Carlos Podalirio Borges de Almeida

Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies

Background: Persistent pain after breast cancer surgery affects up to 60% of patients. Early identification of those at higher risk could help inform optimal management. We conducted a systematic review and meta-analysis of observational studies to explore factors associated with persistent pain among women who have undergone surgery for breast cancer. Methods: We searched the MEDLINE, Embase, CINAHL and PsycINFO databases from inception to Mar. 12, 2015, to identify cohort or case–control studies that explored the association between risk factors and persistent pain (lasting ≥ 2 mo) after breast cancer surgery. We pooled estimates of association using random-effects models, when possible, for all independent variables reported by more than 1 study. We reported relative measures of association as pooled odds ratios (ORs) and absolute measures of association as the absolute risk increase. Results: Thirty studies, involving a total of 19 813 patients, reported the association of 77 independent variables with persistent pain. High-quality evidence showed increased odds of persistent pain with younger age (OR for every 10-yr decrement 1.36, 95% confidence interval [CI] 1.24–1.48), radiotherapy (OR 1.35, 95% CI 1.16–1.57), axillary lymph node dissection (OR 2.41, 95% CI 1.73–3.35) and greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI 1.03–1.30). Moderate-quality evidence suggested an association with the presence of preoperative pain (OR 1.29, 95% CI 1.01–1.64). Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these ORs ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection). High-quality evidence showed no association with body mass index, type of breast surgery, chemotherapy or endocrine therapy. Interpretation: Development of persistent pain after breast cancer surgery was associated with younger age, radiotherapy, axillary lymph node dissection, greater acute postoperative pain and preoperative pain. Axillary lymph node dissection provides the only high-yield target for a modifiable risk factor to prevent the development of persistent pain after breast cancer surgery.

Health care seeking behavior and patient delay in tuberculosis diagnosis

Atrasos no diagnostico de casos de tuberculose sao os principais fatores que impedem o controle da doenca. Os objetivos deste estudo foram descrever a trajetoria de pacientes com tuberculose, avaliando a demora do paciente e o numero de unidades de saude visitadas antes do inicio do tratamento. Estudo transversal foi conduzido com pacientes com idade ≥ 18 anos e com diagnostico de tuberculose pulmonar, que responderam a um questionario. A media de idade dos pacientes foi de 40,4 ± 16,1. Foi encontrada uma mediana de 20 dias no atraso dos pacientes. Tambem foi verificado que 44,8% relataram incorretamente o modo de transmissao da tuberculose. Alem disso, o local do primeiro atendimento para 37,3% dos pacientes foi uma emergencia de hospital publico. Encontrou-se uma mediana de 20 dias no atraso dos pacientes ate o diagnostico da tuberculose; os fatores protetores associados a este atraso na analise multivariada foram perda de peso e ter procurado tratamento por causa do primeiro sintoma.Delays in diagnosis of TB cases are major impeding factors in the control of TB. The objectives of this study were to describe the health care seeking behavior of TB patients, assessing patient delay and the number of health care facilities visited before the start of TB treatment. A cross-sectional study was carried out with adult patients with pulmonary TB presenting to two TB facilities to start treatment. We found a median patient delay of 20 days. The factors associated negatively with patient delay in multivariate analysis were weight loss, and have sought treatment because of the first symptom. We also demonstrated that 44.8% of patients incorrectly reported the mode of transmission of TB. In addition, the local of first attendance was an emergency room of public hospitals in 37.3% of patients. We demonstrated that the median patient delay in TB diagnosis in two TB services in a region with a high prevalence of TB was 20 days, and the protective factors associated with this delay in multivariate analysis were weight loss, and have sought treatment because of the first symptom.

Pulmonary tuberculosis and lung cancer: simultaneous and sequential occurrence

OBJECTIVE: Lung cancer (LC) is the leading cause of cancer-related death and represents a major public health problem worldwide. Another major cause of morbidity and mortality, especially in developing countries, is tuberculosis. The simultaneous or sequential occurrence of pulmonary tuberculosis and LC in the same patient has been reported in various case series and case-control studies. The objective of this study was to describe the characteristics of patients developing tuberculosis and LC, either simultaneously or sequentially. METHODS: This was a cross-sectional study based on the review of medical charts. RESULTS: The study involved 24 patients diagnosed with tuberculosis and LC between 2009 and 2012. The diagnoses of tuberculosis and LC occurred simultaneously in 10 patients, whereas tuberculosis was diagnosed prior to LC in 14. The median time between the two diagnoses was 5 years (interquartile range: 1-30 years). Fourteen patients (58.3%) were male, 20 (83.3%) were White, and 22 (91.7%) were smokers or former smokers. The most common histological type was adenocarcinoma, identified in 14 cases (58.3%), followed by epidermoid carcinoma, identified in 6 (25.0%). Seven patients (29.2%) presented with distant metastases at diagnosis; of those 7 patients, 5 (71%) were diagnosed with LC and tuberculosis simultaneously. CONCLUSIONS: In the present study, most of the patients with tuberculosis and LC were smokers or former smokers, and tuberculosis was diagnosed either before or simultaneously with LC. Non-small cell lung cancer, especially adenocarcinoma, was the most common histological type.

Predictors of in-hospital mortality among patients with pulmonary tuberculosis: a protocol of systematic review and meta-analysis of observational studies

Introduction Tuberculosis (TB) continues to be a major public health issue worldwide, with 1.4 million deaths occurring annually. There is uncertainty regarding which factors are associated with in-hospital mortality among patients with pulmonary TB. This knowledge gap complicates efforts to identify and improve the management of those individuals with TB at greatest risk of death. The aim of this systematic review and meta-analysis is to establish predictors of in-hospital mortality among patients with pulmonary TB to enhance the evidence base for public policy. Methods and analysis Studies will be identified by a MEDLINE, EMBASE and Global Health search. Eligible studies will be cohort and case–control studies that report predictors or risk factors for in-hospital mortality among patients with pulmonary TB and an adjusted analysis to explore factors associated with in-hospital mortality. We will use the Grading of Recommendations Assessment, Development and Evaluation approach to summarise the findings of some reported predictors. Teams of 2 reviewers will screen the titles and abstracts of all citations identified in our search, independently and in duplicate, extract data, and assess scientific quality using standardised forms quality assessment and tools tailored. We will pool all factors that were assessed for an association with mortality that were reported by >1 study, and presented the OR and the associated 95% CI. When studies provided the measure of association as a relative risk (RR), we will convert the RR to OR using the formula provided by Wang. For binary data, we will calculate a pooled OR, with an associated 95% CI. Ethics and dissemination This study is based on published data, and therefore ethical approval is not a requirement. Findings will be disseminated through publication in peer-reviewed journals and conference presentations at relevant conferences. Trial registration number CRD42015025755.

A utilização da noção de vulnerabilidade na produção de conhecimento sobre tuberculose: revisão integrativa

OBJECTIVE to identify how the notion of vulnerability is used in national and international scientific publications that address the problem of tuberculosis. METHOD an integrative review of literature published in the databases of the Biblioteca Virtual em Saúde, the United States National Library of Medicine and the Biblioteca Digital Brasileira de Teses e Dissertações, considering the descriptors Tuberculosis and Vulnerability in Portuguese and English. RESULTS we selected fifty-eight studies published between 1992 and February 2014, which resulted in three categories of analysis. CONCLUSION the link between tuberculosis and the notion of vulnerability has not been sufficiently consolidated in national and international literature. This creates an obstacle for the achievement of the epistemological transformations and pragmatic measures that are required to obtain better results from interventions in the field.

Predictors of In-Hospital Mortality among Patients with Pulmonary Tuberculosis: A Systematic Review and Meta-analysis

Background: There is uncertainty regarding which factors are associated with in-hospital mortality among patients with pulmonary TB (PTB). The aim of this systematic review and meta-analysis is to identify predictors of in-hospital mortality among patients with PTB. Methods: We searched MEDLINE, EMBASE, and Global Health, for cohort and case-control studies that reported risk factors for in-hospital mortality in PTB. We pooled all factors that were assessed for an association, and presented relative associations as pooled odds ratios (ORs). Results: We identified 2,969 records, of which we retrieved 51 in full text; 11 cohort studies that evaluated 5,468 patients proved eligible. Moderate quality evidence suggested an association with co-morbid malignancy and in-hospital mortality (OR 1.85; 95% CI 1.01–3.40). Low quality evidence showed no association with positive sputum smear (OR 0.99; 95% CI 0.40–2.48), or male sex (OR 1.09, 95% CI 0.84–1.41), and very low quality evidence showed no association with diabetes mellitus (OR 1.31, 95% IC 0.38–4.46), and previous TB infection (OR 2.66, 95% CI 0.48–14.87). Conclusion: Co-morbid malignancy was associated with increased risk of in-hospital death among pulmonary TB patients. There is insufficient evidence to confirm positive sputum smear, male sex, diabetes mellitus, and previous TB infection as predictors of in-hospital mortality in TB patients.

Impact of introduction of Xpert MTB/RIF test on tuberculosis (TB) diagnosis in a city with high TB incidence in Brazil

Background Xpert MTB/RIF is increasingly used in many countries as the initial diagnostic test for tuberculosis (TB). Few studies have evaluated the effect of Xpert on TB diagnosis under programmatic conditions in Brazil. The aim of the present study was to evaluate the impact of introduction of Xpert MTB/RIF on TB diagnosis in a city with high TB incidence in Brazil. Methods We included patients evaluated with conventional diagnostic tests during one year before Xpert introduction (pre-Xpert group) and patients evaluated using Xpert during one year after the test introduction (post-Xpert group). Results 620 patients met the inclusion criteria (208 in the pre-Xpert group and 412 in the post-Xpert group) and were included in the analysis. The time until TB diagnosis was shorter in post-Xpert group (0.7 day, IQR: 0.5–1.0 day) than in pre-Xpert group (2.0 days, IQR: 2.0–2.0 days) (p<0.0001). Atypical disease characteristics, such as less weight loss, fever, dyspnea, night sweats, and hemoptysis; a negative sputum smear; a negative culture, and a chest X-ray atypical of TB were more common in post-Xpert group than in pre-Xpert group (p<0.0001 for all). Conclusions We found that the implementation of the Xpert MTB/RIF assay, under programmatic conditions, improve and facilitate TB diagnosis, especially in cases with atypical disease manifestations. These results are likely to be generalizable to settings with a similar high TB incidence.

Como minimizar vieses em revisões sistemáticas de estudos observacionais

Although systematic reviews have numerous advantages, they are vulnerable to biases that can mask the true results of the study and therefore should be interpreted with caution. This article aims at critically reviewing the literature about systematic reviews of observational studies, emphasizing the errors that can affect this type of study design and possible strategies to overcome these errors. This is an integrative literature review whose search was conducted in the databases States National Library of Medicine, Scientific Electronic Library Online and Google Scholar. The following descriptors were used: review, bias (epidemiology) and observational studies as the subject, including relevant books and documents which were consulted. Data collection was conducted between June and July 2016. The most known errors present in the design of systematic reviews were those related to the selection and publication. Although this type of study is subject to possible errors, preventive measures used during the planning of systematic reviews and even during and after their implementation can help ensure scientific rigor. This literature can serve as an important tool for the development and interpretation of systematic reviews of observational studies.

Caracterização de acidente vascular cerebral com enfoque em distúrbios da comunicação oral em pacientes de um hospital regional

Purpose To characterize patients with stroke and to establish the prevalence of oral communication disorders (CD) related by cerebrovascular accident (CVA) and the frequency of indication or request of speech therapy. Methods A retrospective cross-sectional study from the medical report forms of 95 patients hospitalized for stroke between June 2007 and June 2008 in a regional public hospital. Results Out of the 95 patients, 51 (53.7%) were male (mean age was 59.8 years old), 48 (59.3%) had a history of hypertension, 82 (86.3%) had ischaemic stroke and CD were present in 53 (55.8%) of patients. The mean hospital stay was 5 days. There was no significant relationship between the type of stroke and CD, or between the site of neurological damage due to stroke and the occurrence of CD. None of the subjects received an evaluation or speech-language therapy during hospitalization, and there were no referrals to healthcare after discharge. Conclusion More than 50% of individuals affected by stroke had oral communication disorders during the hospitalization. There was no any indication or request for speech therapy in this period, even after discharge. These findings indicate a probable failure to integrate with the speech therapy staff for the treatment of patients with neurological diseases. It is necessary to further evaluate whether this is due absence of speech therapists in the team or just healthcare professionals lacking knowledge about the possibilities of speech therapy along with disturbances in oral communication due to stroke.

[Using the notion of vulnerability in the production of knowledge about tuberculosis: integrative review].

OBJECTIVE to identify how the notion of vulnerability is used in national and international scientific publications that address the problem of tuberculosis. METHOD an integrative review of literature published in the databases of the Biblioteca Virtual em Saúde, the United States National Library of Medicine and the Biblioteca Digital Brasileira de Teses e Dissertações, considering the descriptors Tuberculosis and Vulnerability in Portuguese and English. RESULTS we selected fifty-eight studies published between 1992 and February 2014, which resulted in three categories of analysis. CONCLUSION the link between tuberculosis and the notion of vulnerability has not been sufficiently consolidated in national and international literature. This creates an obstacle for the achievement of the epistemological transformations and pragmatic measures that are required to obtain better results from interventions in the field.