Recomendaciones ALAT para el uso de vacunas respiratorias. Guía de práctica clínica basada en evidencias / ALAT Recommendations for the Use of Respiratory VaccinesEvidence-Based Clinical Practice Guideline

Introducción: Las infecciones respiratorias son las enfermedades respiratorias con mayor mortalidad en el mundo. Las causadas por Streptococcus pneumoniae, virus de influenza, Bordetella pertussis, SARS-CoV-2 y el Virus Sincitial Respiratorio, cuentan hoy día con vacunas seguras y efectivas. Este documento representa una guía de práctica clínica (GPC) de la Asociación Latinoamericana de Tórax (ALAT), elaborada por iniciativa de los departamentos de enfermedades infecciosas y pediatría, con el objetivo de establecer recomendaciones sobre vacunas respiratorias, utilizando la evidencia disponible. Método: Se estableció un grupo de desarrollo de las guías conformado por cinco médicos responsables globales del proyecto, se crearon cinco subgrupos de trabajo, uno por cada vacuna, con expertos neumólogos de adulto, pediatras e infectólogos invitados, que generaron preguntas clínicas. Se trabajó con un grupo de expertos metodólogos que transformaron preguntas clínicas en preguntas PICO, seleccionándose nueve preguntas por método DELPHI. Luego, se utilizó el sistema GRADE (Grading of Recommendations Assessment, Development and Evaluation) para evaluar la evidencia disponible. Resultados: Se obtuvieron recomendaciones para población adulta y pediátrica de las vacunas de neumococo, influenza, tos ferina, COVID-19 y Virus Respiratorio Sincitial basadas en preguntas PICO. También se agregaron recomendaciones basadas en preguntas narrativas relacionadas al uso de vacunas respiratorias en población con enfermedades respiratorias crónicas como asma, EPOC y fibrosis pulmonar.

Introduction: Respiratory infections are the leading cause of respiratory disease-related mortality worldwide. Infections caused by Streptococcus pneumoniae, influenza virus, Bordetella pertussis, SARS-CoV-2 and Respiratory Syncytial Virus (RSV) now have safe and effective vaccines available.This document represents a Clinical Practice Guideline (CPG) by the Latin American Thoracic Association (ALAT), developed through the initiative of the departments of in-fectious diseases and pediatrics, with the goal of establishing recommendations on respiratory vaccines using the available evidence. Method: A guideline development group was established, composed of five lead physicians responsible for the overall project. Five working subgroups were created, one for each vaccine, involving invited experts in adult pulmonology, pediatrics, and infectious diseases, who formulated clinical questions. A group of expert methodologists then transformed these clinical questions into PICO questions, with nine questions selected using the DELPHI method. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was then used to assess the available evidence. Results: Recommendations were obtained for the adult and pediatric populations for pneumococcal, influenza, pertussis, COVID-19 and Respiratory Syncytial Virus vaccines based on PICO questions. Additionally, recommendations based on narrative questions related to the use of respiratory vaccines in populations with chronic respiratory diseases such as asthma, COPD, and pulmonary fibrosis were included.

Parches transdérmicos anticonceptivos: evaluación de tecnología sanitaria / Contraceptive transdermal patches: health technology assessment

INTRODUCCIÓN: La anticoncepción es un derecho, y es obligación del Estado garantizar el acceso a métodos anticonceptivos efectivos, seguros y de calidad. Se realizó una evaluación de tecnología sanitaria sobre los parches anticonceptivos transdérmicos. MÉTODOS: Un equipo multidisciplinario e independiente designado por el Comité Provincial de Biotecnologías de Neuquén buscó información epidemiológica, regulatoria y evidencias científicas sobre eficacia, seguridad y adherencia. Se analizó y sistematizó siguiendo metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation) y CASPe (Critical Appraisal Skills Programme Español). RESULTADOS: El único parche autorizado en Argentina para su comercialización libera 33,9 µg/día de etinilestradiol y 203 µg/día de norelgestromina. Su prospecto en Argentina, EE.UU. y Europa lo asocia al doble de riesgo de enfermedad tromboembólica venosa si se compara con las píldoras anticonceptivas que provee el Estado. Esto coincide con resultados de estudios de cohortes de alta calidad. Los parches proveen similar eficacia anticonceptiva a corto plazo, pero con altas tasas de abandono en el seguimiento. La Organización Mundial de la Salud no los ha incluido en su listado de medicamentos esenciales. Los parches son más costosos que otros métodos disponibles. DISCUSIÓN: Sobre la base de los principios de beneficencia, no maleficencia, de precaución y de proporcionalidad, no se recomienda la incorporación de parches.(AU)

INTRODUCTION: Contraception is a right, being an obligation of the State to guarantee access to effective, safe and quality contraceptive methods. A health technology assessment was carried out on transdermal contraceptive patches. METHODS: A multidisciplinary and independent team appointed by the Provincial Biotechnology Committee of Neuquén searched for epidemiological and regulatory information and scientific evidence on efficacy, safety and adherence. It was analyzed and systematized following the GRADE (Grading of Recommendations Assessment, Development and Evaluation) and CASPe (Critical Appraisal Skills Programme Español) methodology. RESULTS: The only patch authorized for commercialization in Argentina releases 33.9 µg/day of ethinylestradiol and 203 µg/day of norelgestromin. Its package insert in Argentina, the US and Europe highlights that the risk of venous thromboembolic disease is twice as high compared to the contraceptive pills provided by the State. This is consistent with results from high-quality cohort studies. Patches provide similar short-term contraceptive efficacy, but with high dropout rates at follow-up. The World Health Organization has not included them in its list of essential medicines. Patches are more expensive than other available methods. DISCUSSION: Based on the principles of beneficence, non-maleficence, precaution and proportionality, the incorporation of patches is not recommended.(AU)

Are Premature Birth and Low Birth Weight Associated with Delay on the Eruption of Deciduous Teeth? A Systematic Review and Meta-analysis

ABSTRACT Objective: To investigate whether children with premature birth (PB) and/or with low birth weight (LBW) have different tooth eruption patterns than those born at term or with normal weight. Material and Methods: Searches were performed in the PubMed, Cochrane Library, Sc1opus, Web of Science, LILACS, and BBO databases as well as the grey literature. Three independent reviewers were involved in study selection, data extraction, and bias assessment. The risk of bias was assessed using the Modified Newcastle-Ottawa Scale. Meta-analysis was conducted to compute the mean difference (MD) in mean chronological or adjusted age at the eruption of the first deciduous tooth between preterm children and those born at full term. The GRADE approach was used. Results: Among a total of 316 articles identified, 21 were eligible for inclusion and three were included in the meta-analysis. PB was associated with the delay in the first tooth deciduous eruption when chronological age was considered (MD: 1.36; 95%CI: 1.02-1.69) but not when considering adjusted age (MD: -0.30; 95%CI: -0.67-0.07). The evidence was graded as having very low quality. Conclusion: Based on a low certainty of evidence the PB is associated with the delayed eruption of the first deciduous tooth when considering chronological age but not when adjusted age is considered.

Vigabatrina comparado con hormona adrenocorticotrópica para el tratamiento de espasmos infantiles y Síndrome de West / Vigabatrin compared with adrenocorticotropic hormone for the treatment of infantile spasms and West Syndrome

OBJETIVO: Determinar los riesgos y beneficios del uso de vigabatrina comparada con hormona adrenocorticotrópica (ACTH) para el tratamiento de espasmos infantiles. MÉTODO: Se realizó una búsqueda en Epistemonikos. Se extrajeron datos desde las revisiones identificadas. Se realizó un metaanálisis a partir de estudios primarios y se utilizó el método GRADE para la presentación de resultados. RESULTADOS: Se identificaron nueve revisiones sistemáticas. Se observó que el uso de vigabatrina en comparación con ACTH disminuye la resolución de espasmos (RR 0,8, IC 95% 0,65 - 0,98) y podría disminuir la resolución de hipsarritmia (RR 0,71, IC 95% 0,48 - 1,05). No fue posible determinar si el uso de vigabatrina disminuye el riesgo de desarrollar efectos adversos (RR 0,75, IC 95% 0,23 - 2,45) por certeza de evidencia muy baja. CONCLUSIONES: La evidencia parece inclinarse a favor del uso de ACTH. Sin embargo debe considerarse la necesidad de nuevas investigaciones para esclarecer su seguridad.

OBJECTIVE: To determine the risks and benefits of the use of vigabatrin compared to ACTH for the treatment of infantile spasms. METHOD: A search in Epistemonikos was performed. Data were extracted from the identified reviews. A meta-analysis was performed from primary studies and the GRADE method was used to present the results. RESULTS: Nine systematic reviews were identified. Vigabatrin use compared to ACTH was found to decrease resolution of spasms (RR 0.8, 95% CI 0.65 - 0.98) and might decrease resolution of hypsarrhythmia (RR 0.71, 95% CI 0 .48 - 1.05). It was not possible to determine whether the use of vigabatrin reduces the risk of developing adverse effects (RR 0.75, 95% CI 0.23 - 2.45) due to very low certainty of evidence. CONCLUSIONS: The evidence seems to lean in favor of the use of ACTH. However, the need for new research should be considered to clarify its safety.

Guía de práctica clínica para la prevención y el manejo de la enfermedad hipertensiva del embarazo / Clinical practice guideline for the prevention and management of hypertensive disorders of pregnancy

RESUMEN Objetivos: Proveer recomendaciones clínicas basadas en evidencia para la prevención y el manejo de la enfermedad hipertensiva del embarazo (EHE) en el Seguro Social de Salud (EsSalud) del Perú. Materiales y métodos: se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló ocho preguntas clínicas para ser respondidas por la presente Guía de Práctica Clínica (GPC). Se realizaron búsquedas sistemáticas de revisiones sistemáticas y, cuando se consideró pertinente, estudios primarios en PubMed y Central durante 2021. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas . En reuniones de trabajo periódicas, el GEG usó la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE) para calificar la evidencia y formular las recomendaciones. Además se resentan los puntos de buenas prácticas clínicas (BPC) y los flujogramas de prevención, manejo y seguimiento. Finalmente, la GPC fue aprobada por Resolución 112-IETSI-ESSALUD-2021. Resultados: En la presente GPC se formularon 11 recomendaciones (6 fuertes y 5 condicionales) que respondieron las preguntas clínicas definidas en el alcance de la GPC, acompañadas de 32 puntos de BPC y 3 flujogramas que abordan temas de prevención, tratamiento y seguimiento de la EHE. Conclusiones: Como recomendaciones centrales de la guía se dan el uso de sulfato de magnesio para el tratamiento de la preeclampsia severa y la eclampsia. La guía deberá ser actualizada en tres años.

ABSTRACT Objectives: To provide clinical recommendations based on evidence for the prevention and management of Hypertensive disorders of pregnancy (HDP) in the Social Health Insurance (EsSalud) of Peru. Materials and methods: A CPG for the the prevention and management of HDP in EsSalud was developed. To this end, a guideline development group (local GDG) was established, including medical specialists and methodologists. The local GDG formulated 8 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and -when it was considered pertinent- primary studies were searched in PubMed y Central during 2021. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and flowcharts for the prevention, management and follow-up. Finally, the CPG was approved with Resolution 112-IETSI-ESSALUD-2021. Results: This CPG addressed 8 clinical questions, divided into three topics: prevention, management and follow-up of the HDP. Based on these questions, 11 recommendations (6 strong recommendations and 5 weak recommendations), 32 points of good clinical practice, and 3 flowcharts were formulated. Conclusions: The main recommendations in the guideline are the use of magnesium sulfate for the treatment of severe pre-eclampsia and eclampsia. The guideline must be updated in three years' time.

Lineamientos para el uso de terapias pulpares en dientes primarios con pulpas no-vitales / Diretriz sobre o uso de terapia pulpar devitalizada para dentes decíduos / Guidelines for the use of pulp therapy in primary teeth with non-vital pulps

Objetivo: Presentar lineamientos basados en evidencia para el tratamiento de pulpas no vitales debidas a caries profundas o traumatismos en dientes primarios. Métodos: el Grupo de Trabajo de la Academia Americana de Odontología Pediátrica AAPD realizó una revisión sistemática/meta-análisis de estudios acerca de terapia para pulpa no vital en dientes primarios, producto de caries o trauma, usando el enfoque GRADE para determinar el nivel de certeza de la evidencia para recomendaciones clínicas. Resultados: La determinación de GRADE fue de elevada a muy baja. Al comparar dientes con o sin resorción radicular, el éxito de la pulpectomía fue mayor (p<0,001) en los que no presentaban resorción radicular antes del tratamiento. El éxito de las pulpototmías obturadas con ZO/yodoformo/HC EndoflasTM(Laboratorios Sanlor, Cali, Colombia) y ZOE (óxido de zinc con eugenol) no fue diferente al yodoformo(yodoformo + hidróxido de calcio, VitapexTM o MetapexTM) después de 18 meses (p= 0,55); sin embargo el éxito de ZO/iodoformo/HC y ZOE fue cercano al 90% mientras que el del yodoformo fue 71% o menor. El análisis de red demostró que ZO/iodoformo/HC y ZOE son mejores que yodoformo. ELRP fue mejor que pulpectomía (p<0,001) en dientes con resorción radicular previa al tratamiento, pero la pulpectomía fue superior si las raíces estaban íntegras (p= 0,09). La instrumentación de los conductos radiculares fue significativamente más rápida (p<0,001) que la instrumentación manual, pero la calidad de la obturación no presentó diferencia (p= 0,09) y ambas técnicas presentaron éxito similar. El análisis de red clasificó al ZO/iodoformo/HC como mejor, ZOE en segundo lugar, y yodoformo en último lugar a los 18 meses. La tasa de éxito no fue impactada por el método de obturación, método de determinación de la longitud radicular, tipo de diente, número de citas, agentes de irrigación, remoción de la capa de desechos dentinarios o momento/tipo de restauración definitiva. Conclusiones: La tasa de éxito a 18 meses para pulpectomías demuestran que ZO/iodoformo/HC y ZOE son superiores al yodoformo. Las indicaciones de ELRP están limitadas a dientes con resorción radicular y requiere la realización de un seguimiento cercano.

Objetivo: Apresentar uma orientação baseada em evidência para terapias pulpar não vitais de cárie profundas ou trauma em dentes deciduos. Métodos: Um grupo de trabalho da AAPD realizou uma revisão/análise sistemática para estudos não vitais de dentes deciduos resultantes de trauma ou cárie e utilizou a abordagem GRADE para avaliar o nível de certeza de evidência para recomendações clínicas. Resultados: O GRADE foi avaliado de nível alto à muito baixo. Comparando os dentes com/sem reabsorção radicular, o sucesso da pulpectomia foi melhor (p<0,001) naqueles sem reabsorção radicular pré-operatória. OZ/iodofórmio/HC (óxido de zinco + iodofórmio + hidróxido de cálcio; EndoflasTM) e OZE (óxido de zinco e eugenol) o sucesso da pulpectomia não diferiu do iodofórmio (iodofórmio + hidróxido de cálcio; VitapexTM, MetapexTM) (p= 0,55) após 18 meses; contudo, as taxas de sucesso de OZ/iodofórmio/HC e OZE permaneceram perto de 90% enquanto que o iodofórmio foi de 71% ou menos. As taxas de análise da rede mostraram que o OZ/iodofórmio/HC e OZE era melhor do que o iodofórmio. LERT foi melhor (p<0,001) do que a pulpectomia nos dentes com reabsorção radicular pré-operatória, mas os resultados da pulpectomia foram melhores (p= 0,.09) se as raízes estivessem intactas. A instrumentação rotatória dos canais radiculares foi significativamente mais rápida (p<0,001) do que manual, mas a qualidade do preenchimento não diferiu (p= 0.09) e ambos tiveram sucesso comparável. A análise de rede classificou OZ/iodofórmio/HC como o melhor, OZE segundo, e iodofórmio como o mais baixo aos 18 meses. As taxas de sucesso não foram influenciadas pelo método de obturação ou determinação do comprimento da raiz, tipo de dente, número de visitas, irrigantes, remoção da lama dentinária, ou tempo/tipo de restauração final. Conclusões: As taxas de sucesso da pulpectomia de 18 meses favoreceram pulpectomias com OZ/iodofórmio/HC e OZE sobre iodofórmio. O LERT demonstrou indicação limitada para dentes com raízes reabsorvidas e requer um acompanhamento assíduo.

Abstract: Purpose: To present an evidence-based guideline for non-vital pulp therapies due to deep caries or trauma in primary teeth. Methods: The authors, working with the American Academy of Pediatric Dentistry, conducted a systematic review/meta-analysis for studies on non-vital primary teeth resulting from trauma or caries and used the GRADE approach to assess level of certainty of evidence for clinical recommendations. Results: GRADE was assessed from high to very low. Comparing teeth with/without root resorption, pulpectomy success was better (P<0.001) in those without preoperative root resorption. Zinc oxide plus iodoform plus calcium hydroxide ([ZO/iodoform/CH]; EndoflasTM) and zinc oxide and eugenol (ZOE) pulpectomy success did not differ from iodoform (iodoform plus calcium hydroxide; VitapexTM, MetapexTM) (P=0.55) after 18-months; however, ZO/iodoform/CH and ZOE success rates remained near 90 percent while iodoform was 71 percent or less. Network analysis ratings showed ZO/iodoform/CH and ZOE better than iodoform. Lesion sterilization tissue repair (LSTR) was better (P<0.001) than pulpectomy in teeth with preoperative root resorption, but pulpectomy results were better (P=0.09) if roots were intact. Rotary instrumentation of root canals was significantly faster (P<0.001) than manual, but the quality of fill did not differ (P=0.09) and both had comparable success. Network analysis ranked ZO/iodoform/CH the best, ZOE second, and iodoform lowest at 18 months. Success rates were not impacted by method of obturation or root length determination, type of tooth, number of visits, irrigants, smear layer removal, or timing/type of final restoration. Conclusions: Pulpectomy 18-month success rates supported ZO/iodoform/CH and ZOE pulpectomy over iodoform.

Chequeo preventivo basado en la evidencia / Evidence-based health check

Un chequeo preventivo se define como el contacto entre un profesional de salud y una persona asintomática en el que se realizan varias pruebas de tamizaje para evaluar su salud con el objetivo de reducir la morbimortalidad. No obstante, la evidencia científica demuestra que realizar varias pruebas de tamizaje es poco probable que sea beneficioso para ese objetivo y cada examen debe ofrecerse de manera individualizada considerando riesgos y beneficios. Los objetivos de esta revisión son describir la utilidad de estos chequeos, revisar brevemente acciones preventivas y formular grados de recomendación, pudiendo así el lector reconocer las recomendaciones preventivas basadas en evidencia en un adulto sano. En el presente artículo se sintetizan recomendaciones utilizando la metodología GRADE en su formulación. Si bien la mayoría de las recomendaciones revisadas tienen evidencia de moderada a alta certeza, es importante considerar algunas distinciones al momento de ofrecer las acciones preventivas. Luego de este esfuerzo académico, queda en evidencia la necesidad de constituir una organización formal dedicada a la revisión, elaboración y actualización de recomendaciones preventivas en nuestro país, así como evaluar el impacto de estas acciones en cuanto a resultados de salud.

A general health check is defined as the contact between a health professional and an asymptomatic person where several screening tests are performed to assess general health with the aim of reducing morbidity and mortality. However, scientific evidence shows that performing several screening tests are unlikely to be beneficial for those outcomes and each test should be individualized considering risks and benefits.The objectives of this review are to describe the usefulness of these checks, briefly review preventive actions, and formulate degrees of recommendation, thus allowing the reader to recognize evidence-based preventive recommendations in a healthy adult.In this article, recommendations are synthesized using the GRADE methodology in its formulation. While most of the recommendations reviewed have moderate to high certainty evidence, it is important to consider some distinctions when offering preventive actions.After this academic effort, the need to establish a formal organization dedicated to the review, preparation and updating of preventive recommendations in our country is evident, as well as evaluating the impact of these actions in terms of health outcomes

Efectos de la suplementación con vitamina D en el control del asma en pacientes adultos: una revisión sistemática / Effects of vitamin D supplementation on asthma control in adult patients: a systematic review

INTRODUCCIÓN: El asma es una enfermedad crónica inflamatoria de la vía aérea e inmunomediada en su patogénesis. La vitamina D es un inmunomodulador que regula el perfil secretor de citoquinas, entre otras funciones celulares. Una asociación entre la suficiencia de vitamina D y mejoría en la función pulmonar, control de asma y número de exacerbaciones se ha propuesto en adultos, importante dada la elevada prevalencia de insuficiencia de vitamina D globalmente. OBJETIVO: Conocer los efectos de la suplementación con vitamina D en el control del asma en adultos. MÉTODOS: Se realizó una revisión sistemática de la literatura a través de una búsqueda en la base de datos PubMed y EMBASE. Los desenlaces primarios fueron cambios en VEF1, control sintomático, frecuencia de exacerbaciones, además de eventos adversos y FEM como desenlaces secundarios. La calidad de evidencia de los desenlaces fue evaluada a través del modelo GRADE. RESULTADOS: Siete estudios fueron seleccionados después de remover duplicados y aplicar los criterios de inclusión y exclusión, con calidad de evidencia muy baja aplicando sistema GRADE. DISCUSIÓN: No se encontraron diferencias estadísticamente significativas tras la suplementación con vitamina D en los desenlaces evaluados en general, pero dada la calidad de evidencia muy baja y que no se reportaron efectos adversos serios, es necesario tomar cautelosamente estos resultados. Asímismo no se puede descartar la utilidad de esta terapia como tratamiento auxiliar a los pacientes asmáticos con este déficit vitamínico.

BACKGROUND: Asthma is an airway chronic disease, with an important inflammatory component within its pathogenesis, driven by a dysregulated immune response. Vitamin D is an immunomodulator that regulates cell proliferation, differentiation and cytokine secretion profile. An association between vitamin D sufficiency and improvement in pulmonary function, asthma control and a decrease in exacerbations have been proposed in the adult population, which falls into importance given the high prevalence of vitamin D insufficiency globally. OBJECTIVE: To know vitamin D supplementation effects in asthma control in adults. METHODS: Through a PubMed and EMBASE database search, a systematic review of the literature was conducted. Primary outcomes were: changes in FEV1, symptomatic control, exacerbation frequency and PEF and adverse events as secondary outcomes. Outcome evidence quality assessment was made using the GRADE model. Results: Seven studies were selected after taking out duplicates, applying inclusion and exclusion criteria. In all cases, evidence quality assessed by the GRADE system yielded very low quality. CONCLUSIONS: No statistically significant differences were found after vitamin D supplementation in the overall evaluated outcomes. Nonetheless, a cautious interpretation of studies is mandatory, because evidence quality was very low and no serious adverse events were reported. Hence this treatment usefulness as an ancillary therapy for vitamin D deficient asthmatic patients cannot be dismissed.

Aislación relativa comparada con absoluta en restauraciones de resina compuesta en pacientes con dentición permanente / Relative isolation versus rubber dam isolation for composite resin restorations in patients with permanent dentition

RESUMEN: Introducción: La técnica de restauración con resina compuesta requiere un adecuado control de la humedad durante el procedimiento. Para ello, puede realizarse aislación relativa (con tórulas de algodón y eyector de saliva) o aislación absoluta con goma dique de la o las piezas dentarias. Sin embargo, no está claro cuál de estos protocolos sería más efectivo. Métodos: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metaanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Resultados y conclusiones: Identificamos tres revisiones sistemáticas que en conjunto incluyeron dos estudios primarios, todos correspondientes a ensayos aleatorizados. Concluimos que realizar aislación relativa comparado con aislación absoluta podría aumentar el riesgo de falla de restauración a los 6 meses, pero la certeza de la evidencia es baja. No es posible establecer con claridad si la aislación relativa disminuye el riesgo de falla de la restauración a 10 años, debido a que la certeza de la evidencia existente ha sido evaluada como muy baja. No se encontraron estudios que evaluaran los desenlaces caries secundaria, sensibilidad postoperatoria y tinción.

ABSTRACT: Introduction: Resin composite restorations technique requires effective control of moisture during the procedure. Isolation and moisture control can be performed by relative isolation (use of cotton rolls combined with aspiration by saliva ejector) or rubber dam isolation. However, there is uncertainty regarding which one of these protocols would be most beneficial. Methods: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. Results and conclusions: We identified three systematic reviews including two studies overall, of which all were randomized trials. We conclude that relative isolation may increase the risk of failure of the restorations at 6 months. We are uncertain whether relative reduces the risk of failure of the restorations at 10 years as the certainty of the evidence has been assessed as very low. No studies were found that looked at secondary caries, post-operative sensitivity or stained margins.

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)

Abordaje transconjuntival en comparación con abordaje subciliar para el tratamiento de fracturas orbitarias / Transconjunctival versus subciliary approach for the treatment of orbital fractures

RESUMEN: Introducción: Los abordajes transconjuntival preseptal y subciliar han sido ampliamente utilizados para el manejo quirúrgico de las fracturas orbitarias. Sin embargo, aún existe incertidumbre sobre las complicaciones asociadas a cada uno de estos abordajes. Métodos: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios. Realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Resultados y conclusiones: Identificamos seis revisiones sistemáticas que en conjunto incluyeron 21 estudios primarios, de los cuales cuatro corresponden a ensayos aleatorizados. Concluimos que el abordaje transconjuntival preseptal podría disminuir tanto la incidencia de ectropión como de un resultado estético insatisfactorio, pero la certeza de la evidencia es baja. Además, este abordaje probablemente disminuye el riesgo de complicaciones intra y postoperatorias, tales como diplopía, parestesia transitoria, equimosis, exposición escleral, laceración del plato tarsal y laceración palpebral inferior. Por otro lado, el abordaje transconjuntival podría aumentar el riesgo de entropión, pero la certeza de la evidencia también es baja.

ABSTRACT: Introduction: The preseptal transconjunctival and subciliary approach have been widely used for the surgical management of orbital fractures. However, there is still uncertainty about the complications associated with each of these approaches. Methods: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. Results and conclusions: We identified six systematic reviews that included 21 primary studies, four of which correspond to randomized trials. We conclude that the preseptal transconjunctival approach could decrease the incidence of ectropion and an unsatisfactory aesthetic result, but the certainty of the evidence is low. Furthermore, this approach probably decreases the risk of intra and postoperative complications, such as diplopia, transient paresthesia, ecchymosis, scleral show, tarsal plate laceration and lower palpebral laceration. On the other hand, the transconjunctival approach could increase the risk of entropion, but the certainty of the evidence is also low.

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.

Effect of interactive media on the development of children and adolescents: systematic review with meta-analysis

Abstract Aim: to investigate through a systematic review of randomized controlled trials (RCTs) the effects of interactive media on the cognitive, language, and motor development of children and adolescents. Methods: Searches were performed with the Medline, AMED, Embase, PEDro, Cochrane, Psychinfo, and ERIC databases in May 2017 with updated in July 2020. For the search strategy, we used descriptors related to "randomized controlled trial", "interactive media" and "children and adolescents up to 18 years old". RCTs that investigated the effectiveness of interactive media in cognitive, motor, and language development of children and adolescents up to 18 years of age with typical development were included. When appropriate, meta-analyses were conducted using a random-effects model. Pooled data were presented using standardized mean difference and 95% confidence interval. We assessed the quality of evidence using the GRADE methodology and the methodological quality using the PEDro scale. Results: of the trials found, 14 references were eligible for this study. The GRADE methodology was used in 13 RCTs. Estimates showed a low level of evidence of a small effect of media use on cognitive development compared to that in the control group and another intervention. No effect on motor and language development. Conclusion: The results of this systematic review do not support claims about the advantages or disadvantages of interactive media in child development. High-quality evidence was found that interactive media is not superior to other interventions for cognitive and language development outcomes and quality of moderate evidence for motor and language development.

Guía de práctica clínica hospitalaria: elementos de protección personal y testeo prequirúrgico de pacientes asintomáticos para prevención de la diseminación de SARS-CoV2 en el ámbito quirúrgico en cirugía de urgencia / Clinical practice guideline: elements of personal protection and pre-surgical testing of asymptomatic patients for prevention of the spread of SARS-CoV2 in the surgical field in emergency surgery

En epidemias de enfermedades altamente infecciosas como el COVID-19, de transmisión a través de gotas expulsadas por la boca de la persona infectada, los trabajadores de la salud tienen un riesgo mayor de infección que la población en general, debido a su contacto con fluidos corporales y aerosoles generados por los pacientes. La existencia de un porcentaje que podría llegar a ser de hasta un 50 %, de portadores asintomáticos con capacidad de contagio, preocupa al momento de planificar la atención quirúrgica. Con el objetivo de desarrollar la presente guía, se realizó una síntesis y valoración crítica de la evidencia disponible sobre el tema, con el fin de responder determinadas preguntas clínicas (utilización de barbijo N95 vs barbijo quirúrgico en cirugía, realización de test diagnóstico para SARS-CoV2 previo a cirugía) utilizando metodología GRADE. La mascarilla N95 podría ser beneficiosa en el personal que realiza procedimientos que favorecen la aerosolización del virus, tales como traqueostomía y ventilación manual con bolsa de autoinsuflación previo a la intubación, entre otros. El testeo del paciente, previo a una cirugía, puede ser considerado en escenarios en los que existe disponibilidad de la de terminación. Es necesario evaluar la complejidad de la cirugía, evitando que el retraso causado por la realización de la prueba resulte en daño para el paciente. El conjunto de recomendaciones debe ser implementado teniendo en cuenta el recurso disponible de equipos de protección personal, las características de las intervenciones quirúrgicas (procedimientos que generen aerosoles) y el tipo de circulación viral en la población general (existencia de transmisión comunitaria). (AU)

In epidemics of highly contagious diseases such as COVID-19, transmitted through drops expelled from the infected person's mouth, health care workers have a higher risk of infection than the general population, due to their contact with fluidsand patient-generated aerosols. The existence of a percentage that could be up to 50 % of asymptomatic carriers with contagion capacity, worries when planning surgical care. To develop an evidence-based protocol, a synthesis and critical evaluation of the evidence was carried out in order to answer clinical questions (use of N95 chinstrap versus surgical chin during surgery, diagnostic test for SARS-CoV2 before surgery) using the GRADE methodology. The N95 mask could be beneficial for personnel who perform procedures that favor the aerosolization of the virus, such as tracheostomy and manual ventilation with a self-inflating bag before intubation, among others. The testing of patients prior to surgery can be evaluated in scenarios where the inputs for making determinations are available. It is necessary to evaluate the complexity of the surgery, avoiding that the delay caused by the test results in harm to the patient. (AU)

Are Behavior Rating Scales Able to Identify Behavioral Changes in Preschool Children Undergoing a Dental Intervention? A Systematic Review

Abstract Objective: To evaluate the scientific evidence concerning the behavior rating scales efficiency to identify behavioral changes in preschool children undergoing dental treatment, through a systematic review. Material and Methods: MEDLINE/PubMed, Scopus, Cochrane Library, Web of Science, BVS databases and grey literature were searched. Also, a hand search of the included studies reference lists was conducted. Studies that evaluated healthy preschoolers' behavior before and after invasive dental treatments to observe behavioral changes were included. Two independent reviewers selected studies, extracted data and analyzed the risk of bias with a tool for before-and-after studies. The certainty of the evidence was evaluated with the GRADE approach. Results: Three studies were included. The Frankl Scale and North Carolina Behavior Scale were used in these studies. Both scales were able to identify behavioral changes in preschool children undergoing a dental intervention, although two of these included studies were considered fair with a high risk of bias, and one considered good with a low risk of bias. Conclusion: Although Frankl and North Carolina behavior scales were able to identify changes in the children`s behavior during dental treatment, these findings are not supported by strong evidence. Thus, further well-designed studies are needed to confirm this evidence.

Recomendación rápida sobre el uso de antihipertensivos IECA/ARA II en pacientes con riesgo o documentación de COVID-19 / Rapid recommendation on the use of ACEI/ARA antihypertensives in patients at risk or with documented COVID-19

Ciertos hallazgos preclínicos generaron preocupación en la comunidad científica y en la población general sobre el uso de inhibidores de la enzima convertidora de angiotensina (IECA) y los antagonistas del receptor de la angiotensina II (ARAII), y los posibles desenlaces adversos asociados con relación a la infección por el nuevo Coronavirus (SARS-Cov-2).Por este motivo, nos planteamos como objetivo proveer de recomendaciones dinámicas (living recommendations) para el tratamiento con fármacos IECA o ARA II en pacientes con riesgo o documentación de infección por SARS-CoV-2 (en todo su espectro de gravedad). Se utilizó como metodología la adaptación/adopción de guías de práctica clínica bajo el enfoque GRADE, actualizando la evidencia al 7 de abril de 2020 mediante búsquedas en múltiples bases de datos y consultando a un panel multidisciplinario libre de conflictos de interés. Como resultado de este proceso se arribó a la siguiente afirmación: se recomienda, en contexto de la pandemia de COVID-19, en personas que se encuentran en tratamiento con IECA/ARAII, mantener el tratamiento sin cambios por sobre suspenderlo o reemplazarlo por otros fármacos (Recomendación fuerte a favor - calidad de evidencia baja). (AU)

Certain preclinical findings raised concerns in the scientific community and in the general population about the use ofangiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists (ARA) and the possible adverse outcomes associated with the infection with the new Coronavirus (SARS-Cov-2). For this reason, our objective is to provide living recommendations for treatment with ACEI or ARA in patients with risk or documentation of SARS-CoV-2 infection (inall its severity spectrum). The adaptation/adoption of clinical practice guidelines under the GRADE approach was used as a methodology, updating the evidence as of April 7, 2020, by searching multiple databases and consulting a multidisciplinary panel free of conflicts of interest. As a result of this process, the following statement was reached: it is recommended, in the context of the COVID-19 pandemic, in people who are undergoing treatment with ACEI/ARA, to maintain the treatment unchanged instead of its suspension or replacement with other drugs (Strong recommendation in favor - low quality ofevidence). (AU)