Joana Alarcão

Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis

Objective To systematically review longitudinal studies evaluating use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and risk of pneumonia. Design Systematic review and meta-analysis. Data sources Medline through PubMed, Web of Science with conference proceedings (inception to June 2011), and US Food and Drug Administration website (June 2011). Systematic reviews and references of retrieved articles were also searched. Study selection Two reviewers independently selected randomised controlled trials and cohort and case-control studies evaluating the use of ACE inhibitors or ARBs and risk of pneumonia and retrieved characteristics of the studies and data estimates. Data synthesis The primary outcome was incidence of pneumonia and the secondary outcome was pneumonia related mortality. Subgroup analyses were carried according to baseline morbidities (stroke, heart failure, and chronic kidney disease) and patients’ characteristics (Asian and non-Asian). Pooled estimates of odds ratios and 95% confidence intervals were derived by random effects meta-analysis. Adjusted frequentist indirect comparisons between ACE inhibitors and ARBs were estimated and combined with direct evidence whenever available. Heterogeneity was assessed using the I2 test. Results 37 eligible studies were included. ACE inhibitors were associated with a significantly reduced risk of pneumonia compared with control treatment (19 studies: odds ratio 0.66, 95% confidence interval 0.55 to 0.80; I2=79%) and ARBs (combined direct and indirect odds ratio estimate 0.69, 0.56 to 0.85). In patients with stroke, the risk of pneumonia was also lower in those treated with ACE inhibitors compared with control treatment (odds ratio 0.46, 0.34 to 0.62) and ARBs (0.42, 0.22 to 0.80). ACE inhibitors were associated with a significantly reduced risk of pneumonia among Asian patients (0.43, 0.34 to 0.54) compared with non-Asian patients (0.82, 0.67 to 1.00; P<0.001). Compared with control treatments, both ACE inhibitors (seven studies: odds ratio 0.73, 0.58 to 0.92; I2=51%) and ARBs (one randomised controlled trial: 0.63, 0.40 to 1.00) were associated with a decrease in pneumonia related mortality, without differences between interventions. Conclusions The best evidence available points towards a putative protective role of ACE inhibitors but not ARBs in risk of pneumonia. Patient populations that may benefit most are those with previous stroke and Asian patients. ACE inhibitors were also associated with a decrease in pneumonia related mortality, but the data lacked strength.

Clinical trials in palliative care: a systematic review of their methodological characteristics and of the quality of their reporting

BackgroundOver the past decades there has been a significant increase in the number of published clinical trials in palliative care. However, empirical evidence suggests that there are methodological problems in the design and conduct of studies, which raises questions about the validity and generalisability of the results and of the strength of the available evidence. We sought to evaluate the methodological characteristics and assess the quality of reporting of clinical trials in palliative care.MethodsWe performed a systematic review of published clinical trials assessing therapeutic interventions in palliative care. Trials were identified using MEDLINE (from its inception to February 2015). We assessed methodological characteristics and describe the quality of reporting using the Cochrane Risk of Bias tool.ResultsWe retrieved 107 studies. The most common medical field studied was oncology, and 43.9% of trials evaluated pharmacological interventions. Symptom control and physical dimensions (e.g. intervention on pain, breathlessness, nausea) were the palliative care-specific issues most studied. We found under-reporting of key information in particular on random sequence generation, allocation concealment, and blinding.ConclusionsWhile the number of clinical trials in palliative care has increased over time, methodological quality remains suboptimal. This compromises the quality of studies. Therefore, a greater effort is needed to enable the appropriate performance of future studies and increase the robustness of evidence-based medicine in this important field.

Carga e custo da fibrilhação auricular em Portugal

INTRODUCTION AND OBJECTIVES Atrial fibrillation is the most prevalent sustained arrhythmia. This paper estimates the burden and cost of illness attributable to atrial fibrillation in Portugal based on demographic and health statistics. METHODS Mortality data by cause of death came from the European Detailed Mortality Database of the World Health Organization (WHO). Hospital data were taken from the Portuguese diagnosis-related groups database. The burden of disease was measured using DALYs (disability-adjusted life years), a metric adopted by the WHO. Costs studied included resource use and lost productivity. The burden and cost of illness are those attributable to atrial fibrillation and its main complication, ischemic stroke. RESULTS In Portugal, 4070 deaths were attributable to atrial fibrillation in 2010, corresponding to 3.8% of all deaths. In total, the burden of disease attributable to atrial fibrillation was estimated at 23,084 DALYs: 10,521 resulting from premature deaths (1.7% of the total DALYs due to death in 2010 in Portugal), and 12,563 resulting from disability. The total estimated direct costs attributable to atrial fibrillation at 2013 prices were €115 million: €34 million for inpatient care and €81 million for outpatient care. Indirect costs resulting from lost production due to disability were estimated at €25 million. CONCLUSIONS Atrial fibrillation has an important social impact in Portugal due to its associated mortality and morbidity, and was responsible in 2013 for a total cost of €140 million, about 0.08% of gross domestic product.

Cost-Effectiveness Of Idelalisib In Combination With Rituximab For The Treatment Of Relapsed/Refractory Chronic Lymphocytic Leukemia (Cll) In Portugal.

TREATMENT OF RELAPSED/REFRACTORY CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) IN PORTUGAL Gouveia M1, Silva MG2, Alarcao J3, Fiorentino F 3, Carda J 4, Costa R 5, Mariz JM 6, Raposo J 7, Costa J 7, Borges M 8 1Catolica Lisbon School of Business and Economics, Lisbon, Portugal, 2Instituto Portugues Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal, 3Center for Evidence Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 4Centro Hospitalar Universitario de Coimbra, Coimbra, Portugal, 5Hospital Garcia de Orta, Almada, Portugal, 6Instituto Portugues de Oncologia do Porto Francisco Gentil, Oporto, Portugal, 7Centro Hospitalar Lisboa Norte, Lisbon, Portugal, 8Institute of Molecular Medicine, Lisbon, Portugal

Cost and Burden of Non-Small Cell Lung Cancer's in Portugal.

Borges M1,2,3, Gouveia M4, Alarcão J1, Sousa R1, Teixeira E5, Barata F6, Laranjeira E1, Lopes F1, Parente B7, Pinheiro L1, Vaz-Carneiro A1, Costa J1,2 1 Center for Evidence Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal 2 Clinical Pharmacology Unit, Institute of Molecular Medicine, Lisbon, Portugal 3 Centro Hospitalar Lisboa Central, Lisbon Portugal 4 Católica Lisbon School of Business and Economics, Lisbon, Portugal 5 Centro Hospitalar Lisboa Norte, Lisbon, Portugal 6 Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal 7 Hospital CUF Porto, Porto, Portugal

1047PNON-SMALL CELL LUNG CANCER'S BURDEN OF DISEASE IN PORTUGAL

ABSTRACT Aim: To estimate the Disability Adjusted Life-Years (DALY) associated with Non-Small Cell Lung Cancer (NSCLC) during 2012 in Portugal. Methods: DALY combines Years of Life Lost (YLL) due to premature mortality and Years Lost due to Disability (YLD). The YLL correspond to the number of deaths multiplied by the present valued socially weighted life expectancy at the age at which death occurs using a standardized life table. For the distribution of lung cancer mortality by age and gender the WHO European mortality database was used. To estimate the proportion of these deaths that is due to NSCLC we applied a ratio (85.7%) based on data from the Diagnosis-Related Groups database. To estimate YLD in a particular time period, the number of incident cases in that period is multiplied by the average duration of the disease on a scale ranging from 0 (perfect health) to 1 (death). NSCLC incidence was estimated from Portuguese National and Regional Cancer Registry. The average duration of the disease was derived from the survival curves published by the International Association for the Study of Lung Cancer. Disability weights were taken from the Disability Weights for Diseases in the Netherlands Study. Results: A total of 3,180 deaths in Portugal in 2012 were caused by NSCLC, which corresponds to 2.0% of the total deaths in Portugal. The DALYs resulting from premature deaths caused by NSCLC in 2012 totaled 25,071 representing 4.5% of years lost generated by all deaths in the country. For 2012 it is estimated that 3,236 life years were lost due to disability. The total disease burden attributable to NSCLC is thus estimated at 28,307 DALY. Conclusions: NSCLC is an important cause of disease burden in Portugal and should receive adequate attention from policy makers. Disclosure: M.F. Borges: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; M. Gouveia: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; J. Alarcao: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; R. Sousa: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; F. Barata: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; E. Laranjeira: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; F. Lopes: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; B. Parente: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; L. Pinheiro: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; M.E. Teixeira: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; A. Vaz-Carneiro: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study; J. Costa: The Faculty of Medicine, University of Lisbon received an unrestricted grant from Laboratorios Pfizer Lda. to conduct this study.