Cardiovascular events risk in patients with systemic autoimmune diseases: a prognostic systematic review and meta-analysis.

BACKGROUND: Chronic inflammation is considered a risk factor for the development of atherosclerosis and cardiovascular (CV) events. We seek to assess the risk of CV events in patients with Systemic autoimmune diseases (SAD), such as Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA), Psoriasis (Ps) and Ankylosing Spondylitis (AS), compared with the general population. METHODS AND RESULTS: A systematic search of MEDLINE from inception up to May 2021 was performed. Observational studies including individuals with and without autoimmune diseases (SLE, RA, Ps, AS), which reported a measure of association and variability for the effect of SAD on CV events, were included. The random effects meta-analysis was performed using the Hartung-Knapp-Sidik-Jonkman approach to obtain the pooled estimates. Cardiovascular Events including CV mortality, non-fatal myocardial infarction (MI), non-fatal stroke and coronary revascularization were the main outcomes evaluated. Fifty-four studies were selected, with a total of 24,107,072 participants. The presence of SAD was associated with an increased risk of CV mortality (HR 1.49 [95% CI 1.10-2.03]), non-fatal MI (HR 1.42 [95% CI 1.23-1.62]), and non-fatal stroke (HR 1.47 [95% CI 1.28-1.70]). RA, SLE, and Ps (particularly with arthritis) were significantly associated with a higher risk of MI and stroke. SAD was also associated with an increased risk of Major Adverse Cardiovascular Events (MACE) (HR 1.45 [95% CI 1.16-1.83]). CONCLUSION: Patients with SAD present an increased risk of CV morbidity and mortality, which should be considered when establishing therapeutic strategies. These findings support the role of systemic inflammation in the development of atherosclerosis-driven disease.

Treatments for non-small cell lung cancer: a systematic quality assessment of clinical practice guidelines

Aim To evaluate the methodological quality of clinical practice guidelines (CPGs) on treatments for non-small cell lung cancer (NSCLC). Methods We searched MEDLINE, CPG developer websites, lung cancer societies, and oncology organizations to identify CPGs providing recommendations on treatments for NSCLC. The methodological quality for each CPG was determined independently by three appraisers using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument. Results Twenty-two CPGs met the eligibility criteria. The median scores per AGREE II domain were: scope and purpose 90.7% (64.8–100%), stakeholder involvement 76.9% (27.8–96.3%); rigor of development 80.9% (27.1–92.4%); clarity of presentation 89.8% (50–100%); applicability 46.5% (12.5–87.5%); and editorial independence 91.7% (27.8–100%). Most of the CPGs (54.5%) were rated as “recommended with modifications” for clinical use. Conclusions Overall, the methodological quality of CPGs proving recommendations on the management of NSCLC is moderate, but there is still room for improvement in their development and implementation (AU)

Exogenous Volatile Organic Compound (EVOC®) Breath Testing Maximizes Classification Performance for Subjects with Cirrhosis and Reveals Signs of Portal Hypertension.

Background: Cirrhosis detection in primary care relies on low-performing biomarkers. Consequently, up to 75% of subjects with cirrhosis receive their first diagnosis with decompensation when causal treatments are less effective at preserving liver function. We investigated an unprecedented approach to cirrhosis detection based on dynamic breath testing. Methods: We enrolled 29 subjects with cirrhosis (Child-Pugh A and B), and 29 controls. All subjects fasted overnight. Breath samples were taken using Breath Biopsy® before and at different time points after the administration of 100 mg limonene. Absolute limonene breath levels were measured using gas chromatography-mass spectrometry. Results: All subjects showed a >100-fold limonene spike in breath after administration compared to baseline. Limonene breath kinetics showed first-order decay in >90% of the participants, with higher bioavailability in the cirrhosis group. At the Youden index, baseline limonene levels showed classification performance with an area under the roc curve (AUROC) of 0.83 ± 0.012, sensitivity of 0.66 ± 0.09, and specificity of 0.83 ± 0.07. The best performing timepoint post-administration was 60 min, with an AUROC of 0.91, sensitivity of 0.83 ± 0.07, and specificity of 0.9 ± 0.06. In the cirrhosis group, limonene bioavailability showed a correlation with MELD and fibrosis indicators, and was associated with signs of portal hypertension. Conclusions: Dynamic limonene breath testing enhances diagnostic performance for cirrhosis compared to static testing. The correlation with disease severity suggests potential for monitoring therapeutic interventions. Given the non-invasive nature of breath collection, a dynamic limonene breath test could be implemented in primary care.

Disparities in Stroke Incidence Over Time by Sex and Age in Latin America and the Caribbean Region 1997 to 2021: A Systematic Review and Meta-Analysis.

Background High-income country studies show unfavorable trends in stroke incidence (SI) in younger populations. We aimed to estimate temporal change in SI disaggregated by age and sex in Latin America and the Caribbean region. Methods and Results A search strategy was used in MEDLINE, WOS, and LILACS databases from 1997 to 2021, including prospective population-based observational studies with first-ever stroke incidence in Latin America. Reports without data broken down by age and sex were excluded. Risk of bias was assessed with The Joanna Briggs Institute's guide. The main outcomes were incidence rate ratio and relative temporal trend ratio of SI, comparing time periods before 2010 with after 2010. Pooled relative temporal trend ratios considering only studies with 2 periods in the same population were calculated by random-effects meta-analysis. Meta-regression analysis was used to evaluate incidence rate determinants. From 9242 records identified, 6 studies were selected including 4483 first-ever stroke in 4 101 084 individuals. Crude incidence rate ratio in younger subjects (<55 years) comparing before 2010:after 2010 periods showed an increase in SI in the past decade (incidence rate ratio, 1.37 [95% CI, 1.23-1.50]), in contrast to a decrease in older people during the same period (incidence rate ratio, 0.83 [95% CI, 0.76-0.89]). Overall relative temporal trend ratio (<55:≥55 years) was 1.65 (95 CI%, 1.50-1.80), with higher increase in young women (pooled relative temporal trend ratio, 3.08 [95% CI, 1.18-4.97]; P for heterogeneity <0.001). Conclusions An unfavorable change in SI in young people, especially in women, was detected in population-based studies in the past decade in Latin America and the Caribbean. Further investigation of the explanatory variables is required to ameliorate stroke prevention and inform local decision-makers. Registration URL: https://www.crd.york.ac.uk/prospero/ Identifier: CRD42022332563.

Treatments for non-small cell lung cancer: a systematic quality assessment of clinical practice guidelines.

AIM: To evaluate the methodological quality of clinical practice guidelines (CPGs) on treatments for non-small cell lung cancer (NSCLC). METHODS: We searched MEDLINE, CPG developer websites, lung cancer societies, and oncology organizations to identify CPGs providing recommendations on treatments for NSCLC. The methodological quality for each CPG was determined independently by three appraisers using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument. RESULTS: Twenty-two CPGs met the eligibility criteria. The median scores per AGREE II domain were: scope and purpose 90.7% (64.8-100%), stakeholder involvement 76.9% (27.8-96.3%); rigor of development 80.9% (27.1-92.4%); clarity of presentation 89.8% (50-100%); applicability 46.5% (12.5-87.5%); and editorial independence 91.7% (27.8-100%). Most of the CPGs (54.5%) were rated as "recommended with modifications" for clinical use. CONCLUSIONS: Overall, the methodological quality of CPGs proving recommendations on the management of NSCLC is moderate, but there is still room for improvement in their development and implementation.

Factores pronósticos que influyen en los resultados de tratamiento de la periimplantitis: Una revisión sistemática

Objetivo: Esta revisión sistemática tiene como objetivo identificar los factores pronósticos y/o determinantes del éxito del tratamiento de la periimplantitis. Materiales y métodos: Se realizó una búsqueda bibliográfica estructurada y exhaustiva para identificar referencias relevantes en las bases de datos MEDLINE (PubMed), Scielo y Springerlik. La estrategia de búsqueda se realizó combinando los términos periimplantitis con factores pronósticos y / o determinantes del éxito del tratamiento como MeSH y texto libre combinando con los operadores booleanos AND y OR. Se utilizó la clasificación de SIGN (Scottish Intercollegiate Guidelines Network) para analizar el nivel de evidencia. Resultados: De los 239 artículos revisados, 17 cumplieron con los criterios de selección para el análisis cualitativo de la evidencia. Conclusiones: El tipo de implante (macro y microgeometría) y la morfología del defecto, los cuales dificulta el acceso a las superficies contaminadas, son factores que influyen en el resultado del tratamiento de la periimplantitis. No hay evidencia sobre el método de descontaminación más eficaz. Las condiciones generales como la diabetes mellitus y la presencia de enfermedad periodontal activa afectan el resultado del tratamiento, así como la frecuencia de un programa de mantención de higiene profesional postquirúrgica, la cual mejora la sobrevida del implante.

Objective: This systematic review aimed at identifying prognostic factors influencing periimplantitis treatment outcomes. Materials and methods: A structured and comprehensive literature search was performed to identify relevant references from MEDLINE (PubMed), Scielo and Springerlik databases. The search strategy was carried out combining the search terms periimplantitis with prognostic factors and/or determinants of treatment success as MeSH and free text combining with the boolean logical operators AND and OR. The SIGN (Scottish Intercollegiate Guidelines Network) was used to analyze the level of evidence. Results: From 239 articles reviewed, 18 fulfilled the selection criteria for the qualitative analysis of the evidence. Conclusions: The type of implant (macro and microgeometry) and the defect morphology, which make access to contaminated surfaces difficult, are factors that influence the outcome of peri-implantitis treatment. There is no evidence on the most effective decontamination method. General conditions such as diabetes mellitus and the presence of active periodontal disease affect the outcome of the treatment. as Also, the frequency of a post-surgical professional hygiene maintenance program improves the dental implant survival post-treatment.

Mental training in dentistry: A scoping review.

INTRODUCTION: Clinical motor skills are essential to train dental students. There is evidence that imagery serves to acquire and improve motor skills, but there is scarce information on its application in dental education. In order to broadly map the available evidence and to detect knowledge gaps in the mental training used to develop motor skills in dentistry, a scoping review was conducted. MATERIALS AND METHODS: A structured search was conducted to identify relevant references from the Web of Science, Scopus and MEDLINE/PubMed databases for studies addressing mental training methods applied to develop motor skills in dentistry. RESULTS: A total of 758 articles were screened and four were selected, all of which were randomized clinical trials. Three studies investigated the effectiveness of visual imagery, and one investigated kinesthetic imagery. The research theme identified was motor skill acquisition. CONCLUSION: The reviewed studies indicate the usefulness of mental training for skill acquisition in dentistry. To improve the generalizability of the results, further research with standardized mental training on motor skills in dentistry is needed.

Stroke in Latin America: Systematic review of incidence, prevalence, and case-fatality in 1997-2021.

BACKGROUND: Stroke is a major global cause of death and disability. Most strokes occur in populations of low-middle-income country (LMIC); therefore, the subsequent disease burden is greater than in populations of high-income countries. Few epidemiological data exist for stroke in Latin America, composed primarily of LMIC. AIMS: To determine epidemiological measures of incidence, prevalence, and 1-month case-fatality for stroke in Latin America/Caribbean (LAC) during 1997-2021. SUMMARY OF REVIEW: A structured search was conducted to identify relevant references from MEDLINE, WOS, and LILACS databases for prospective observational and cross-sectional studies in LAC populations from January 1997 to December 2021. A total of 9242 records were screened and 12 selected for analysis, seven incidence studies and five prevalence studies. Case-fatality was reported in six articles. Sub-group analysis by age, sex, and income countries was performed. A narrative synthesis of the findings was performed. Meta-analysis was performed using random-effect model to obtain pooled estimates with 95% confidence intervals (CIs). Studies quality was assessed according to the risk of bias criteria described in the Joanna Briggs Institute's guide. The overall crude annual incidence rate of first-ever stroke in LAC was 119.0 (95% CI = 95.9-142.1)/100,000 people (with high heterogeneity between studies (I2 = 98.1%)). The overall crude prevalence was 3060 (95% CI: 95.9-142.1)/100,000 people (with high heterogeneity between studies (I2 = 98.8%)). The overall case-fatality at 1 month after the first stroke was 21.1% (95% CI = 18.6-23.7) (I2 = 49.40%). CONCLUSION: This review contributes to our understanding regarding the burden caused by stroke in LAC. More studies with comparable designs are needed to generate reliable data and should include both standardized criteria, such as the World Health Organization clinical criteria and updated standard methods of case assurance, data collection, and reporting.

Drugs for preventing lung cancer in healthy people.

BACKGROUND: This is the second update of this Cochrane Review. Some studies have suggested a protective effect of antioxidant nutrients and higher dietary levels of fruits and vegetables on lung cancer. OBJECTIVES: To determine whether vitamins and minerals and other potential agents, alone or in combination, reduce lung cancer incidence and lung cancer mortality in healthy populations. SEARCH METHODS: We searched CENTRAL, MEDLINE and Embase from 1974 to May 2019 and screened references included in published studies and reviews. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing vitamins or mineral supplements with placebo, administered to healthy people with the aim of preventing lung cancer. DATA COLLECTION AND ANALYSIS: Four review authors independently selected the trials to be included in the review, assessed their methodological quality and extracted data. For dichotomous outcomes we calculated risk ratios (RRs) and 95% confidence intervals (CIs) and pooled results using the random-effects model. We assessed the risk of bias using Cochrane's 'Risk of bias' assessment tool and certainty of evidence using the GRADE approach. MAIN RESULTS: In this update, we identified three new trials for a total of 12 studies. Six analysed vitamin A, three vitamin C, three combined vitamin D3 + calcium, four vitamin E combined with other products, one selenium supplements and nine studied combinations of two or more products. Four studies included only men and five only women. Vitamin A results in little to no difference in lung cancer incidence (RR 1.09, 95% CI 1.00 to 1.19; 5 RCTs, 212314 participants; high-certainty evidence) and lung cancer mortality (RR 1.06, 95% CI 0.81 to 1.38; 3 RCTs, 190118 participants; high-certainty evidence). But in smokers or asbestos workers vitamin A increases the risk of lung cancer incidence (RR 1.10, 95% CI 1.01 to 1.20; 3 RCTs, 43995 participants; high-certainty evidence), lung cancer mortality (RR 1.18, 95% CI 1.01 to 1.38; 2 RCTs, 29426 participants; high-certainty evidence) and all-cause mortality (RR 1.09, 95% CI 1.05 to 1.13; 2 RCTs, 32883 participants; high-certainty evidence). Vitamin A increases the risk of minor side effects, such as yellowing of the skin and minor gastrointestinal symptoms (high-certainty evidence). Vitamin C likely results in little to no difference in lung cancer incidence (RR 1.29, 95% CI 0.67 to 2.49; 2 RCTs, 14953 participants; moderate-certainty evidence). In women, vitamin C increases the risk of lung cancer incidence (RR 1.84, 95% CI 1.14 to 2.95; 1 RCT, 7627 participants; high-certainty evidence). In men, vitamin C results in little to no difference in mortality for lung cancer (RR 0.81, 95% CI 0.53 to 1.23; 1 RCT, 7326 participants; high-certainty evidence). Vitamin D + calcium may result in little to no difference in lung cancer incidence in postmenopausal women (RR 0.90, 95% CI 0.39 to 2.08; 3 RCTs, 37601 women; low-certainty evidence). Vitamin E results in little to no difference in lung cancer incidence (RR 1.01, 95% CI 0.90 to 1.14; 3 RCTs, 36841 participants; high-certainty evidence) or to lung cancer mortality (RR 0.96, 95% CI 0.77 to 1.18; 2 RCTs, 29214 participants; high-certainty evidence), but increases the risk of haemorrhagic strokes (hazard ratio (HR), 1.74, 95% CI 1.04 to 2.91; 1 RCT, 14641 participants; high-certainty evidence). Calcium results in little to no difference in lung cancer incidence in postmenopausal women (RR 0.65, 95% CI 0.13 to 3.18; 1 RCT, 733 participants) or in risk of renal calculi (RR 1.94, 95% CI 0.20 to 18.57; 1 RCT, 733 participants; low-certainty evidence). Selenium in men results in little to no difference in lung cancer incidence (RR 1.11, 95% CI 0.80 to 1.54; 1 RCT, 17448 participants; high-certainty evidence) and lung cancer mortality (RR 1.09, 95% CI 0.72 to 1.66; 1 RCT, 17448 participants; high-certainty evidence) and increases the risk for grade 1 to 2 dermatitis (RR 1.16, 95% CI 1.04 to 1.31; 1 RCT, 17448 participants; high-certainty evidence) and for alopecia (RR 1.28, 95% CI 1.07 to 1.53; 1 RCT, 17448 participants; high-certainty evidence). The combination of vitamins A, C, E + selenium + zinc results in little to no difference in lung cancer incidence (RR 0.64, 95% CI 0.28 to 1.48; 1 RCT, 12741 participants; high-certainty evidence). AUTHORS' CONCLUSIONS: Well-designed RCTs have shown no beneficial effect of supplements for the prevention of lung cancer and lung cancer mortality in healthy people. Vitamin A supplements increase lung cancer incidence and mortality in smokers or persons exposed to asbestos. Vitamin C increases lung cancer incidence in women. Vitamin E increases the risk of haemorrhagic strokes.

Improving Dental Students Fine Motor Skills by Visualization and Mental Imagery: A Pilot Randomized Clinical Trial / Mejora de las Habilidades Motoras Finas de los Estudiantes de Odontología Mediante Visualización e Imaginería: Ensayo Clínico Aleatorizado Piloto

ABSTRACT: Clinical motor skills are essential to train dental students. There is evidence that imagery serves to acquire and improve motor skills, since imagining an action, activates the same neural areas as when this is physically performed. The aim of this pilot randomized clinical trial was to examine the feasibility of tridimensional visualization associated with mental imagery on the development of fine motor skills of dental students compared to conventional training. Seventeen dental students without previous preclinical experiences, between 18-25 years old were recruited. After giving a theoretical lecture on the inlay preparation, participants were randomly allocated in two groups. The Experimental Group (N=9) performed daily 30 minutes of "mental practice" after visualizing a video showing the execution of an ideal inlay preparation alternating it with black screen periods to facilitate the imagery. The Control Group (N= 8) performed a 30 minutes "hands on practice" daily of the same preparation. On the fifth day, both groups carried out an inlay preparation physically, which was scanned and overlapped to the virtual preparation to assess accuracy. The execution time and accuracy of the preparation performed with regard to an ideal preparation were compared between groups. The learning style and fine motor skills at baseline were similar in all participants (P>0.001). No statistically significant differences were found between the groups in terms of accuracy. The time of execution in the experimental group was significantly lower than the control group. This pilot study showed that visualization associated to mental imagery could develop fine motor skills in dental students, requiring less execution time than physical practice.

RESUMEN: Las habilidades motoras clínicas son esenciales para entrenar a los estudiantes de odontología. Existe evidencia que la imaginería sirve para adquirir y mejorar las habilidades motoras, ya que al imaginar una acción, se activan las mismas áreas neuronales que cuando la acción se realiza físicamente. El objetivo de este ensayo clínico aleatorizado piloto fue examinar la factibilidad del uso de visualización tridimensional asociada con imaginería para el desarrollo de las habilidades motoras finas en estudiantes de odontología comparado con el entrenamiento convencional. Se reclutaron diecisiete estudiantes de odontología, entre 18-25 años de edad, sin experiencias preclínicas previas. Después de recibir una clase teórica sobre la preparación de una incrustación, los participantes fueron asignados aleatoriamente a dos grupos. El grupo experimental (N = 9) realizó diariamente 30 minutos de "práctica mental" después de visualizar un video que muestra la ejecución de una preparación de incrustación ideal alternando con períodos de pantalla negra para facilitar la imaginación. El grupo de control (N = 8) realizó una práctica diaria de 30 minutos de la misma preparación. El quinto día, ambos grupos llevaron a cabo físicamente una preparación de incrustación, que fue escaneada y esta imagen se superpuso a la preparación virtual ideal para evaluar la precisión. El tiempo de ejecución y la precisión de la preparación realizada con respecto a una preparación ideal se compararon entre ambos grupos. El estilo de aprendizaje y las habilidades motoras finas al inicio del estudio fueron similares en todos los participantes (P > 0,001). No se encontraron diferencias estadísticamente significativas entre los grupos en términos de precisión. El tiempo de ejecución en el grupo experimental fue significativamente menor que en el grupo control. Este estudio piloto mostró que la visualización asociada a imaginería podría desarrollar habilidades motoras finas en estudiantes de odontología, requiriendo menos tiempo de ejecución que la práctica física.

Use of Antibiotics in Dental Implant Surgery: A Decision Based on Evidence from Systematic Review / Uso de Antibióticos en la Cirugía de Implantes Dentales: una Decisión Basada en la Evidencia desde la Revisión Sistemática

Questions remain whether postoperative infections and implant failure can be reduced with the use of antibiotics. Especially, when its routine use can cause adverse effects and may contribute to the development of antibiotic-resistant bacteria. Moreover, there is no consensus regarding appropriate dosage regimen of antibiotics to prevent bacterial infection in implant dentistry. To determine effectiveness of different antibiotics regimens to prevent early infection after implant placement. A systematic review of all relevant studies addressing the use of antibiotic for dental implant surgery was carried-out. Implant groups not using antibiotics, were also analyzed. Primary outcomes were incidence of postoperative infection and frequency of implant failure due to infection. From 164 articles reviewed, 11 fulfilled the selection criteria representing 9472 placed implants. Regimens associated with the use of postoperative antibiotics showed a lower incidence of early infection (postoperative regimens 0%, pre and postoperative regimens 0.22% and 0.53%, long- and short-course, respectively (P= 0.275)). Regarding failure due to infection, no differences between groups were found (P= 0.249). A trend favoring the use of postoperative antibiotic to prevent early infections was observed. Further studies should be carried out in order to provide evidence-based clinical guidelines for use of antibiotics in dental implant placement.

Todavía se mantiene el integorrante acerca de si las infecciones postoperatorias y el fracaso de los implantes se pueden reducir con el uso de antibióticos. Especialmente, cuando su uso rutinario puede causar efectos adversos y puede contribuir al desarrollo de bacterias resistentes a los antibióticos. Por otra parte, no hay consenso en cuanto al régimen de dosificación apropiado de antibióticos para prevenir la infección bacteriana en los implantes dentales. Para determinar la efectividad de los diferentes regímenes de antibióticos destinados a prevenir la infección temprana después de la colocación del implante, se llevó a cabo una revisión sistemática de todos los estudios pertinentes sobre el uso de antibióticos para la cirugía del implante dental. También fueron analizados grupos de pacientes en los que se colocaron implantes sin el uso de antibióticos. Los resultados iniciales demostraron la existencia de infección postoperatoria y el fracaso del implante debido a la infección. De 164 artículos revisados, 11 cumplieron con los criterios de selección, representando un total de 9.472 implantes colocados. Estudios asociados con el uso de antibióticos postoperatorios mostraron una menor incidencia de infección temprana (regímenes postoperatorios 0%, regímenes pre y postoperatoria 0,22% y 0,53%, a largo y corto plazo, respectivamente (P= 0,275)). En cuanto al fracaso debido a la infección, no se encontraron diferencias entre los grupos (p= 0,249). Se observó una tendencia a favor del uso de antibióticos para prevenir infecciones postoperatorias tempranas. Nuevos estudios deben llevarse a cabo con el fin de proporcionar directrices clínicas, basadas en la evidencia, para el uso de antibióticos en la colocación del implante dental.

Análisis crítico de la literatura: un proceso elemental en el ejercicio de la práctica clínica basada en la evidencia / Critical analysis of literature: a basic process in exercising evidence based clinical practice

Para realizar una práctica clínica basada en la evidencia (PCBE), se requiere adquirir una serie de habilidades; entre ellas la búsqueda de literatura en forma sistemática y eficiente y la aplicación de reglas formales para la evaluación de la literatura encontrada. De este modo, se logra obtener de forma precisa la mejor evidencia disponible. Es así como, se podría resumir que el proceso de PCBE incluye varios pasos, uno de los cuales es el análisis crítico de la evidencia encontrada en la búsqueda de la literatura. Es fundamental comprender que no toda la información proveniente de revistas científicas es confiable o verdadera y por ende adecuada para ser instaurada como guía para la práctica clínica. Por tal razón, la información debe ser analizada de forma crítica; es decir, examinar cuidadosa y sistemáticamente la investigación para juzgar su validez y confiabilidad; o dicho de otra forma, su valor y relevancia en un contexto particular. El objetivo de este artículo fue jerarquizar la información existente respecto de estrategias para realizar un análisis crítico de la literatura científica y describir las herramientas más utilizadas con este fin.

To carry out clinical practice based on evidence (CPBE), it is necessary to acquire some skills, including systematic literature search and application of formal rules for evaluation of the literature found, thereby obtaining the best evidence available. Thus, one could summarize the CPBE process includes several steps, one of which is critical appraisal of the evidence found in literature search. It is essential to understand that not all the information from scientific journals is reliable or valid, and therefore suitable to be instituted in clinical practice. For this reason, the information must be critically analyzed; i.e. carefully and systematically examining research to judge its validity and reliability, or stated another way, its value and relevance in a particular context. The aim of this article is to hierarchy the existing information on strategies to realize critical analysis of the scientific literature and to describe the tools most commonly used for this purpose.

Characteristics of randomized trials published in Latin America and the Caribbean according to funding source.

INTRODUCTION: Few studies have assessed the nature and quality of randomized controlled trials (RCTs) in Latin America and the Caribbean (LAC). METHODS AND FINDINGS: The aims of this systematic review are to evaluate the characteristics (including the risk of bias assessment) of RCT conducted in LAC according to funding source. A review of RCTs published in 2010 in which the author's affiliation was from LAC was performed in PubMed and LILACS. Two reviewers independently extracted data and assessed the risk of bias. The primary outcomes were risk of bias assessment and funding source. A total of 1,695 references were found in PubMed and LILACS databases, of which 526 were RCTs (N = 73.513 participants). English was the dominant publication language (93%) and most of the RCTs were published in non-LAC journals (84.2%). Only five of the 19 identified countries accounted for nearly 95% of all RCTs conducted in the region (Brazil 70.9%, Mexico 10.1%, Argentina 5.9%, Colombia 3.8%, and Chile 3.4%). Few RCTs covered priority areas related with Millennium Development Goals like maternal health (6.7%) or high priority infectious diseases (3.8%). Regarding children, 3.6% and 0.4% RCT evaluated nutrition and diarrhea interventions respectively but none pneumonia. As a comparison, aesthetic and sport related interventions account for 4.6% of all trials. A random sample of RCTs (n = 358) was assessed for funding source: exclusively public (33.8%); private (e.g. pharmaceutical company) (15.3%); other (e.g. mixed, NGO) (15.1%); no funding (35.8%). Overall assessments for risk of bias showed no statistically significant differences between RCTs and type of funding source. Statistically significant differences favoring private and others type of funding was found when assessing trial registration and conflict of interest reporting. CONCLUSION: Findings of this study could be used to provide more direction for future research to facilitate innovation, improve health outcomes or address priority health problems.

Protocol for immediate implant replacement of infected teeth.

Extraction and immediate implant placement has become routine procedure due to reduced treatment time and the preservation of anatomical structures. However, in many cases, this technique involves teeth with different degrees of tissue compromise due to underlying infections. Until now, the degree of implant compromise has not been described, nor has a clinical management protocol been established for these cases. The aim of this article is to report the clinical results of a protocol used for immediate implant placement and provisionalization in infected extraction sockets. A classification of the implant surface compromise (in contact with previously infected tissue) is also described to facilitate the comparative analysis. It is possible to maintain the benefits of immediate implant placement and provisionalization in infected sites by applying a clinical protocol that considers antibiotic therapy, a thorough curettage of the infected tissue, antisepsis, and sufficient primary implant stability.

Trial registration in Latin America and the Caribbean's: study of randomized trials published in 2010.

OBJECTIVE: To determine the prevalence of trial registration in randomized controlled trials (RCTs) published in 2010 (PUBMED/LILACS) from Latin America and the Caribbean's (LAC) and to compare methodological characteristics between registered and nonregistered RCTs. STUDY DESIGN AND SETTING: A search for detecting RCTs in which at least the first/contact author had a LAC's affiliation was made. We determined if RCTs were registered in the International Clinical Trial Registry Platform (ICTRP). Data were independently extracted by two authors. The risk of bias (RoB) was assessed in all registered RCTs (n=89) and in a sample of nonregistered RCTs (n=237). RESULTS: The search identified 1,695 references; 526 RCTs from 19 countries were included. 16.9% (89/526) of RCTs were registered in the ICTRP; however, only 21 (4.0%) were prospectively registered. A significant difference was found in the overall assessment of the RoB between registered and nonregistered RCTs. Overall, registered RCTs were multinational, had larger sample size and longer follow-up, and reported more frequently information on funding, conflict of interests, and ethic issues. No significant differences were found when analyzing prospectively registered RCTs. CONCLUSION: This study shows that trial registration rates are still low in LAC and the quality of reporting needs to be improved.

Clozapine versus other atypical antipsychotics for schizophrenia.

BACKGROUND: Clozapine is an atypical antipsychotic demonstrated to be superior in the treatment of refractory schizophrenia which causes fewer movement disorders. Clozapine, however, entails a significant risk of serious blood disorders such as agranulocytosis which could be potentially fatal. Currently there are a number of newer antipsychotics which have been developed with the purpose to find both a better tolerability profile and a superior effectiveness. OBJECTIVES: To compare the clinical effects of clozapine with other atypical antipsychotics (such as amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, sertindole, ziprasidone and zotepine) in the treatment of schizophrenia and schizophrenia-like psychoses. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Groups Register (June 2007) and reference lists of all included randomised controlled trials. We also manually searched appropriate journals and conference proceedings relating to clozapine combination strategies and contacted relevant pharmaceutical companies. SELECTION CRITERIA: All relevant randomised, at least single-blind trials, comparing clozapine with other atypical antipsychotics, any dose and oral formulations, for people with schizophrenia or related disorders. DATA COLLECTION AND ANALYSIS: We selected trials and extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) based on a random-effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated mean differences (MD) again based on a random-effects model. MAIN RESULTS: The review currently includes 27 blinded randomised controlled trials, which involved 3099 participants. Twelve randomised control trials compared clozapine with olanzapine, five with quetiapine, nine with risperidone, one with ziprasidone and two with zotepine. Attrition from these studies was high (overall 30.1%), leaving the interpretation of results problematic. Clozapine had a higher attrition rate due to adverse effects than olanzapine (9 RCTs, n=1674, RR 1.60 CI 1.07 to 2.40, NNT 25 CI 15 to 73) and risperidone (6 RCTs, n=627, RR 1.88 CI 1.11 to 3.21, NNT 16 CI 9 to 59). Fewer participants in the clozapine groups left the trials early due to inefficacy than risperidone (6 RCTs, n=627, RR 0.40 CI 0.23 to 0.70, NNT 11 CI 7 to 21), suggesting a certain higher efficacy of clozapine.Clozapine was more efficacious than zotepine in improving the participants general mental state (BPRS total score: 1 RCT, n=59, MD -6.00 CI -9.83 to -2.17), but not consistently more than olanzapine, quetiapine, risperidone and ziprasidone. There was no significant difference between clozapine and olanzapine or risperidone in terms of positive or negative symptoms of schizophrenia. According to two studies from China quetiapine was more efficacious for negative symptoms than clozapine (2 RCTs, n=142, MD 2.23 CI 0.99 to 3.48).Clozapine produced somewhat fewer extrapyramidal side-effects than risperidone (use of antiparkinson medication: 6 RCTs, n=304, RR 0.39 CI 0.22 to 0.68, NNT 7 CI 5 to 18) and zotepine (n=59, RR 0.05 CI 0.00 to 0.86, NNT 3 CI 2 to 5). More participants in the clozapine group showed decreased white blood cells than those taking olanzapine, more hypersalivation and sedation than those on olanzapine, risperidone and quetiapine and more seizures than people on olanzapine and risperidone. Also clozapine produced an important weight gain not seen with risperidone.Other differences in adverse effects were less documented and should be replicated, for example, clozapine did not alter prolactin levels whereas olanzapine, risperidone and zotepine did; compared with quetiapine, clozapine produced a higher incidence of electrocardiogram (ECG) alterations; and compared with quetiapine and risperidone clozapine produced a higher increase of triglyceride levels. Other findings that should be replicated were: clozapine improved social functioning less than risperidone and fewer participants in the clozapine group had to be hospitalised to avoid suicide attempts compared to olanzapine.Other important outcomes such as service use, cognitive functioning, satisfaction with care or quality of life were rarely reported. AUTHORS' CONCLUSIONS: Clozapine may be a little more efficacious than zotepine and risperidone but further trials are required to confirm this finding. Clozapine differs more clearly in adverse effects from other second generation antipsychotics and the side-effect profile could be key in the selection of treatment depending on the clinical situation and a patient's preferences. Data on other important outcomes such as cognitive functioning, quality of life, death or service use are currently largely missing, making further large and well-designed trials necessary. It is also important to take into account that the large number of people leaving the studies early limits the validity and interpretation of our findings.

A meta-analysis of head-to-head comparisons of second-generation antipsychotics in the treatment of schizophrenia.

OBJECTIVE: Whether there are differences in efficacy among second-generation antipsychotics in the treatment of schizophrenia is a matter of heated debate. The authors conducted a systematic review and meta-analysis of blinded studies comparing second-generation antipsychotics head-to-head. METHOD: Searches of the Cochrane Schizophrenia Group's register (May 2007) and MEDLINE (September 2007) were conducted for randomized, blinded studies comparing two or more of nine second-generation antipsychotics in the treatment of schizophrenia. All data were extracted by at least three reviewers independently. The primary outcome measure was change in total score on the Positive and Negative Syndrome Scale; secondary outcome measures were positive and negative symptom subscores and rate of dropout due to inefficacy. The results were combined in a meta-analysis. Various sensitivity analyses and metaregressions were used to examine bias. RESULTS: The analysis included 78 studies with 167 relevant arms and 13,558 participants. Olanzapine proved superior to aripiprazole, quetiapine, risperidone, and ziprasidone. Risperidone was more efficacious than quetiapine and ziprasidone. Clozapine proved superior to zotepine and, in doses >400 mg/day, to risperidone. These differences were due to improvement in positive symptoms rather than negative symptoms. The results were rather robust with regard to the effects of industry sponsorship, study quality, dosages, and trial duration. CONCLUSIONS: The findings suggest that some second-generation antipsychotics may be somewhat more efficacious than others, but the limitations of meta-analysis must be considered. In tailoring drug treatment to the individual patient, small efficacy superiorities must be weighed against large differences in side effects and cost.