Aldemar Araújo Castro

Colony-Stimulating Factors for Chemotherapy-Induced Febrile Neutropenia: A Meta-Analysis of Randomized Controlled Trials

PURPOSE Current treatment for febrile neutropenia (FN) includes hospitalization for evaluation, empiric broad-spectrum antibiotics, and other supportive care. Clinical trials have reported conflicting results when studying whether the colony-stimulating factors (CSFs) improve outcomes in patients with FN. This Cochrane Collaboration review was undertaken to further evaluate the safety and efficacy of the CSFs in patients with FN. METHODS An exhaustive literature search was undertaken including major electronic databases (CANCERLIT, EMBASE, LILACS, MEDLINE, SCI, and the Cochrane Controlled Trials Register). All randomized controlled trials that compare CSFs plus antibiotics versus antibiotics alone for the treatment of established FN in adults and children were sought. A meta-analysis of the selected studies was performed. RESULTS More than 8,000 references were screened, with 13 studies meeting eligibility criteria for inclusion. The overall mortality was not influenced significantly by the use of CSF (odds ratio [OR] = 0.68; 95% CI, 0.43 to 1.08; P = .1). A marginally significant result was obtained for the use of CSF in reducing infection-related mortality (OR = 0.51; 95% CI, 0.26 to 1.00; P = .05). Patients treated with CSFs had a shorter length of hospitalization (hazard ratio [HR] = 0.63; 95% CI, 0.49 to 0.82; P = .0006) and a shorter time to neutrophil recovery (HR = 0.32; 95% CI, 0.23 to 0.46; P < .00001). CONCLUSION The use of the CSFs in patients with established FN caused by cancer chemotherapy reduces the amount of time spent in hospital and the neutrophil recovery period. The possible influence of the CSFs on infection-related mortality requires further investigation.

Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta‐analysis

Background  There is little agreement on prophylactic use of drains in anastomoses in elective colorectal surgery despite many randomized clinical trials. Once anastomotic leakage occurs it is generally agreed that drains should be used for therapeutic purposes. However, on prophylactic use no such agreement exists.

Clinical Value of Preoperative Mechanical Bowel Cleansing in Elective Colorectal Surgery: A Systematic Review

AbstractPURPOSE: This study was designed to establish scientific evidence for and clinical results of preoperative mechanical bowel cleansing before elective colorectal surgery. METHODS: Systematic literature searches in electronic databases, conference proceedings, and hand searches of reference lists of previously retrieved literature without any language restrictions were used. Only randomized trials were included. A quality assessment of each retrieved trial was performed. Outcome measures were surgical infections, mortality, and anastomotic dehiscence. Meta-analyses of the selected trials were performed using the Peto odds ratio. RESULTS: The results of each outcome were as follows. 1) Overall anastomotic leakage —six studies: 5.5 percent with cleansing compared with 2.9 percent without cleansing; odds ratio 1.94, 95 percent confidence interval: 1.09 to 3.43 (P = 0.02). 2) Peritonitis— three studies: 5.1 percent with cleansing compared with 2.8 percent without cleansing; odds ratio 1.90, 95 percent confidence interval: 0.78 to 4.64 (not significant). 3) Wound infection —six studies: 7.4 percent with cleansing compared with 5.7 percent without cleansing; odds ratio 1.34, 95 percent confidence interval: 0.85 to 2.13 (not significant). CONCLUSIONS: There is no evidence in the literature for beneficial effects from the use of bowel cleansing before elective colorectal surgery. Cleansing seems to be associated with an increased risk of more anastomotic dehiscence. Further studies stratifying between rectal and colonic surgery are warranted.

Hormonal cryptorchidism therapy: systematic review with metanalysis of randomized clinical trials

The importance of cryptorchidism treatment concerns the possibility of diminishing risk of malignant degeneration and improving fertility. Success rates of hormonal treatment vary: 0–55%with human chorionic gonadotropin (hCG) and 9–78% with gonadotropin-releasing hormone (GnRH). Due to uncertainties regarding the effectiveness of this treatment, a systematic review and meta-analysis of randomized controlled trials (RCTs) on hormonal cryptorchidism treatment was done using the methodology of Cochrane Collaboration. Two studies compared hCG with GnRH, with a testicular descent rate of 25% vs. 18%, respectively. Nine trials compared intranasal LHRH with placebo, with complete testicular descent rates of 19% vs. 5%. Two other studies comparing doses and administration intervals could not be pooled together due to heterogeneity. With the information analyzed until the present, the evidence for the use of hCG vs. GnRH shows advantages for hCG, and this review also shows that there is evidence that luteinizing hormone releasing hormone (LHRH) is more effective than placebo. But because this evidence is based on few trials, with small sample sizes and moderated risk of bias, this treatment cannot be recommended for everyone, and there is no evidence that supports hCG’s use in larger doses and larger intervals. Results from this systematic review are important for developing better RCTs that may decrease the uncertainty of cryptorchidism treatment.

Optimal search strategy for clinical trials in the Latin American and Caribbean Health Science Literature Database (LILACS)

OBJECTIVE To define and disseminate the optimal search strategy for clinical trials in the Latin American and Caribbean Health Science Literature (LILACS). This strategy was elaborated based on the optimal search strategy for MEDLINE recommended by Cochrane Collaboration for the identification of clinical trials in electronic databases. DESIGN Technical information. SETTING Clinical Trials and Meta-Analysis Unit, Federal University of São Paulo, in conjunction with the Brazilian Cochrane Center, São Paulo, Brazil. (http://www.epm.br/cochrane). DATA LILACS/CD-ROM (Latin American and Caribbean Health Science Information Database), 27th edition, January 1997, edited by BIREME (Latin American and Caribbean Health Science Information Center). LILACS Indexes 670 journals in the region, with abstracts in English, Portuguese or Spanish; only 41 overlap in the MEDLINE-EMBASE. Of the 168,902 citations since 1982, 104,016 are in human trials, and 38,261 citations are potentiality clinical trials. Search strategy was elaborated combining headings with text word in three languages, adapting the interface of the LILACS. We will be working by locating clinical trials in LILACS for Cochrane Controlled Trials Database. This effort is being coordinated by the Brazilian Cochrane Center.

Atenção integral ao portador de pé diabético

Sao apresentadas, nessa separata, as principais orientacoes sobre a atencao as complicacoes do pe diabetico. A neuropatia, com suas diversas apresentacoes que acometem os membros inferiores dos diabeticos, as lesoes da doenca arterial obstrutiva periferica (DAOP), as multiplas apresentacoes da infeccao do pe diabetico, e, principalmente, os cuidados preventivos que possam impedir o estabelecimento ou a evolucao dessas complicacoes sao tratados de forma sistematica e simplificada, visando a atencao integral desses doentes. Especial cuidado e dado as orientacoes diferenciadas para os diversos niveis de atencao nos servicos publicos de saude, porta de entrada virtual de 80% dos infelizes portadores dessa complicacao. Sao aqui apresentados modelos de atencao e sugeridos protocolos que podem contribuir para a efetiva reducao do numero de amputacoes, internacoes e obitos de diabeticos com complicacoes nos membros inferiores.

Fatores predisponentes para amputação de membro inferior em pacientes diabéticos internados com pés ulcerados no estado de Sergipe

OBJETIVO: Determinar os fatores predisponentes para a amputacao de membros inferiores nos doentes internados com diabetes melito e ulceras nos pes. METODOS: Foram acompanhados os pacientes diabeticos com ulceras nos pes internados no periodo de 6 meses e analisadas as amputacoes nesses doentes em relacao a idade, sexo, amputacao previa, numero de ulceracoes, tempo de diagnostico do diabete, tempo de ulceracao, tempo medio de internacao, gravidade das lesoes, presenca de pulso. RESULTADOS: Verificou-se que 55% (44/80) dos doentes evoluiram para algum tipo de amputacao de membros inferiores; a mediana das idades foi de 61 anos, porem a ocorrencia de amputacao foi significativamente maior na faixa etaria dos 60 aos 90 anos (P = 0,03). Nao se observou uma variacao significativa da mediana do tempo de diagnostico do diabetes, do tempo de ulceracao e do tempo medio de internacao em relacao ao grupo de pacientes que foram amputados. Entretanto, as lesoes mais graves, quando avaliadas pela classificacao de Wagner (P <0,001) e pela ausencia de deteccao dos dois pulsos distais (P <0,001) dos membros inferiores, revelaram-se bastante significativas com relacao ao desfecho de amputacao. CONCLUSAO: Foram considerados fatores predisponentes para a ocorrencia de amputacao nesses doentes a gravidade das lesoes, a ausencia de pulsos e as idades acima de 60 anos.

Diet plus insulin compared to diet alone in the treatment of gestational diabetes mellitus: a systematic review

Fetuses of mothers with gestational diabetes mellitus are at increased risk to develop perinatal complications mainly due to macrosomia. However, in view of the marked heterogeneity of this disease, it seems difficult to set guidelines for diagnosis and treatment. This complicates the choice of assigning patients either to diet or to insulin therapy. Also of concern is how much benefit could be expected from insulin therapy in preventing fetal complications in these patients. In a systematic review of the literature assessing the efficacy of insulin in preventing macrosomia in fetuses of mothers with gestational diabetes, we found six randomized controlled trials comparing diet alone to diet plus insulin. The studies included a total of 1281 patients (644 in the diet plus insulin group and 637 in the diet group), with marked differences among trials concerning diagnostic criteria, randomization process and treatment goals. Meta-analysis of the data resulted in a risk difference of -0.098 (95%CI: -0.168 to -0.028), and a number-necessary-to-treat of 11 (95%CI: 6 to 36), which means that it is necessary to treat 11 patients with insulin to prevent one case of macrosomia. This indicates a potential benefit of insulin, but not significantly enough to set treatment guidelines. Because of the heterogeneous evidence available in the literature about this matter, we conclude that larger trials addressing the efficacy of these two therapeutic modalities in preventing macrosomia are warranted.

Systematic reviews on leptospirosis

OBJECTIVES To find the existing clinical evidence on interventions for leptospirosis. The objective is to evaluate the effectiveness and safety of any intervention on leptospirosis through systematic reviews of randomized controlled trials (RCTs). DATA SOURCE The sources of studies used (where there were no limitations concerning language, date, or other restrictions) were: EMBASE, LILACS, MEDLINE, the Cochrane Controlled Clinical Trials Database, and the Cochrane Hepato-Biliary Group Randomized Trials register. SELECTION OF STUDIES TYPE OF STUDY All systematic reviews of randomized controlled trials. PARTICIPANTS patients with clinical and/or laboratorial diagnosis of leptospirosis, and subjects potencially exposed to leptospirosis as defined by the authors INTERVENTIONS any intervention for leptospirosis (as antibiotics or vaccines for prevention or treatment). DATA COLLECTION The assessment will be independently made by the reviewers and cross-checked. The external validity was assessed by analysis of: studies, interventions, and outcomes. DATA SYNTHESIS Located 163 studies using the search strategy described above, at the electronic databases above. Only 2 hits were selected, which are protocols of systematic reviews of Cochrane Collaboration, and not full reviews. One of the protocols evaluates antibiotics for treatment, and the other evaluates antibiotics for prevention of leptospirosis. CONCLUSIONS There were not complete systematic reviews on interventions for leptospirosis. Any interventions for leptospirosis, such as prevention and treatment remains unclear for guidelines and practice.

Intermittent diazepam and continuous phenobarbital to treat recurrence of febrile seizures: a systematic review with meta-analysis

UNLABELLED Convulsions triggered by fever are the most common type of seizures in childhood, and 20% to 30% of them have recurrence. The prophylactic treatment is still controversial, so we performed a systematic review to find out the effectiveness of continuous phenobarbital and intermittent diazepam compared to placebo for febrile seizure recurrence. METHOD Only randomized, double-blind, placebo-controlled trials were analyzed. The recurrence of febrile seizure was assessed for each drug. RESULTS Ten eligible clinical trials were included. Febrile seizure recurrence was smaller in children treated with diazepam or phenobarbital than in placebo group. Prophylaxis with either phenobarbital or diazepam reduces recurrences of febrile seizures. The studies were clinical, methodological, and statistically heterogeneous. CONCLUSION The effectiveness of phenobarbital and diazepam could not be demonstrated because clinical trials were heterogeneous, and the recommendation for treatment recurrence should rely upon the experience of the assistant physician yet.