. CONCLUSIONS: The proposed critical analysis checklist is useful to standardize the assessment of the quality of evidence in all types of economic evaluations.

Zinc supplementation for treating diarrhea in children: a systematic review and meta-analysis.

OBJECTIVE: To update the available evidence about zinc use for treating diarrhea in children and to assess its effect on the malnourished population, a subgroup that has not been fully explored in previous analyses. METHODS: A systematic review was performed of randomized clinical trials that assessed children up to 5 years old with acute diarrhea who received zinc supplementation. Controls received a placebo or oral rehydration therapy. After searching the main databases, without language restrictions, two independent reviewers selected eligible studies, extracted the data, and assessed the risk of bias of included studies. Meta-analyses were calculated using Mantel-Haenszel or inverse variance random effects. RESULTS: Eighteen of 1 041 studies retrieved were included in the review (n = 7 314 children). Zinc was beneficial for reducing the duration of diarrhea in hours (mean difference [MD] = -20.12, 95% confidence interval [CI] = -29.15 to -11.09, I² = 91%). The effect was greater in malnourished children (MD = -33.17, 95% CI = -33.55 to -27.79, I² = 0%). Diarrhea prevalence on days 3, 5, and 7 was lower in the zinc group. The incidence of vomiting was significantly greater in the group that received zinc than in the control group. Included randomized controlled trials were of low risk of bias in most domains assessed. CONCLUSIONS: Oral zinc supplementation significantly decreases diarrhea duration and has a greater effect on malnourished children. Zinc supplementation seems to be an appropriate public health strategy, mainly in areas of endemic deficiencies.

Antioxidants for preventing preeclampsia: a systematic review.

OBJECTIVE: To investigate the efficacy of antioxidants for preventing preeclampsia and other maternal and fetal complications among pregnant women with low, moderate, or high risk of preeclampsia. METHODS: We searched MEDLINE, Embase, CENTRAL, mRCT, and other databases, with no language or publication restrictions. Two independent reviewers selected randomized controlled trials that evaluated the use of antioxidants versus placebo and extracted the relevant data. Relative risks (RRs) and 95% confidence intervals (95% CIs) were calculated. The data were compiled through the random effects model. MAIN RESULTS: Fifteen studies were included (21,012 women and 21,647 fetuses). No statistically significant difference was found between women who received antioxidant treatment and women who received placebo for preeclampsia (RR = 0.92; 95% CI: 0.82-1.04), severe preeclampsia (RR = 1.03; 95% CI: 0.87-1.22), preterm birth (RR = 1.03; 95% CI: 0.94-1.14), and small for gestational age <10th centile (RR = 0.92; 95% CI: 0.80-1.05). Side effects were numerically more frequent in the antioxidants group compared to placebo, but without significant statistical difference (RR = 1.24; 95% CI: 0.85-1.80). CONCLUSIONS: The available evidence reviewed does not support the use of antioxidants during pregnancy for the prevention of preeclampsia and other outcomes.

[Maternal periodontitis and low birth weight: systematic review and meta-analysis]. / Periodontite materna e baixo peso ao nascer: revisão sistemática e metanálise.

Recent evidence points to the influence of periodontal inflammatory processes on the occurrence of low birth weight. Although many studies employed robust investigation methods, there is still no general agreement on the relationship between maternal periodontitis and low birth weight. The search for studies was conducted until April 2019. The studies included cohort and case-control studies that estimated the association between periodontitis and low birth weight, with no restriction on language or date of publication. Analysis of the heterogeneity of studies, subgroup analyses and meta-analyses with a random effects model were performed. Summary association measurements were estimated using the crude and adjusted Odds Ratio, with respective 95% confidence intervals. Visual inspection of graphs was used to assess publication bias. A total of 21 articles were identified, all of which were selected for the meta-analysis. The final model indicates that periodontitis in pregnant women was associated with low birth weight (ORgross=2.13; CI95%=1.60-2.83; I2=80.0% and ORadjusted=2.64; CI95%=2.04-3.42; I2=17.4%). Pregnant women with periodontitis may be more than twice as likely to have low birth weight babies.

Evidências recentes apontam para a influência de processos inflamatórios periodontais na ocorrência de baixo peso ao nascer. Embora muitos estudos empregaram métodos robustos de investigação, ainda não existe consenso sobre o tópico. Analisar sistematicamente a relação entre a periodontite materna e o baixo peso ao nascer. A busca por estudos foi realizada até abril de 2019. Os delineamentos de estudos incluídos foram coorte e caso-controle que estimaram a associação entre a periodontite e o baixo peso ao nascer, sem limite quanto ao idioma ou data da publicação. Análise de heterogeneidade dos estudos, análises de subgrupo e metanálises com modelo de efeitos randômicos foram realizadas. Foram estimadas as medidas de associação sumária por meio da Odds Ratio bruta e ajustada, com respectivos intervalos de confiança a 95%. A inspeção visual de gráficos foi empregada para avaliar viés de publicação. Um total de 21 artigos foram identificados e todos foram selecionados para a metanálise. O modelo final aponta que a periodontite em gestantes se associou ao baixo peso ao nascer (ORbruta=2,13; IC95%=1,60-2,83; I2=80,0% e ORajustada=2,64; IC95%=2,04-3,42; I2=17,4%). Gestantes com periodontite podem ter mais que o dobro de probabilidade de terem filhos com baixo peso ao nascer.

Validation of a search strategy for randomized clinical trials related to periodontitis.

BACKGROUND: Systematic reviews, considered the gold standard for the assessment of scientific evidence, may present conflicting findings for the same clinical issue, and such dissent may be justified by the forms of elaboration of the electronic search strategy. This paper aims to validate a search strategy to identify randomized clinical trials related to periodontitis. A gold standard reference set was developed to validate the identified clinical trials using the relative recall method. The choice of periodontitis is due to the fact that this disease has a high prevalence among chronic non-communicable diseases, is considered the second most common oral disease in the world, is associated with several health problems, such as cardiovascular diseases and diabetes, and, principally, has not been investigated sufficiently to prevent possible damages resulting from it. METHODS: A validation study was developed in MEDLINE/PubMed. In Stage 1, a methodological filter recommended by the Cochrane Collaboration to identify randomized clinical trials was applied. Stage 2 identified articles related only to periodontitis (gold standard reference set) from among the articles retrieved using the eligibility criteria. In Stage 3, a search statement for the retrieval of periodontitis-related articles was elaborated by experts. Stage 4 defined the proposed search strategy comprising of the combination of the search statement developed with the aforementioned methodological filter and subsequent application in MEDLINE/PubMed. The obtained data were analyzed using the set of articles identified in Stage 2, as the gold standard reference set. The following performance values were calculated - sensitivity, specificity, accuracy, and number needed to read - with their respective 95% confidence interval (95%CI). RESULTS: The search strategy under evaluation compared to the gold-standard showed a sensitivity of 93.2% (95%CI, 83.8-97.3), specificity of 99.9% (95%CI 99.8-99.9), and a precision of 77.5% (95%CI, 66.48-85.63). In addition, the number needed to read was 1.3. CONCLUSION: According to the proposed methodological approach, the search strategy under evaluation performed well in the identification of randomized clinical trials related to periodontitis.

Oropharyngeal colostrum immunotherapy and nutrition in preterm newborns: meta-analysis.

OBJECTIVE: To investigated the effect of oropharyngeal colostrum immunotherapy in reducing the time required for very low birth weight preterm newborns (VLBW-PTNB: < 1,500g and < 37 weeks) to achieve full enteral nutrition. METHODS: Literature search was conducted using four databases, including gray literature, with additional manual search of the references of selected articles. Eligibility criteria consisted of randomized clinical trials, without restriction regarding the date or language of the publication. Two independent reviewers performed the article selection and data extraction. The random-effects meta-analysis used a non-standard technique to assess the mean difference in days to achieve full enteral nutrition, carried out by the Stata 15 statistic program. RESULTS: The systematic review comprised 10 studies, and five were selected for meta-analysis, with a population of 764 VLBW-PTNB and gestational age of birth between 25 and 32 weeks. The studies were conducted between 2011 and 2018 in North America, Asia and Africa, with only one conducted in South America. Altogether, they reported the number of days it took 708 VLBW-PTNB to achieve full enteral nutrition, with newborns treated with immunotherapy showing a shorter time in only three studies. Meta-analysis showed a mean difference of -4.26 days, (95% CI -7.44; -1.08d), with high heterogeneity (I2 = 83.1%). CONCLUSION: The use of oropharyngeal colostrum immunotherapy can reduce the time for VLBW-PTNB to achieve full nutrition when compared to those who used a placebo or received routine care.

Associated factors to abusive alcoholic beverage consumption in suicide victims.

BACKGROUND: Suicide is a worldwide phenomenon, as well as a challenge for public health, and alcoholic beverage abuse is one of the most important risk factors. However, the association between possible factors related to alcoholic beverage consumption in suicide victims has rarely been investigated. OBJECTIVE: To evaluate the factors associated with abusive alcoholic beverage consumption among people who died from suicide in the Brazilian Federal District (BFD). METHOD: A population-based and cross-sectional study with suicide victims in the BFD between 2016 and 2017. Information was collected about sociodemographic characteristics, autopsy appraisal, and drug use. A trained team evaluated all cases to define factors associated with abusive alcoholic beverage consumption. This outcome was measured using the Blood Alcohol Concentration. Poisson regression analysis was applied to calculate the Prevalence Ratios and respective populational confidence intervals. RESULTS: The findings of the present study were collected from a database containing information related to 278 suicide victims. Being male and having cocaine identified in the toxicological test were the factors that showed a strong association with abusive alcohol beverage consumption in suicide victims. Other factors showed a slight association (PR < 1.5): having an education level with greater than 8 years of study, being black, having a professional occupation or being retired or pensioner, and having the presence of cannabis in the toxicological test. CONCLUSION: Socioeconomic-demographic and behavioral factors proved to be positively associated with abusive alcoholic beverage consumption among suicide victims, suggesting the need for effective public health policy measures to combat this health problem.

An accuracy study of the clinical diagnosis of periodontitis in pregnant women.

BACKGROUND: There exists a diverse range of criteria used in epidemiological studies for the diagnosis of periodontitis. The results from these studies should be evaluated with consideration to the diagnostic criteria used, and this may account for differences between studies especially in some population groups such as pregnant females. The objective is to evaluate the diagnostic criteria used in a variety of epidemiologic studies of periodontitis in pregnant females. METHODS: An accuracy study with cross-sectional design was performed out from a database of 671 pregnant females, using six different sets of criteria for the diagnosis of periodontitis. Women were classified for periodontitis, as follows: Center for Disease Control and Prevention/American Academy of Periodontology (CDC/AAP, 2012 criterion), the gold standard, Gomes-Filho et al.(2018) criterion, Albandar et al.(2007) criterion, Bassani et al.(2007) criterion, López et al.(2002) criterion, and Nesse et al.(2008) criterion. For comparison amongst the gold standard and the other criteria, sensitivity, specificity, predictive values, and likelihood ratio were determined. RESULTS: The frequency of periodontitis ranged from 25.0% to 90.2%. The Bassani et al. (2007) criterion was found to be more sensitive among the studies, and thus more suitable for diagnostic screening studies. Gomes-Filho et al.(2018), Albandar et al. (2007), López et al. (2002), and Nesse et al. (2008) criteria were considered more specific, which makes them more useful for studies of periodontitis with the aim of using diagnosis for confirmation of disease. CONCLUSIONS: A variation in the occurrence of periodontitis was observed. The criterion must be chosen according to the research aims and population characteristics.

Knowledge translation in the reality of Brazilian public health.

The term knowledge translation has been used to describe the process of applying research results to the real world, in order to enhance the quality and effectiveness of health care and services. The aim of this article is to discuss the incorporation of knowledge translation in the Brazilian public health. The article addresses the basic activities of knowledge translation and lists challenges and perspectives in Brazilian scenario. Brazil began to move towards understanding the process of translating scientific knowledge into practice. Investing in pilot studies to adapt the so-called effective interventions to the Brazilian scenario may be an alternative. Increasing the qualification of Brazilian researchers in the design and evaluation of implementation studies is relevant to improve this field in the country.

Maternal Exposure to Alcohol and Low Birthweight: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate the relationship between maternal exposure to alcohol and low birthweight (LBW). METHODS: The literature search was performed in January 2017 using the following electronic databases: Medline, Embase, LILACS, SciELO, Web of Science, Scopus, CINHAL, Proquest, and PsychInfo. The search strategy used the following terms: alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol addiction/use/abuse/consumption, light/moderate/social/low drinking, low birthweight, case-control studies, retrospective studies, and cohort studies. No restrictions regarding language or publication date were considered. The literature search yielded 2,383 articles, and after screening and eligibility assessment, 39 articles were included in the systematic review, and 38 studies were included in the meta-analysis. RESULTS: Maternal alcohol consumption was associated with LBW among retrospective cohort studies (relative risk [RR] = 1.37; 95%CI [confidence interval]:1.10-1.77; I2 = 98.4%; p < 0.01). Prospective cohort studies (RR = 1.11; 95%CI: 0.98-1.25; I2 = 81.5%; p < 0.01), and case-control studies (odds ration [OR] = 1.16; 95%CI: 0.68-1.97; I2 = 61.2%; p = 0.05) showed no association between alcohol and LBW. No publication bias was identified, and the meta-regression showed that the sample size influenced the high heterogeneity among retrospective cohort studies. The subgroup analysis showed differences in association between groups when compared by sample size, type of adjustment, or crude measures and publication year. CONCLUSIONS: We have not found an association between alcohol consumption during gestation and LBW in the analysis in all of the subgroups. In addition, we have found a high heterogeneity between the primary studies, which is related to methodological differences in the conduction of these studies.

OBJETIVO: Investigar a associação entre a exposição maternal ao álcool e o baixo peso ao nascer. MéTODO: A busca na literatura ocorreu em janeiro de 2017 nas seguintes bases de dados eletrônicas: Medline, Embase, LILACS, SciELO, Web of Science, Scopus, CINHAL, Proquest, e PsychInfo. A estratégia de busca utilizou os seguintes termos: alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol addiction/use/abuse/consumption, light/moderate/social/low drinking, low birthweight, case-control studies, retrospective studies, e cohort studies. Não houve restrição de idioma e ano de publicação. A busca na literatura identificou 2.383 artigos, e depois de analisados conforme os critério de elegibilidade, foram incluídos na revisão sistemática 39 estudos, e 38 estudos foram incluídos na metanálise. RESULTADOS: A amostra foi composta por 497.023 gestantes. O consumo materno de álcool foi associado ao baixo peso ao nascer entre os estudos de coorte retrospectiva (risco relativo [RR] = 1,37; IC [intervalo de confiança] 95%: 1,10­1,77; I2 = 98,4%; p < 0,01). Os estudos de coorte prospectiva (RR = 1,11; IC95%: 0,98­1,25; I2 = 81,5%; p < 0,01) e caso-controle (razão de chances [OR, na sigla em inglês] = 1,16; IC95%: 0,68­1,97; I2 = 61,2%; p = 0,05) não apresentaram associação entre o consumo e o desfecho. Não foi identificado viés de publicação, e a metarregressão mostrou que o tamanho da amostra influenciou a heterogeneidade entre os estudos de coorte prospectiva. Na análise por subgrupo, houve diferenças entre os grupos por tamanho de amostra, por tipo de ajuste e por ano de publicação. CONCLUSãO: Não encontramos associação entre o consumo e o baixo peso ao nascer em todas as análises por subgrupo. Além disso, encontramos alta heterogeneidade entre os estudos primários, e isto se deve possivelmente às diferenças metodológicas na condução destes estudos.

Maternal anemia and birth weight: A prospective cohort study.

OBJECTIVE: To investigate the association between maternal anemia and low/insufficient birth weight. DESIGN: A prospective cohort study of pregnant women who underwent prenatal care at the healthcare units in a municipality of northeast Brazil together with their newborn infants was carried out. The pregnant women were classified as having anemia when the hemoglobin level was below 11 g/dl. Infants who were born full term weighing less than 2500 grams were classified as low birth weight, and those weighing between 2500 and 2999 grams were classified as insufficient weight. The occurrence of maternal anemia and its association with birth weight was verified using crude and adjusted Relative Risk (RR) estimates with their corresponding 95% confidence intervals (95%CIs). RESULTS: The final sample was comprised of 622 women. Maternal anemia was considered a risk factor for low/insufficient birth weight, after adjusting the effect measurement for maternal age, family income, urinary infection, parity, alcoholic beverage consumption during pregnancy and gestational body mass index: RRadjusted = 1.38 [95% CI: 1.07 to 1.77]. CONCLUSIONS: Maternal anemia was associated with low/insufficient birth weight, representing a risk factor for the gestational outcomes studied.

Diagnosis and control of polypharmacy in the elderly.

The article had the purpose of commenting on studies on polypharmacy in the elderly, focusing on diagnosis and control. Polypharmacy is defined as the use of a number of medications at the same time and the use of additional drugs to correct drug adverse effects. The fact that the elderly take more medications for the treatment of several diseases makes them more susceptible to the occurrence of adverse reactions. Prophylactic actions such as balanced prescriptions are vital to reduce the incidence of these reactions and prevent longer hospital stay, increased costs and aggravation of the elderly health condition.

[Prevalence of breastfeeding in Brazilian capital cities]. / Prevalência do aleitamento materno nas capitais brasileiras.

OBJECTIVE: To estimate the prevalence of breastfeeding and of exclusive breastfeeding in Brazilian capital cities, in the 5 major geographical areas of Brazil and in the whole country, at the ages of 30, 120 and 180 days, as agreed among specialists. METHODS: Restudy of data from the population inquiry about breastfeeding in 25 capital cities and in the Federal District during a mass immunization campaign, on October 16th, 1999, National Day of Vaccination, supervised by one of the authors. The random sample of this study refers to 10,778 children, according to the ages mentioned above. The point and interval estimates (95% CI) were given for the capital cities and then extrapolated to the major geographical areas and to Brazil. The regression analysis was used on the SAS statistical program. RESULTS: The estimated prevalence of breastfeeding in Brazil was 87.3% (CI 95%: 86.8-87.7) at the age of 30 days, 77.5% (77.1-78.0) at the age of 120 days and 68.6% (68.2-69.1) at the age of 180 days. The exclusive breastfeeding prevalence was 47.5% (46.4-48.5), 17.7% (17.2-18.3) and 7.7% (7.2-8.2) at the ages mentioned. At the age of 30 days, variation of the frequency of exclusive breastfeeding was wide, from 73.4% (Fortaleza) to 25.2% (Cuiabá). At the age of 180 days, the prevalence ranged from 16.9% in Belém to 2.8% in Cuiabá. CONCLUSION: There was a moderate reduction of the prevalence of breastfeeding and a steep decline of the prevalence of exclusive breastfeeding from birth to the age of 180 days. Important differences were noted in the frequency of exclusive breastfeeding among the capital cities surveyed.

Prevalence and associated factors of self-medication in adults living in the Federal District, Brazil: a cross-sectional, population-based study. / Prevalência e fatores associados à automedicação em adultos no Distrito Federal: estudo transversal de base populacional.

OBJECTIVE: to assess the prevalence of self-medication and to investigate its associated factors in adults living in the Federal District, Brazil. METHODS: this is a cross-sectional population-based study conducted with adults selected through probabilistic sampling; self-medication prevalence was obtained from those who reported having used any medicine in the previous seven days; Poisson regression model with robust variance was applied to adjust the prevalence ratios. RESULTS: 1,820 individuals were interviewed, of which 646 had taken at least one medicine; self-medication prevalence was of 14.9% (95%CI: 12.6%;17.5%); the adjusted analysis showed negative association in people aged 50 to 65 years (PR=0.26; 95%CI: 0.15;0.47) and with chronic diseases (PR=0.38; 95%CI: 0.28;0.51); adults with difficulties in performing daily activities (PR=2.25; 95%CI: 1.43;3.53) practiced more self-medication. CONCLUSION: self-medication was associated to young adults and those with problems in performing daily activities.

Prevalence of health services utilization in Brazil: a systematic review and meta-analysis. / Prevalência de utilização de serviços de saúde no Brasil: revisão sistemática e metanálise.

OBJECTIVE: to analyze the prevalence of use of health services in Brazil. METHODS: systematic review and meta-analysis of population-based cross-sectional studies; MEDLINE, EMBASE, other sources, and microdata of surveys were searched; two researchers selected the studies, extracted the data and assessed methodological quality to include in the meta-analysis. RESULTS: from 1,979 retrieved references, 27 studies were included; the prevalence of medical visits in the previous year was 71% (confidence interval of 95% [95%CI] = 69; 73%; I2=99%); the proportion of women in each study (p=0.001; R2=25%) and the recall period (p>0.001; R2= 72%) contributed to the heterogeneity; prevalence of dental consultation was 37% (95%CI = 32; 42%; I2=100%), and of hospitalization, 10% (95%CI = 9; 11%; I2=98%), in the last year. CONCLUSION: more than half of the population had at least one medical visit, about one-third had a dental consultation and a tenth was hospitalized in the previous year.

Withdrawal of biologic agents in rheumatoid arthritis: a systematic review and meta-analysis.

The aim of this study is to assess the efficacy of withdrawing biologics from patients with rheumatoid arthritis in sustained remission or low disease activity. This is a systematic review of clinical trials that randomized withdrawal or continuation of biologics. We searched MEDLINE, Embase, and other databases. Three authors independently selected and extracted the data from the studies. The GRADE approach was employed to assess the quality of the evidence. We calculated meta-analyses of random effects model and estimated the heterogeneity by I (2). The number needed to treat (NNT) was calculated for significant outcomes. We included six trials (N = 1927 patients), most were industry-sponsored. Compared to withdrawing, continuing biologics increased the probability of low disease activity (relative risk [RR] = 0.66, 95 % CI 0.51-0.84, I (2) = 91 %, NNT = 4, low quality), remission (0.57, 0.44-0.74, I (2) = 82 %, NNT = 3, low quality), and radiographic progression (RR = 0.91, 95 % CI 0.85-0.98, I (2) = 13 %, NNT = 12, moderate quality). No significant difference was detected in the incidence of serious adverse events, serious infection, malignancy, and scores of improvement of tender and swollen joints between these strategies (low quality). A worse profile of outcomes was experienced by those patients when compared to the ones that continued biologics, but almost half of patients maintained low disease activity after withdrawal. As the quality of evidence was low, the conclusions may change as new results become available. The potential harms and benefits of this decision must be discussed with patients.