Sexual Function of Patients with Deep Endometriosis after Surgical Treatment: A Systematic Review.

OBJECTIVE: To review the current state of knowledge on the impact of the surgical treatment on the sexual function and dyspareunia of deep endometriosis patients. DATA SOURCE: A systematic review was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted systematic searches in the PubMed, EMBASE, LILACS, and Web of Science databases from inception until December 2022. The eligibility criteria were studies including: preoperative and postoperative comparative analyses; patients with a diagnosis of deep endometriosis; and questionnaires to measure sexual quality of life. STUDY SELECTION: Two reviewers screened and reviewed 1,100 full-text articles to analyze sexual function after the surgical treatment for deep endometriosis. The risk of bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration's tool for randomized controlled trials. The present study was registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration CRD42021289742). DATA COLLECTION: General variables about the studies, the surgical technique, complementary treatments, and questionnaires were inserted in an Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, United States) spreadsheet. SYNTHESIS OF DATA: We included 20 studies in which the videolaparoscopy technique was used for the excision of deep infiltrating endometriosis. A meta-analysis could not be performed due to the substantial heterogeneity among the studies. Classes III and IV of the revised American Fertility Society classification were predominant and multiple surgical techniques for the treatment of endometriosis were performed. Standardized and validated questionnaires were applied to evaluate sexual function. CONCLUSION: Laparoscopic surgery is a complex procedure that involves multiple organs, and it has been proved to be effective in improving sexual function and dyspareunia in women with deep infiltrating endometriosis.

OBJETIVO: Revisar a literatura publicada sobre o impacto do tratamento cirúrgico na função sexual e na dispareunia de pacientes com endometriose profunda. FONTE DE DADOS: Uma revisão sistemática foi realizada de acordo com as diretrizes Meta-Analysis of Observational Studies in Epidemiology (MOOSE). Realizamos pesquisas sistemáticas nas bases de dados PubMed, EMBASE, LILACS e Web of Science desde o início até dezembro de 2022. Os critérios de elegibilidade foram estudos que incluíam: análises comparativas pré- e pós-operatórias; pacientes com diagnóstico de endometriose profunda; e a aplicação de questionários para avaliar a função sexual. SELEçãO DOS ESTUDOS: Dois revisores selecionaram e revisaram 1.100 artigos para analisar a da função sexual após o tratamento cirúrgico da endometriose profunda. O risco de viés foi calculado usando-se a escala de Newcastle-Ottawa para estudos observacionais e a ferramenta para ensaios clínicos randomizados da Cochrane Collaboration. O estudo foi cadastrado no International Prospective Register of Systematic Reviews (PROSPERO; cadastro CRD42021289742). COLETA DE DADOS: Variáveis gerais sobre os estudos, a técnica cirúrgica, os tratamentos complementares e os questionários foram inseridas em uma planilha do Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, Estados Unidos). SíNTESE DOS DADOS: Foram incluídos 20 estudos em que se usou a técnica de videolaparoscopia para a excisão da endometriose profunda. Uma meta-análise não pôde ser realizada devido à heterogeneidade substancial entre os estudos incluídos. As classes III e IV da escala revisada da American Fertility Society foram predominantes, e múltiplas técnicas cirúrgicas foram usadas para o tratamento da endometriose. Questionários padronizados e validados foram aplicados para avaliar a função sexual. CONCLUSãO: A cirurgia laparoscópica é um procedimento complexo que envolve múltiplos órgãos, e provou ser eficaz na melhora da função sexual e da dispareunia em mulheres com endometriose profunda.

Mirabegron and Anticholinergics in the Treatment of Overactive Bladder Syndrome: A Meta-analysis.

OBJECTIVE: To compare the use of mirabegron with anticholinergics drugs for the treatment of overactive bladder (OB). DATA SOURCE: Systematic searches were conducted in EMBASE, PUBMED, Cochrane, and LILACS databases from inception to September 2021. We included RCTs, women with clinically proven OB symptoms, studies that compared mirabegron to antimuscarinic drugs, and that evaluated the efficacy, safety or adherence. DATA COLLECTION: RevMan 5.4 was used to combine results across studies. We derived risk ratios (RRs) and mean differences with 95% CIs using a random-effects meta-analytic model. Cochrane Collaboration Tool and GRADE was applied for risk of bias and quality of the evidence. DATA SYNTHESIS: We included 14 studies with a total of 10,774 patients. Fewer total adverse events was reported in mirabegron group than in antimuscarinics group [RR 0.93 (0.89-0.98)]. The risk of gastrointestinal tract disorders and dry mouth were lower with mirabegron [RR 0,58 (0.48-0.68); 9375 patients; RR 0.44 (0.35-0.56), 9375 patients, respectively]. No difference was reported between mirabegron and antimuscarinics drugs for efficacy. The adherence to treatment was 87.7% in both groups [RR 0.99 (0.98-1.00)]. CONCLUSION: Mirabegron and antimuscarinics have comparable efficacy and adherence rates; however, mirabegron showed fewer total and isolated adverse events.

OBJETIVO: Comparar o uso de mirabegrom com anticolinérgicos para o tratamento da bexiga hiperativa (BH). FONTE DE DADOS: Buscas sistemáticas foram realizadas nas bases de dados EMBASE, PUBMED, Cochrane e LILACS desde o início até setembro de 2021. Incluímos ECR, mulheres com sintomas de BH clinicamente comprovados, estudos que compararam mirabegrom a medicamentos antimuscarínicos e avaliaram a eficácia, segurança ou adesão. COLETA DE DADOS: RevMan 5.4 foi usado para combinar os resultados entre os estudos. Derivamos razões de risco (RRs) e diferenças médias com intervalo de confiança (IC) de 95% usando um modelo meta-analítico de efeitos aleatórios. Cochrane Collaboration Tool e GRADE foi aplicado para risco de viés e qualidade da evidência. SíNTESE DOS DADOS: Foram incluídos 14 estudos com um total de 10.774 pacientes. Menos eventos adversos totais foram relatados no grupo mirabegrom do que no grupo antimuscarínicos [RR: 0,93 (0,89­0,98)]. O risco de distúrbios do trato gastrointestinal e boca seca foram menores com mirabegrom [RR: 0,58 (0,48­0,68); 9.375 pacientes; RR: 0,44 (0,35­0,56), 9.375 pacientes, respectivamente]. Nenhuma diferença foi relatada entre mirabegrom e drogas antimuscarínicos para eficácia. A adesão ao tratamento foi de 87,7% em ambos os grupos [RR: 0,99 (0,98­1,00)]. CONCLUSãO: Mirabegrom e antimuscarínicos têm eficácia e taxas de adesão comparáveis, porém o mirabegrom apresentou menos eventos adversos totais e isolados.

Mirabegron and Anticholinergics in the Treatment of Overactive Bladder Syndrome: A Meta-analysis / Mirabegron e anticolinérgicos no tratamento da síndrome da bexiga hiperativa: metanálise

Abstract Objective To compare the use of mirabegron with anticholinergics drugs for the treatment of overactive bladder (OB). Data Source Systematic searches were conducted in EMBASE, PUBMED, Cochrane, and LILACS databases from inception to September 2021. We included RCTs, women with clinically proven OB symptoms, studies that compared mirabegron to antimuscarinic drugs, and that evaluated the efficacy, safety or adherence. Data Collection RevMan 5.4 was used to combine results across studies. We derived risk ratios (RRs) and mean differences with 95% CIs using a random-effects meta-analytic model. Cochrane Collaboration Tool and GRADE was applied for risk of bias and quality of the evidence. Data Synthesis We included 14 studies with a total of 10,774 patients. Fewer total adverse events was reported in mirabegron group than in antimuscarinics group [RR 0.93 (0.89-0.98)]. The risk of gastrointestinal tract disorders and dry mouth were lower with mirabegron [RR 0,58 (0.48-0.68); 9375 patients; RR 0.44 (0.35-0.56), 9375 patients, respectively]. No difference was reported between mirabegron and antimuscarinics drugs for efficacy. The adherence to treatment was 87.7% in both groups [RR 0.99 (0.98-1.00)]. Conclusion Mirabegron and antimuscarinics have comparable efficacy and adherence rates; however, mirabegron showed fewer total and isolated adverse events.

Resumo Objetivo Comparar o uso de mirabegrom com anticolinérgicos para o tratamento da bexiga hiperativa (BH). Fonte de Dados Buscas sistemáticas foram realizadas nas bases de dados EMBASE, PUBMED, Cochrane e LILACS desde o início até setembro de 2021. Incluímos ECR, mulheres com sintomas de BH clinicamente comprovados, estudos que compararam mirabegrom a medicamentos antimuscarínicos e avaliaram a eficácia, segurança ou adesão. Coleta de Dados RevMan 5.4 foi usado para combinar os resultados entre os estudos. Derivamos razões de risco (RRs) e diferenças médias com intervalo de confiança (IC) de 95% usando um modelo meta-analítico de efeitos aleatórios. Cochrane Collaboration Tool e GRADE foi aplicado para risco de viés e qualidade da evidência. Síntese dos Dados Foram incluídos 14 estudos com um total de 10.774 pacientes. Menos eventos adversos totais foram relatados no grupo mirabegrom do que no grupo antimuscarínicos [RR: 0,93 (0,89-0,98)]. O risco de distúrbios do trato gastrointestinal e boca seca foram menores com mirabegrom [RR: 0,58 (0,48-0,68); 9.375 pacientes; RR: 0,44 (0,35-0,56), 9.375 pacientes, respectivamente]. Nenhuma diferença foi relatada entre mirabegrom e drogas antimuscarínicos para eficácia. A adesão ao tratamento foi de 87,7% em ambos os grupos [RR: 0,99 (0,98-1,00)]. Conclusão Mirabegrom e antimuscarínicos têm eficácia e taxas de adesão comparáveis, porém o mirabegrom apresentou menos eventos adversos totais e isolados.

Sexual Function of Patients with Deep Endometriosis after Surgical Treatment: A Systematic Review / Função sexual em pacientes com endometriose profunda após o tratamento cirúrgico: Revisão sistemática

Abstract Objective To review the current state of knowledge on the impact of the surgical treatment on the sexual function and dyspareunia of deep endometriosis patients. Data Source A systematic review was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted systematic searches in the PubMed, EMBASE, LILACS, and Web of Science databases from inception until December 2022. The eligibility criteria were studies including: preoperative and postoperative comparative analyses; patients with a diagnosis of deep endometriosis; and questionnaires to measure sexual quality of life. Study Selection Two reviewers screened and reviewed 1,100 full-text articles to analyze sexual function after the surgical treatment for deep endometriosis. The risk of bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration's tool for randomized controlled trials. The present study was registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration CRD42021289742). Data Collection General variables about the studies, the surgical technique, complementary treatments, and questionnaires were inserted in an Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, United States) spreadsheet. Synthesis of Data We included 20 studies in which the videolaparoscopy technique was used for the excision of deep infiltrating endometriosis. A meta-analysis could not be performed due to the substantial heterogeneity among the studies. Classes III and IV of the revised American Fertility Society classification were predominant and multiple surgical techniques for the treatment of endometriosis were performed. Standardized and validated questionnaires were applied to evaluate sexual function. Conclusion Laparoscopic surgery is a complex procedure that involves multiple organs, and it has been proved to be effective in improving sexual function and dyspareunia in women with deep infiltrating endometriosis.

Resumo Objetivo Revisar a literatura publicada sobre o impacto do tratamento cirúrgico na função sexual e na dispareunia de pacientes com endometriose profunda. Fonte de Dados Uma revisão sistemática foi realizada de acordo com as diretrizes Meta-Analysis of Observational Studies in Epidemiology (MOOSE). Realizamos pesquisas sistemáticas nas bases de dados PubMed, EMBASE, LILACS e Web of Science desde o início até dezembro de 2022. Os critérios de elegibilidade foram estudos que incluíam: análises comparativas pré- e pós-operatórias; pacientes com diagnóstico de endometriose profunda; e a aplicação de questionários para avaliar a função sexual. Seleção dos Estudos Dois revisores selecionaram e revisaram 1.100 artigos para analisar a da função sexual após o tratamento cirúrgico da endometriose profunda. O risco de viés foi calculado usando-se a escala de Newcastle-Ottawa para estudos observacionais e a ferramenta para ensaios clínicos randomizados da Cochrane Collaboration. O estudo foi cadastrado no International Prospective Register of Systematic Reviews (PROSPERO; cadastro CRD42021289742). Coleta de dados Variáveis gerais sobre os estudos, a técnica cirúrgica, os tratamentos complementares e os questionários foram inseridas em uma planilha do Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, Estados Unidos). Síntese dos dados Foram incluídos 20 estudos em que se usou a técnica de videolaparoscopia para a excisão da endometriose profunda. Uma meta-análise não pôde ser realizada devido à heterogeneidade substancial entre os estudos incluídos. As classes III e IV da escala revisada da American Fertility Society foram predominantes, e múltiplas técnicas cirúrgicas foram usadas para o tratamento da endometriose. Questionários padronizados e validados foram aplicados para avaliar a função sexual. Conclusão A cirurgia laparoscópica é um procedimento complexo que envolve múltiplos órgãos, e provou ser eficaz na melhora da função sexual e da dispareunia em mulheres com endometriose profunda.

Symptoms and Surgical Technique of Bladder Endometriosis: A Systematic Review.

OBJECTIVE: This systematic review aimed to review all the available evidence regarding bladder endometriosis (BE) surgical techniques, resolution of symptoms, and nodule size. DATA SOURCES: We conducted systematic searches in PubMed MEDLINE, Embase, Latin American and Caribbean Centre on Health Sciences Information, Cochrane Library, and Web of Science databases from inception to December 2021. METHODS OF STUDY SELECTION: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature search yielded 1279 articles. Two reviewers independently screened abstracts and reviewed full-text articles to meet the eligibility criteria: women diagnosed as having BE, treated surgically to remove the BE nodule, and reported of the nodule size and/or symptoms after the surgery. We included 28 studies, which mainly were case reports and case series. TABULATION, INTEGRATION, AND RESULTS: The following information was extracted from the included studies: author, country, publication year, study design, number of patients, age, surgery performed, follow-up time, operation time, nodule location, nodule size, and postsurgical symptoms. Patients' ages range from 26 to 44 years and most women were nulliparous. The BE nodule size ranged from 0.7 to 5.5 cm, and the most frequent location (63.57%) was the posterior wall. Dysuria was reported by 27.18% of women and generic lower urinary tract symptoms were reported by 27.95%. After surgery, the recurrence rate of urinary symptoms was 7.34%. Most studies performed a partial cystectomy to remove the nodule, showing that the disease affects the bladder mucosa frequently. CONCLUSION: Surgical treatment with complete excision of BE lesion was shown to improve complaints of urinary symptoms in patients with BE. Given that most of the studies evaluated were descriptive, additional studies with a large sample population and a better level of evidence for this condition are needed.

Conservative versus Radical Surgery for Women with Deep Infiltrating Endometriosis: Systematic Review and Meta-analysis of Bowel Function.

OBJECTIVE: To assess bowel function in women with deep infiltrating endometriosis according to surgical approach (radical vs conservative). DATA SOURCES: Five databases were searched from 1970 to September 2021 to retrieve studies comparing radical (colorectal segmental resection) and conservative (shaving or discoid excision) surgery for bowel function in women with deep infiltrating endometriosis. METHODS OF STUDY SELECTION: No language restriction was applied. Two reviewers extracted and combined data from the included studies, applying a meta-analytic model with random effects in all calculations. Results are expressed in risk ratio (RR) with 95% confidence interval (CI). Assessment of risk of bias and quality of evidence was performed by the Newcastle-Ottawa and Grading of Recommendations, Assessment, Development and Evaluation, respectively. TABULATION, INTEGRATION, AND RESULTS: We included 13 studies in our meta-analysis, and most of them were of nonrandomized design. Conservative surgery had fewer events of constipation and frequent bowel movements when compared with radical surgery (RR, 2.31; 95% CI, 1.21-4.43; I2 = 0%; 3 studies; RR, 2.80; 95% CI 1.17-6.75; I2 = 0%; 2 studies, respectively). Defecation pain, anal incontinence loss, minor and major lower anterior resection syndrome, and Clavien-Dindo complications grade I to IV showed no statistically significant difference between surgeries. Grading of Recommendations, Assessment, Development and Evaluation assessment was low to very low for all outcomes. CONCLUSION: Conservative surgery (shaving or discoid excision) presented fewer events of constipation and frequent bowel movements than colorectal segmental resection. There was a very low quality of evidence to provide recommendations regarding bowel function.

A Cost Effectiveness Model of Long-Acting Reversible Contraceptive Methods in the Brazilian National Health System.

INTRODUCTION: The use of long-acting reversible contraceptives is low among adolescents owing to the high up-front cost. In this study, a 5-year cost-effectiveness model and budget impact analysis were used to compare the use of long-acting reversible contraceptives with the use of combined oral contraceptives among Brazilian adolescents. METHODS: A Markov model was developed to mirror the clinical and economic effects of long-acting reversible contraceptives among sexually active Brazilian adolescents in the public health system for a 5-year duration, starting from 2018. The costs were expressed in U.S.$, and a 5% discount rate was applied for both costs and benefits. Model inputs included costs of the contraceptive methods, contraceptive discontinuation and adherence rates, abortion, and birth costs associated with unintended pregnancies. The model outcomes were avoided pregnancies, abortions, and births. Univariate and probabilistic sensitivity analyses were conducted. RESULTS: Copper intrauterine device use was dominant 100% of the time for all outcomes, and a budget impact analysis revealed a cost savings of $422,431,269.10 in the 5-year period. Levonorgestrel intrauterine system and subdermal implant use were cost effective for all outcomes. The budget impact analyses revealed costs of $65,645,417.54 for levonorgestrel intrauterine system and $302,852,972.12 for subdermal implant use during the 5-year study period. CONCLUSIONS: According to this Brazilian model, copper intrauterine device use is dominant, and levonorgestrel intrauterine systems and subdermal implants are more cost effective than combined oral contraceptives.

Pooled incidence of continuation and pregnancy rates of four contraceptive methods in young women: a meta-analysis.

BACKGROUND: Continuation rates of contraceptive methods in young women vary among studies, and there is scarce data regarding the pregnancy rate in this population. METHODS: Four independently systematic searches were performed in PUBMED, EMBASE, LILACS, and Cochrane databases from inception until January 2021 for oral contraceptive pill (OCP), copper IUD, levonorgestrel intrauterine system (LNG-IUS), and subdermal implant. Inclusion criteria were observational or RCT studies that reported continuation for at least 12 months and/or pregnancy rate of these contraceptives methods in girls aged 22 years old or younger. Two authors extracted data from the study design and the outcomes. Pooled proportions of each method were applied using the inverse variance in all calculations with LOGIT transformation, using the random-effects model. Cochrane collaboration tool and New Castle-Ottawa were used to assess the quality and bias of all included studies. GRADE criteria evaluated the quality of evidence. RESULTS: Continuation rate for OCP was 51% (95%CI 34%-68%), while for cooper IUD was 77% (95%CI 74%-80%), LNG-IUS 84% (95%CI 80%-87%), and implant 85% (95%CI 81%-88%). The pooled estimated pregnancy rate for OCP was 11% (95%CI 6%-20%), while for cooper IUD was 5% (95%CI 3%-7%), LNG-IUS 1.6% (95%CI 1.2%-2.3%), and implant 1.8% (95%CI 0.4%-8.4%). CONCLUSION: Long-acting contraceptive methods presented higher continuation rates and lower pregnancy rates when compared to OCPs.

Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis.

OBJECTIVE: To assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children. DESIGN: Systematic review according to the Cochrane guidelines and meta-analysis using random-effects modelling. METHODS: We searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Cochrane and SciELO databases from inception until April 2021. We conducted a quality appraisal for each study using the Newcastle-Ottawa Scale and Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0 checklist. MAIN OUTCOME: The primary outcome measure was UE rates per 100 intubation days. RESULTS: We screened 10 091 records and finally included 11 studies. Six studies were pre/post-intervention studies, and five were interrupted time-series studies. The methodological quality was 'good' in 70%, and the remaining as 'fair' (30%). The most frequently used implementation strategies were staff education (100%), root cause analysis (100%), and audit and feedback (82%). Key bundle care components comprised identification of high-risk patients, endotracheal tube care and sedation protocol. Not all studies fully completed the SQUIRE V.2.0 checklist. Meta-analysis revealed a reduction in UE rate following the introduction of care bundles (rate ratio: 0.40 (95% CI: 0.19 to 0.84); p=0.02), which equates to a 60% reduction in UE rates. CONCLUSIONS: We found that identifying high-risk patients, endotracheal tube care and protocol-directed sedation are core elements in care bundles for preventing UEs. However, there are several methodological gaps in the literature, including poor evaluation of adherence to bundle components. Future studies should address these gaps to strengthen their validity.

Wistar rat as an animal model to study high-fat induced kidney damage: a systematic review.

The effects of high-fat-associated kidney damage in humans are not completely elucidated. Animal experiments are essential to understanding the mechanisms underlying human diseases. This systematic review aimed to compile evidence of the role of a high-fat diet during the development of renal lipotoxicity and fibrosis of Wistar rats to understand whether this is a satisfactory model for the study of high fat-induced kidney damage. We conducted systematic searches in PUBMED, EMBASE, Lilacs, and Web of Science databases from inception until May 2021. The risk of bias was assessed using SYRCLE toll. Two reviewers independently screened abstracts and reviewed full-text articles. A total of 11 studies were included. The damage varied depending on the age and sex of the animals, time of protocol, and amount of fat in the diet. In conclusion, the Wistar rat is an adequate animal model to assess the effects of a high-fat diet on the kidneys.HighlightsA high-fat diet may promote kidney damage in Wistar rats.Wistar rat is efficient as an animal model to study high-fat-induced kidney damage.The effect of the diet depends on the fat amount, consumption time, and animal age.

Willingness to pay for short- and long-acting contraceptives among female adolescents and their parents in Brazil:a pilot study.

OBJECTIVE: To evaluate willingness to pay for short- and long-acting reversible contraceptive methods among female Brazilian adolescents and their parents, as well as their perspective on using such methods. METHODS: This is a cross-sectional study of female adolescents aged 13 to 19 years and their parents. We surveyed to estimate their willingness to pay for contraceptive methods. The values are expressed as mean±standard deviation in Brazilian reals (R$). Spearman correlation was employed for socioeconomic status of parents, age of adolescents and their standpoints. The methods types and adolescent and parent perspectives were analyzed by the test χ2. To determine an agreement between pairs and their willingness to pay, we used the Bland-Altman plot. RESULTS: A total of 165 surveys were collected. Short-acting method was significantly more acceptable to pay than the long-action method, by both parents and their daughters. Parents and their daughters are willing to pay out-of-pocket R$ 52,25±22,48 and R$ 51,63±21,24 for short-acting reversible contraception method, and R$ 176,83±130,34 and R$ 174,83±143,64, for long-acting method, respectively. Bland-Altman analysis indicated an agreement on both perspectives and the price they are willing to pay for each contraceptive method. CONCLUSION: Parents and adolescent daughters are more willing to pay for short-acting methods. We showed an agreement between the parent and the daughter for the values paid for each method.

Who is going to turn on the ventilators?

OBJECTIVE: To analyze the COVID-19 pandemic in Brazil, a continental-sized country, considered as an emerging economy but with several regional nuances, focusing on the availability of human resources, especially for intensive care units. METHODS: The database of the National Registry of Health Facilities was accessed. Healthcare professionals in the care of COVID-19 were georeferenced. We correlated the number of professionals with the parameters used by the World Health Organization. According to the Brazilian Intensive Care Medicine Association, we correlated the data for adult intensive care unit beds in each state with the number of professionals for each ten intensive care unit beds. The number of professionals, beds, and cases were then organized by state. RESULTS: The number of physicians per 100 thousand inhabitants followed the World Health Organization recommendations; however, the number of nurses did not. The number of intensivists, registered nurses, nurse technicians specialized in intensive care, and respiratory therapists, necessary for every ten intensive care beds, was not enough for any of these professional categories. A complete team of critical care specialists was available for 10% of intensive care unit beds in Brazil. CONCLUSION: There is a shortage of professionals for intensive care unit, as we demonstrated for Brazil. Intensive care physical resources to be efficiently used require extremely specialized human resources; therefore, planning human resources is just as crucial as planning physical and structural resources.

Uma análise de custo-efetividade de propofol versus midazolam para sedação de pacientes adultos admitidos à unidade de terapia intensiva / A cost-effectiveness analysis of propofol versus midazolam for the sedation of adult patients admitted to the intensive care unit

RESUMO Objetivo: Construir um modelo de custo-efetividade para comparar o uso de propofol com o de midazolam em pacientes críticos adultos sob uso de ventilação mecânica. Métodos: Foi construído um modelo de árvore decisória para pacientes críticos submetidos à ventilação mecânica, o qual foi analisado sob a perspectiva do sistema privado de saúde no Brasil. O horizonte temporal foi o da internação na unidade de terapia intensiva. Os desfechos foram custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e custo-efetividade por hora de ventilação mecânica evitada. Foram obtidos os dados do modelo a partir de metanálise prévia. Assumiu-se que o custo da medicação estava incluído nos custos da unidade de terapia intensiva. Conduziram-se análises univariada e de sensibilidade probabilística. Resultados: Pacientes mecanicamente ventilados em uso de propofol tiveram diminuição de sua permanência na unidade de terapia intensiva e na duração da ventilação mecânica, respectivamente, em 47,97 horas e 21,65 horas. Com o uso de propofol, ocorreu redução média do custo de U$2.998,971 em comparação ao uso do midazolam. A custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e por hora de ventilação mecânica evitada foi dominante, respectivamente, em 94,40% e 80,8% do tempo. Conclusão: Ocorreu diminuição significante do custo associado ao uso de propofol, no que se refere à permanência na unidade de terapia intensiva e à duração da ventilação mecânica para pacientes críticos adultos.

ABSTRACT Objective: To build a cost-effectiveness model to compare the use of propofol versus midazolam in critically ill adult patients under mechanical ventilation. Methods: We built a decision tree model for critically ill patients submitted to mechanical ventilation and analyzed it from the Brazilian private health care system perspective. The time horizon was that of intensive care unit hospitalization. The outcomes were cost-effectiveness per hour of intensive care unit stay avoided and cost-effectiveness per hour of mechanical ventilation avoided. We retrieved data for the model from a previous meta-analysis. We assumed that the cost of medication was embedded in the intensive care unit cost. We conducted univariate and probabilistic sensitivity analyses. Results: Mechanically ventilated patients using propofol had their intensive care unit stay and the duration of mechanical ventilation decreased by 47.97 hours and 21.65 hours, respectively. There was an average cost reduction of US$ 2,998.971 for propofol when compared to midazolam. The cost-effectiveness per hour of intensive care unit stay and mechanical ventilation avoided were dominant 94.40% and 80.8% of the time, respectively. Conclusion: There was a significant reduction in costs associated with propofol use related to intensive care unit stay and duration of mechanical ventilation for critically ill adult patients.

Reduction of oxidative stress and inflammatory signaling in the commissural nucleus of the solitary tract (commNTS) and rostral ventrolateral medulla (RVLM) in treadmill trained rats.

Inflammation has been associated with cardiovascular diseases and the key point is the generation of reactive oxygen species (ROS). Exercise modulates medullary neurons involved in cardiovascular control. We investigated the effect of chronic exercise training (Tr) in treadmill running on gene expression (GE) of ROS and inflammation in commNTS and RVLM neurons. Male Wistar rats (N = 7/group) were submitted to training in a treadmill running (1 h/day, 5 days/wk/10 wks) or maintained sedentary (Sed). Superoxide dismutase (SOD), catalase (CAT), neuroglobin (Ngb), Cytoglobin (Ctb), NADPH oxidase (Nox), cicloxigenase-2 (Cox-2), and neuronal nitric oxide synthase (NOS1) gene expression were evaluated in commNTS and RVLM neurons by qPCR. In RVLM, Tr rats increased Ngb (1.285 ± 0.03 vs. 0.995 ± 0.06), Cygb (1.18 ± 0.02 vs.0.99 ± 0.06), SOD (1.426 ± 0.108 vs. 1.00 ± 0.08), CAT (1.34 ± 0.09 vs. 1.00 ± 0.08); and decreased Nox (0.55 ± 0.146 vs. 1.001 ± 0.08), Cox-2 (0.335 ± 0.05 vs. 1.245 ± 0.02), NOS1 (0.51 ± 0.08 vs. 1.08 ± 0.209) GE compared to Sed. In commNTS, Tr rats increased SOD (1.384 ± 0.13 vs. 0.897 ± 0.101), CAT GE (1.312 ± 0.126 vs. 0.891 ± 0.106) and decreased Cox-2 (0.052 ± 0.011 vs. 1.06 ± 0.207) and NOS1 (0.1550 ± 0.03559 vs. 1.122 ± 0.26) GE compared to Sed. Therefore, GE of proteins of the inflammatory process reduced while GE of antioxidant proteins increased in the commNTS and RVLM after training, suggesting a decrease in oxidative stress of downstream pathways mediated by nitric oxide.

A systematic review and meta-analysis of propofol versus midazolam sedation in adult intensive care (ICU) patients.

PURPOSE: Compare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam. METHODS: We searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE. We separated patients into two groups: acute surgical patients (hospitalization up to 24 h) and critically-ill patients (hospitalization over 24 h and whose articles mostly mix surgical, medical and trauma patients). RESULTS: Globally, propofol was associated with a reduced MV time of 4.46 h (MD: -4.46 [95% CI -7.51 to -1.42] p = 0.004, I2 = 63%, 6 studies) and extubation time of 7.95 h (MD: -7.95 [95% CI -9.86 to -6.03] p < 0.00001, I2 = 98%, 16 studies). Acute surgical patients sedation with propofol compared to midazolam was associated with a reduced ICU stay of 5.07 h (MD: -5.07 [95% CI -8.68 to -1.45] p = 0.006, I2 = 41%, 5 studies), MV time of 4.28 h (MD: -4.28; [95% CI -4.62 to -3.94] p < 0.0001, I2 = 0%, 3 studies), extubation time of 1.92 h (MD: -1.92; [95% CI -2.71 to -1.13] p = 0.00001, I2 = 89%, 9 studies). In critically-ill patients sedation with propofol compared to midazolam was associated with a reduced extubation time of 32.68 h (MD: -32.68 [95% CI -48.37 to -16.98] p = 0.0001, I2 = 97%, 9 studies). GRADE was very low for all outcomes. CONCLUSIONS: Sedation with propofol compared to midazolam is associated with improved clinical outcomes in ICU, with reduced ICU stay MV time and extubation time in acute surgical patients and reduced extubation time in critically-ill patients.

A cost-effectiveness analysis of propofol versus midazolam for the sedation of adult patients admitted to the intensive care unit. / Uma análise de custo-efetividade de propofol versus midazolam para sedação de pacientes adultos admitidos à unidade de terapia intensiva.

OBJECTIVE: To build a cost-effectiveness model to compare the use of propofol versus midazolam in critically ill adult patients under mechanical ventilation. METHODS: We built a decision tree model for critically ill patients submitted to mechanical ventilation and analyzed it from the Brazilian private health care system perspective. The time horizon was that of intensive care unit hospitalization. The outcomes were cost-effectiveness per hour of intensive care unit stay avoided and cost-effectiveness per hour of mechanical ventilation avoided. We retrieved data for the model from a previous meta-analysis. We assumed that the cost of medication was embedded in the intensive care unit cost. We conducted univariate and probabilistic sensitivity analyses. RESULTS: Mechanically ventilated patients using propofol had their intensive care unit stay and the duration of mechanical ventilation decreased by 47.97 hours and 21.65 hours, respectively. There was an average cost reduction of US$ 2,998.971 for propofol when compared to midazolam. The cost-effectiveness per hour of intensive care unit stay and mechanical ventilation avoided were dominant 94.40% and 80.8% of the time, respectively. CONCLUSION: There was a significant reduction in costs associated with propofol use related to intensive care unit stay and duration of mechanical ventilation for critically ill adult patients.

OBJETIVO: Construir um modelo de custo-efetividade para comparar o uso de propofol com o de midazolam em pacientes críticos adultos sob uso de ventilação mecânica. MÉTODOS: Foi construído um modelo de árvore decisória para pacientes críticos submetidos à ventilação mecânica, o qual foi analisado sob a perspectiva do sistema privado de saúde no Brasil. O horizonte temporal foi o da internação na unidade de terapia intensiva. Os desfechos foram custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e custo-efetividade por hora de ventilação mecânica evitada. Foram obtidos os dados do modelo a partir de metanálise prévia. Assumiu-se que o custo da medicação estava incluído nos custos da unidade de terapia intensiva. Conduziram-se análises univariada e de sensibilidade probabilística. RESULTADOS: Pacientes mecanicamente ventilados em uso de propofol tiveram diminuição de sua permanência na unidade de terapia intensiva e na duração da ventilação mecânica, respectivamente, em 47,97 horas e 21,65 horas. Com o uso de propofol, ocorreu redução média do custo de U$2.998,971 em comparação ao uso do midazolam. A custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e por hora de ventilação mecânica evitada foi dominante, respectivamente, em 94,40% e 80,8% do tempo. CONCLUSÃO: Ocorreu diminuição significante do custo associado ao uso de propofol, no que se refere à permanência na unidade de terapia intensiva e à duração da ventilação mecânica para pacientes críticos adultos.

Nutrition Therapy Cost-Effectiveness Model Indicating How Nutrition May Contribute to the Efficiency and Financial Sustainability of the Health Systems.

BACKGROUND: Malnutrition is highly prevalent in hospitalized patients but seldom recognized and treated. Malnutrition poses several adverse events, such as increased infection rates, length of hospital stay, and mortality, as well as costs. Early nutrition interventions have been shown to decrease the associated malnutrition burdens, leading to relevant savings. Thus, this study aims to evaluate the cost-effectiveness of nutrition therapy, including oral supplements to at-risk or malnourished adult inpatients admitted to the Brazilian Public System (SUS) hospitals. METHOD: A cost-effectiveness model, encompassing a 1-year period and regarding total costs, length of hospital stay, readmissions, and mortality related to malnutrition, was developed, having the provision of early nutrition therapy as the intervention variable. The number of avoided hospitalization days, prevented hospital readmissions, and prevented deaths defined the effectiveness of the model. All the costs were estimated based on the SUS database. RESULTS: Early nutrition therapy provided to all at-risk or malnourished patients would represent cost-effectiveness of US $92.24, US $544.59, US $1848.12, and US $3698.92, for each day of hospitalization avoided, for additional patients having access to hospitalization, for preventing readmission, and for prevented death, respectively. The highest impact on savings was represented by the mean reduction in the length of hospital stay. CONCLUSION: Early oral nutrition intervention for patients malnourished or at risk of malnutrition resulted in overall reduced hospital costs. These findings provide a rationale to tackle the implementation of educational programs focusing on the care of inpatients with malnutrition or its risk.

Who is going to turn on the ventilators? / Quem vai ligar os ventiladores?

ABSTRACT Objective To analyze the COVID-19 pandemic in Brazil, a continental-sized country, considered as an emerging economy but with several regional nuances, focusing on the availability of human resources, especially for intensive care units. Methods The database of the National Registry of Health Facilities was accessed. Healthcare professionals in the care of COVID-19 were georeferenced. We correlated the number of professionals with the parameters used by the World Health Organization. According to the Brazilian Intensive Care Medicine Association, we correlated the data for adult intensive care unit beds in each state with the number of professionals for each ten intensive care unit beds. The number of professionals, beds, and cases were then organized by state. Results The number of physicians per 100 thousand inhabitants followed the World Health Organization recommendations; however, the number of nurses did not. The number of intensivists, registered nurses, nurse technicians specialized in intensive care, and respiratory therapists, necessary for every ten intensive care beds, was not enough for any of these professional categories. A complete team of critical care specialists was available for 10% of intensive care unit beds in Brazil. Conclusion There is a shortage of professionals for intensive care unit, as we demonstrated for Brazil. Intensive care physical resources to be efficiently used require extremely specialized human resources; therefore, planning human resources is just as crucial as planning physical and structural resources.

RESUMO Objetivo Analisar a pandemia da COVID-19 no Brasil, um país de dimensões continentais, considerado uma economia emergente, mas com inúmeras diferenças regionais, abordando a disponibilidade de recursos humanos, especialmente para unidades de terapia intensiva. Métodos Foi acessado o banco de dados do Cadastro Nacional de Estabelecimentos de Saúde. Os profissionais de saúde que atuavam nos cuidados para COVID-19 foram georreferenciados. O número de profissionais foi correlacionado com os parâmetros utilizados pela Organização Mundial da Saúde. De acordo com a Associação de Medicina Intensiva Brasileira, correlacionaram-se os dados de leitos de terapia intensiva adulta em cada unidade federativa com o número de profissionais para cada dez leitos de terapia intensiva. Os números de profissionais, leitos e casos foram, então, organizados por unidade federativa. Resultados O número de médicos por 100 mil habitantes seguiu as recomendações da Organização Mundial da Saúde; mas não o número de enfermeiras. O número de intensivistas, enfermeiros, técnicos de enfermagem especializados em terapia intensiva e fisioterapeutas respiratórios, necessário a cada dez leitos de terapia intensiva, não foi suficiente para nenhuma dessas categorias profissionais. Uma equipe completa desses especialistas esteve disponível para 10% dos leitos de terapia intensiva do Brasil. Conclusão Há carência de profissionais para unidade de terapia intensiva, como demonstrado no Brasil. Os recursos físicos da terapia intensiva, para serem usados de forma eficiente, precisam de recursos humanos extremamente especializados; portanto, o planejamento de recursos humanos é tão crucial quanto o planejamento de recursos físicos e estruturais.

Acute renal denervation normalizes aortic function and decreases blood pressure in spontaneously hypertensive rats.

Mechanisms involved in the acute responses to renal denervation (RDN) have yet to be fully understood. We assessed urinary volume, autonomic control and aorta vascular reactivity after acute RDN. Male normotensive Wistar rats and spontaneously hypertensive rats (SHR) were divided into normotensive + RDN (ND) or sham surgery (NS), and hypertensive + RDN (HD) or sham surgery (HS). Metabolic parameters and hemodynamic measurements were recorded 72h and 4 days after intervention, respectively. Aortic rings were studied 7 days post RDN in an isometric myograph. Concentration-response curves to phenylephrine, sodium nitroprusside and acetylcholine (10-10-10-5 M) were performed. Two-way ANOVA was used for group comparisons and differences reported when p < 0.05. Results are presented as mean ± SEM. Urinary volume was 112% higher in HD vs. HS (HS = 14.94 ± 2.5 mL; HD = 31.69 ± 2.2 mL) and remained unchanged in normotensive rats. Systolic BP was lower in HD rats (HS = 201 ± 12 vs. HD = 172 ± 3 mmHg) without changes in normotensive group. HD group showed increased HF and LF modulation (HS = 5.8 ± 0.7 ms2 vs. HD = 13.4 ± 1.4 ms2; HS = 3.5 ± 0.7 ms2 vs. HD = 10.5 ± 1.7 ms2, respectively). RDN normalized vascular reactivity in HD rats and increased phenylephrine response in ND rats. Acute fall in BP induced by RDN is associated with increased urinary volume, which in turn may also have contributed to functional changes of the aorta.