Compreendendo o GRADE: PICO e qualidade dos estudos / Understanding GRADE system: PICO and study quality

A saúde baseada em evidências se refere ao uso criterioso do conhecimento científico existente, oriundo de pesquisas clínicas, utilizando metodologias específicas que garantam solidez e clareza nas informações a serem aplicadas na tomada de decisão clínica. Dessa forma, reduzem-se as incertezas no julgamento clínico. O objetivo deste artigo foi descrever a metodologia PICO e a qualidade dos estudos com base no sistema GRADE. (AU)

Evidence-based health refers to the judicious use of existing scientific knowledge from clinical research, using specific methodologies that ensure solidity and clarity to the information to be applied in clinical decision-making, thus reducing uncertainties in clinical judgment. The objective of this article is to describe PICO methodology and the quality of studies in the GRADE system. (AU)

Compreendendo a avaliação da qualidade dos estudos pela Classificação de Recomendações, Avaliação, Desenvolvimento e Análises (GRADE): da evidência às recomendações / Understanding study quality assessment through the Grading of Recommendations, Assessment, Development and Evaluations (GRADE): from evidence to recommendations

A saúde baseada em evidências refere-se ao cuidadoso e preciso uso do conhecimento científico existente oriundo de pesquisas clínicas, reduzindo assim as incertezas no julgamento clínico frente ao paciente. As diretrizes destinadas a fornecer recomendações claras, devem seguir um conjunto de metodologias es- pecíficas. O objetivo deste artigo é descrever a metodologiae a aplicação da Classificação de Recomendações, Avaliação, Desenvolvimento e Análises como ferramenta fundamental neste delicado processo científico.

Evidence-based healthcare is the careful and accurate use of scientific knowledge arising from clinical research, which reduces uncertainties regarding the medical judgement for the patient. As these guidelines intend to provide clear recommendations, they shall follow a set of specific methodologies. This study aims at describing the methodology and the application of the Grading of Recommendations, Assessment, Development and Evaluations as a critical tool in this intricate scientific process.

How to translate scientific knowledge into practice? Concepts, models and application / ¿Cómo traducir el conocimiento científico a la práctica? Conceptos, modelos y aplicación / Como traduzir o conhecimento científico à prática? Conceitos, modelos e aplicação

ABSTRACT Objectives: to present the concept of Knowledge Translation and Exchange as it has been used in the international literature and in Canada, particularly. Next, to describe a renowned conceptual model to guide its implementation, entitled Knowledge-to-Action Cycle. Results: we described the use of the model in the context of the municipal primary health care system in southern Brazil for the implementation of pain management strategies during vaccination. Conclusions: in this theoretical reflection, we argue that in order to promote health equity and quality of care in the Unified Health System (Brazilian SUS) it is important to translate scientific knowledge to various practice settings and create opportunities for exchange with users of this knowledge, such as health professionals, managers, policy makers, patients, family members and other stakeholders.

RESUMEN Objetivos: presentar el concepto de Traducción e Intercambio de Conocimiento tal como se ha utilizado en la literatura internacional y, en particular, en Canadá. A continuación, describir un modelo conceptual reconocido para guiar su implementación, titulado Ciclo del Conocimiento a la Acción. Resultados: ilustramos el uso del modelo en el contexto del sistema municipal de atención primaria de salud en el sur de Brasil para implementar estrategias de manejo del dolor durante la vacunación. Conclusiones: en esta reflexión teórica, argumentamos sobre la importancia de traducir el conocimiento científico a los diversos contextos de práctica y de crear oportunidades de intercambio con los usuarios de este conocimiento, como profesionales sanitarios, gerentes, formuladores de políticas públicas, pacientes, familias y otros grupos de interés para promover la equidad y la calidad de los cuidados en el Sistema Único de Salud.

RESUMO Objetivos: apresentar o conceito de Tradução e Intercâmbio do Conhecimento tal como vem sendo utilizado na literatura internacional e, em particular, no Canadá. A seguir, descrever um renomado modelo conceitual para orientar a sua implementação, intitulado Ciclo do Conhecimento à Ação. Resultados: ilustramos a utilização do modelo no contexto do sistema municipal de atenção básica à saúde no sul do Brasil, na implementação de estratégias de manejo da dor durante a vacinação. Conclusões: nesta reflexão teórica, argumentamos sobre a importância de se traduzir o conhecimento científico aos diversos contextos de prática e criar oportunidades de intercâmbio com os usuários desse saber, como profissionais de saúde, gestores, formuladores de políticas públicas, pacientes, familiares e demais grupos de interesse, para promover equidade e qualidade dos cuidados no Sistema Único de Saúde.

Matriz de recomendações para farmacoterapia da Hipertensão Arterial Sistêmica: recurso para subsidiar a adaptação de guias de prática clínica / Matrix of recommendations for pharmacotherapy of arterial hypertension: resource to subsidize the adaptation of clinical practice guidelines

A hipertensão arterial sistêmica (HAS) é uma doença crônica altamente prevalente, que pode ser controlada com tratamento farmacológico. Para tal, recomenda-se aplicar as melhores evidências clínicas por meio da utilização de guias de prática clínica (GPC) de alta qualidade. No entanto, o processo de desenvolvimento de GPC requer recursos humanos e tempo, sendo a adaptação uma opção para reduzir a duplicação de esforços e adequar o GPC para uso local. O objetivo deste trabalho foi sintetizar as recomendações de GPC para o tratamento farmacológico da HAS. Aplicou-se o método de adaptação ADAPTE, realizando as duas primeiras fases: Configuração e Adaptação. Na fase de Configuração, o Grupo CHRONIDE realizou o planejamento e registrou a pesquisa no Próspero. Na fase de Adaptação, realizou-se uma revisão sistemática. Os critérios de eligibilidade foram: GPC que continham recomendações para o tratamento farmacológico da HAS em atenção primária, publicados em inglês, português ou espanhol, no período de 01/01/2011 a 31/12/2016. Em 31/11/2017 atualizou-se GPC incluídos. Para a determinação da qualidade destes GPC, três avaliadores, de forma independente, aplicaram o Appraisal of Guidelines for Research & Evaluation II (AGREE II). Dos 37 GPC avaliados, 6 foram considerados de alta qualidade (escore 60% ou mais no domínio Rigor de desenvolvimento do AGREE II). As recomendações destes foram extraídas e incluídas nas matrizes. Os GPC apresentaram divergências em suas recomendações. As divergências mais relevantes foram as recomendações mais rigorosas do GPC de 2017 da American College of Cardiology e American Heart Association (ACC/AHA), que trouxe metas terapêuticas e níveis pressóricos para indicação de farmacoterapia mais baixos que os demais. A maioria dos GPC recomendou o uso de diuréticos tiazídicos como farmacoterapia de primeira linha para tratamento da HAS e contraindicou o uso combinado de inibidores da enzima conversora de angiotensina e bloqueadores dos receptores de angiotensina II. Portanto, em uma discussão para adaptação local de recomendações, um dos pontos principais, além da questão do acesso aos medicamentos, seria adotar ou não os paramêtros mais rigorosos do GPC 2017 ACC/AHA

Arterial hypertension is a high prevalent chronic disease that can be controlled with pharmacologic treatment. For such, is recommended the use of the high clinical evidences presented in high quality clinical practice guidelines (CPG). However, the guideline development process requires time and capable human resources, which transform the adaptation to an option to reduce a duplication of efforts and to adapt the CPG to local use. The objective of this work was to synthesize the recommendations of CPG for the pharmacological treatment of arterial hypertension. The ADAPTE method was applied, using 2 steps: Configuration and Adaptation. In the Configuration step, the CHRONIDE group carried out the planning and the method was registered in Prospero. In the Adaptation step a systematic review was performed. The eligibility criteria were: CPG containing recommendations for the pharmacological treatment of arterial hypertension in primary care, published in English, Portuguese or Spanish, from 01/01/2011 to 12/31/2016. On 11/31/2017 it was updated the GPC included. To determine the CPG quality, 3 independent reviewers, assessed the CPG using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool. Of the 37 evaluated CPG, 6 were considered to being as high quality (score 60% or higher in the domain " Rigour of Development "). The recommendations were extracted and included in the matrix of recommendations. The CPG has presentes differences in their recommendations. The most relevant divergences were the further rigorous recommendations described on CPG 2017 of the American College of Cardiology and American Heart Association (ACC/AHA), which brought therapeutic goals and blood pressure levels lower for pharmacotherapy than the others recommendations. The majority of CPG has recommended the use of thiazide diuretics as first-line pharmacotherapy for the treatment of arterial hypertension and has contraindicated the combined use of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. Therefore, in a discussion for local adaptation of recommendations, one of the main points, apart from the issue of access to medicines, would be to adopt or would not be adopt the futher rigorous parameters of GPC 2017 ACC/AHA

Resumen comentado de las nuevas guías de la Sociedad Europea de Cardiología, Münich 25-29 de Agosto 2018 / Summary and Comments of the New Guides of the European Society of Cardiology held in Münich (august 2018)

El Congreso 2018 de la Sociedad Europea de Cardiología publicó cuatro nuevas guías de práctica clínica sobre: Hipertensión arterial, síncope, revascularización miocárdica y enfermedad cardiovascular durante el embarazo, así como un documento de consenso sobre la Cuarta Definición Universal del Infarto del Miocardio. Esta guías resumen toda la evidencia reciente, investigación y experticia relevante a estas condiciones cardiovasculares, proveyendo un recurso vital para los profesionales en su práctica clínica diaria y se han realizado de manera más concisa y mucho más visual con ilustraciones y amplio uso de gráficas y figuras(AU)

ESC Congress 2018 brought the release of four new ESC Clinical Practice Guidelines on: Arterial Hypertension; Syncope; Myocardial Revascularization; and Cardiovascular Diseases during Pregnancy, as well as a consensus document on the Fourth Universal Definition of Myocardial Infarction. This guidelines summarize all recent evidence, research and expertise relevant to these cardiovascular conditions and provides a vital resource for practicing healthcare professionals , made more concise and much more visual with illustrations and extensive use of graphics and figures(AU)

Diarreia aguda: manejo baseado em evidências / Acute diarrhea: evidence-based management

Resumo Objetivos: Descrever as recomendações atuais sobre a melhor maneira de conduzir o paciente pediátrico com doença diarreica aguda. Fonte dos dados: PubMed, Scopus, Scholar Google. Síntese dos dados: Houve pouco avanço no uso dos sais de reidratação oral (SRO) nas últimas décadas apesar de ser amplamente divulgado por meio de diretrizes internacionais. Vários estudos vêm sendo feitos na tentativa de melhorar a eficácia do SRO. Hidratação venosa com solução salina isotônica, infundida de forma rápida, deve ser indicada em casos de desidratação grave. A nutrição deve ser assegurada logo após a resolução da desidratação e é primordial para a saúde intestinal e imunológica. Restrições alimentares usualmente não são benéficas e podem ser prejudiciais. As medicações sintomáticas têm indicação restrita e antibióticos são indicados em casos específicos, cólera e shiguelose moderada a grave. Conclusões: A hidratação e a nutrição continuam a ser as intervenções com melhor impacto sobre o curso da diarreia aguda.

Abstract Objectives: To describe the current recommendations on the best management of pediatric patients with acute diarrheal disease. Data source: PubMed, Scopus, Google Scholar. Data summary: There has been little progress in the use of oral rehydration salts (ORS) in recent decades, despite being widely reported by international guidelines. Several studies have been performed to improve the effectiveness of ORS. Intravenous hydration with isotonic saline solution, quickly infused, should be given in cases of severe dehydration. Nutrition should be ensured after the dehydration resolution, and is essential for intestinal and immune health. Dietary restrictions are usually not beneficial and may be harmful. Symptomatic medications have limited indication and antibiotics are indicated in specific cases, such as cholera and moderate to severe shigellosis. Conclusions: Hydration and nutrition are the interventions with the greatest impact on the course of acute diarrhea.

Evidence-Based Practice: a survey regarding behavior, knowledge, skills, resources, opinions and perceived barriers of Brazilian physical therapists from São Paulo state

BACKGROUND: Evidence-Based Practice (EBP) has been widely used by health professionals. However, no study in Brazil has investigated the data regarding the knowledge and difficulties related to EBP from a representative sample of physical therapists.OBJECTIVE: To identify behavior, knowledge, skills, resources, opinions and perceived barriers of Brazilian physical therapists from the state of São Paulo regarding EBP.METHOD: A customized questionnaire about behavior, knowledge, skills, resources, opinions and perceived barriers regarding EBP was sent by email to a sample of 490 physical therapists registered by the Registration Board of São Paulo, Brazil. Physical therapists who did not respond to the questionnaire were contacted by telephone and/or letter. The data were analyzed descriptively.RESULTS: The final response rate was 64.4% (316/490). Because 60 physical therapists were no longer practicing, 256 answers were analyzed. The physical therapists reported that they routinely read scientific papers (89.5%) as a resource for professional development, followed by continuing education courses (88.3%) and books (86.3%). Approximately 35% of the respondents reported a clear understanding of the implementation of research findings in their practice; approximately 37% reported no difficulties in critically appraising scientific papers; and 67.2% strongly agreed that EBP is important for their practice. The most commonly reported barriers were related to difficulties in obtaining full-text papers (80.1%), using EBP may represent higher cost (80.1%) and the language of publication of the papers (70.3%).CONCLUSION: Physical therapists from São Paulo state believe that they have knowledge and skills to use EBP. Although they have favorable opinions regarding its implementation, they still encounter difficulties in implementing EBP successfully.

Usage evaluation of the Physiotherapy Evidence Database (PEDro) among Brazilian physical therapists

BACKGROUND: It is unclear whether the Physiotherapy Evidence Database (PEDro) is widely and equally used by physical therapists in Brazil. As PEDro is considered a key resource to support evidence-based physical therapy, analyses of PEDro usage could reflect the extent of dissemination of evidence-based practice.OBJECTIVE: To describe the usage of PEDro among the five regions of the World Confederation for Physical Therapy (WCPT) and, in more detail, in the South American region and Brazil over a 5-year period.METHOD: PEDro home-page sessions and the number of searches performed were logged for a 5-year period (2010-2014). Absolute usage and relative usage were calculated for each region of the WCPT, each country in the South American region of WCPT, and each Regional Council (CREFITO) in Brazil.RESULTS: Europe had the highest absolute and relative usage among the five regions of the WCPT (971 searches per million-population per year), with the South American region ranked 4th in absolute terms and 3rd in relative terms (486). Within the South American region, Brazil accounted for nearly 60% of searches (755). Analysis at a national level revealed that usage per physical therapist in Brazil is very low across all CREFITOs. The highest usage occurred in CREFITO 6 with 1.3 searches per physical therapist per year.CONCLUSIONS: PEDro is not widely and equally used throughout Brazil. Strategies to promote PEDro and to make PEDro more accessible to physical therapists speaking Portuguese are needed.

La fuerza de tareas de Estados Unidos recomienda el rastreo de cáncer de pulmón por medio de la tomografía axial computada: ¿es suficiente la evidencia para apoyar su adopción en el contexto sanitario de nuestro país? / The Task Force recommends the US Lung cancer screening using computed tomography: is it sufficient evidence to support its adoption in healthcare context of our country?

A fines del 2013, la Fuerza de Tareas de Servicios Preventivos de Estados Unidos (USPSTF) recomendó el rastreo anual para el cáncer de pulmón con tomografía computarizada de baja dosis (TCBD). Dada la ausencia de guías nacionales sobre esta práctica, existe incertidumbre sobre si debe adoptarse o no esta r recomendación. El presente estudio tuvo como objetivo evaluar la calidad y exhaustividad del cuerpo de evidencia que sustenta esta recomendación a través de métodos rigurosos. La calidad de la guía y la revisión sistemática sobre la que se sustenta la recomendación de uso del rastreo difundida por la USPSTF es de calidad intermedia. Se identificaron otras revisiones sistemáticas no incluidas en esta guía, cuyos resultados no son tan contundentes respecto al balance de riesgos y beneficios de esta práctica. La adopción de una práctica como política o programa en nuestro país, mas aun cuando es de relativo alto costo, y no está exenta de efectos adversos, requiere una evaluación rigurosa, exhaustiva y, por sobre todo, participativa. Los resultados que se presentan buscan aportar elementos para el debate, al que deben sumarse entidades gubernamentales, sociedades científicas, aseguradores y otros grupos de interés, incluyendo las voces de los propios pacientes. PALABRAS CLAVE: Neoplasias Pulmonares, Tamizaje Masivo, Tomografía Computarizada Multidetector, Guías de Práctica Clínica.

In 2013 the United States Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with low-dose (TCBD) CT for certain population. Given the absence of national guidelines on this practice, there is uncertainty about whether this recommendation should be adopted or not. The present study aimed to evaluate the quality and completeness of the body of evidence that underpins this recommendation through rigorous methods. The quality of the guideline, and the systematic review on which is based the recommendation by the USPSTF is of intermediate quality, identified. Other systematic reviews not included, whose results are not so conclusive about the balance of risks and benefits of this practice were identified. The adoption of these recommendations policy or regular program in our country requires a rigorous, exhaustive and participatory evaluation, because it is costly, and it is not free of side effects The results aim to provide elements for this debate that should include the government, the scientific societies, insurers and other stakeholders, and the voices of patients as well. KEYWORDS: Lung Neoplasms, Mass Screening, Multidetector Computed Tomography Practice Guidelines.

Beers-Fick criteria and drugs available through the Farmácia Dose Certa program / Critérios de Beers-Fick e medicamentos disponíveis no Programa Farmácia Dose Certa

CONTEXT AND OBJECTIVE: Farmácia Dose Certa is a program available in the State of São Paulo that is a national reference for providing drugs free of charge to the population. Elderly people receiving care deserve special attention regarding drugs that are appropriate for their age group. The objective was to assess the drugs in the program considered to be inappropriate for the elderly. DESIGN AND SETTING: Descriptive study evaluating free drug distribution in the State of São Paulo, Brazil. METHODS: Following the criteria proposed by Beers and Fick (drugs or drug classes that should be avoided among elderly people, independent of the diagnosis or clinical condition, because of the high risk of side effects and because other, safer drugs are available), the drugs in the Farmácia Dose Certa program that might be inappropriate for elderly people and the levels of evidence for each drug included were assessed. RESULTS: Among the available drugs, 10 (25.6 percent) were included within the Beers-Fick criteria. The drugs selected were: amitriptyline, cimetidine, diazepam, digoxin, fluoxetine, methyldopa, nifedipine, promethazine, thioridazine and ferrous sulfate. CONCLUSION: The list of drugs available within the Farmácia Dose Certa program may be considered appropriate for the general population, but not completely for the elderly population. Adjusting this list to the pharmacological aspects of aging will reduce the risks of drug interactions, falls, mental confusion and excessive sedation that result from drugs that are considered inappropriate for consumption by elderly people.

CONTEXTO E OBJETIVO: Programa Dose Certa é programa estadual para disponibilizar medicamentos de forma gratuita à população do Estado de São Paulo que é referência nacional no assunto. O segmento de idosos na população assistida merece atenção especial quanto aos fármacos adequados a este segmento etário. O objetivo foi avaliar as drogas no programa que são impróprias para idosos. TIPO DE ESTUDO E LOCAL: Estudo descritivo avaliando a distribuição de medicamentos no estado de São Paulo. MÉTODOS: Seguindo-se os critérios propostos por Beers e Fick (medicamentos ou classes deles que deveriam ser evitados em idosos, independentemente do diagnóstico ou da condição clínica, devido ao alto risco de efeitos colaterais e pela existência de outros fármacos mais seguros), avaliaram-se quais medicamentos do programa Dose Certa são impróprios para idosos e os níveis de evidência para cada medicamento incluído. RESULTADOS: Dos medicamentos disponíveis, 10 (25,6 por cento) foram incluídos nos critérios de Beers-Fick: amitriptilina, cimetidina, diazepam, digoxina, fluoxetina, metildopa, nifedipina, prometazina, tiorodazida e sulfato ferroso. CONCLUSÃO: A lista de fármacos disponível no Programa Dose Certa pode ser considerada apropriada para a população em geral, mas não totalmente para idosos. Adequá -los a aspectos farmacológicos do envelhecimento reduzirá riscos de interaç ões medicamentosas, quedas, confusão mental e sedação excessiva decorrente de medicamentos considerados impróprios para o consumo de idosos.

Nurses knowledge and practice to evidence-based guidelines for the prevention of ventilator associated pneumonia in pediatric intensive care units

Ventilator associated pneumonia is the most common hospital-acquired infection among patients receiving mechanical ventilation in pediatric intensive care unit. Using an evidence based guidelines for the prevention of ventilator associated pneumonia [VAP] are recommended. To investigate nurses' knowledge and practice toward evidence-based guidelines for the prevention of ventilator associated pneumonia in pediatric intensive care units. A quasi-experimental pre-post intervention study was done on 51 nurses of different categories working in medical, neurology and surgical ICU at Mansoura university children's Hospital, Egypt. Three tools were used; An interview questionnaire sheet was developed by the researcher in Arabic language. Nurses' knowledge of evidence-based guidelines for the prevention of VAP, multiple choice questionnaire and observational checklist for nurses' performance to ventilator bundles for VAP prevention. Mean score level of nurses general knowledge about VAP, knowledge of Evidence-based guidelines for VAP prevention and nurses performance to ventilator bundled for VAP prevention where the mean score were 8.6078 +/- 19908, 2.4706 +/- 1.3469, 2.1400 +/- 1.4287 respectively before program implementation compared to 12.1569 +/- 1.0464, 7.2941 +/- 1.7005, 5.5800 +/- 1.5265 respectively after program. There is a highly significant difference between nurses knowledge and practices to Evidence-based guidelines for prevention of VAP before and after the program [t= -11.059, -22.106, -13.796 and p=.000, 0.000, 0.000 respectively]. Adequate improvement in nurses' knowledge and practice after applied evidence based guidelines for prevention of ventilator associated pneumonia in pediatric intensive care unit