Marcelo Fonseca

Efficacy of Clodronate, Pamidronate, and Zoledronate in Reducing Morbidity and Mortality in Cancer Patients With Bone Metastasis: A Meta-Analysis of Randomized Clinical Trials

BACKGROUND Complications from skeletal-related events (SREs) constitute a challenge in the care of patients with metastatic bone disease (MBD) that originated from any type of malignancy. OBJECTIVE The purpose of this article was to compare the efficacy of clodronate, pamidronate, and zoledronate with that of placebo in reducing morbidity and overall mortality in cancer patients with MBD. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched (from inception to January 2009) to retrieve randomized clinical trials that evaluated the bisphosphonates of interest. The search included articles published in English, French, Italian, Portugese, and Spanish. Patients with a definite (ie, biopsy-proven) diagnosis of MBD were included in the analysis. We extracted and combined data from studies that reported the number of patients with SREs and mortality data. A random-effects, meta-analytic model was applied in all calculations. The Jadad scale was used to assess the quality of study reporting. RESULTS The literature search identified 62 potential full-text studies; 44 of these studies were excluded and 18 were evaluated. The mean (SD) quality of reporting of the included studies was 57.8% (22.6%), or 2.89/5 (1.1/5). Each of the 3 drugs was found to be more effective than placebo in preventing all SREs in cancer patients with MBD. The relative risk of developing SREs was 0.70 (95% CI, 0.61-0.81; N = 1211) for zoledronate, 0.81 (95% CI, 0.73-0.91; N = 2251) for pamidronate, and 0.87 (95% CI, 0.75-1.00; N = 681) for clodronate. However, no clear advantage of one drug over the others was observed (CIs overlapped substantially). None of the bisphosphonates was more beneficial than placebo in reducing the number of deaths in the course of the trials (P = NS). CONCLUSION Clodronate, pamidronate, and zoled-ronate were associated with reductions in morbidity in cancer patients with MBD with regard to preventing SREs, but were not associated with a reduction in overall mortality.

Comparison between the Comfort and Hartwig sedation scales in pediatric patients undergoing mechanical lung ventilation

CONTEXT A high number of hospitalized children do not receive adequate sedation due to inadequate evaluation and use of such agents. With the increase in knowledge of sedation and analgesia in recent years, concern has also risen, such that it is now not acceptable that incorrect evaluations of the state of childrens pain and anxiety are made. OBJECTIVE A comparison between the Comfort and Hartwig sedation scales in pediatric patients undergoing mechanical lung ventilation. DESIGN Prospective cohort study. SETTING A pediatric intensive care unit with three beds at an urban teaching hospital. PATIENTS Thirty simultaneous and independent observations were conducted by specialists on 18 patients studied. DIAGNOSTIC TEST Comfort and Hartwig scales were applied, after 3 minutes of observation. MAIN MEASUREMENTS Agreement rate (kappa). RESULTS On the Comfort scale, the averages for adequately sedated, insufficiently sedated, and over-sedated were 20.28 (SD 2.78), 27.5 (SD 0.70), and 15.1 (SD 1.10), respectively, whereas on the Hartwig scale, the averages for adequately sedated, insufficiently sedated, and over-sedated were 16.35 (SD 0.77), 20.85 (SD 1.57), and 13.0 (SD 0.89), respectively. The observed agreement rate was 63% (p = 0.006) and the expected agreement rate was 44% with a Kappa coefficient of 0.345238 (z = 2.49). CONCLUSIONS In our study there was no statistically significant difference whether the more complex Comfort scale was applied (8 physiological and behavioral parameters) or the less complex Hartwig scale (5 behavioral parameters) was applied to assess the sedation of mechanically ventilated pediatric patients.

Estimated health and economic impact of quadrivalent HPV (types 6/11/16/18) vaccination in Brazil using a transmission dynamic model

BackgroundCervical cancer is the second most common cancer among women in Brazil. We examined the health and economic impacts of quadrivalent HPV vaccination in Brazil.MethodsWe adapted a previously developed transmission dynamic model to estimate the effectiveness of HPV vaccination on cervical cancer, cervical intraepithelial neoplasia grades 2 and 3 (CIN2/3), CIN1, and genital warts. We evaluated following vaccination strategies: routine vaccination of 12-year-old girls and routine vaccination in combination with a catch-up vaccination of 12 to 26-year-old women.ResultsThe model projected that the vaccination would reduce the incidence rates of HPV 6/11/16/18-related cervical cancer, CIN2/3, CIN1, and female genital warts by 94% to 98% at year 100. Routine vaccination in combination with a catch-up vaccination could prevent approximately 163,000 cases of cervical cancer, 48,000 deaths from cervical cancer, 2.3 million cases of CIN2/3, and 11.4 million genital warts in the next 50 years. The incremental cost-effectiveness ratios for female vaccination strategies ranged from R

Cost-effectiveness analysis of pneumococcal polysaccharide vaccination from age 60 in São Paulo State, Brazil

350 to R

Preditores de falha da extubação em crianças no pós-operatório de cirurgia cardíaca submetidas à ventilação pulmonar mecânica

720 (US

Risk Factors for Extubation Failure in Infants With Severe Acute Bronchiolitis

219 to US

Electric impedance tomography, the final frontier is close: the bedside reality.

450) per quality-adjusted life year (QALY) gained.ConclusionsOur study demonstrates that quadrivalent HPV female vaccination can be a cost-effective public health intervention that can substantially reduce the burden of cervical diseases and genital warts in Brazil.

Step by step: challenging pediatric and neonatal healthcare-acquired infection.

Vaccination of adults aged 60 years and older against Streptococcus pneumonia is not recommended in Brazil. The 23-valent polysaccharide pneumococcal vaccine (PPV23) is only available for institutionalized persons or with underlying diseases despite the substantial medical and economic burden related to pneumococcal infections in adults over than 59 years. The study aimed at evaluating the cost effectiveness of implementing a large PPV program in this population. This analysis was performed using a static decision tree model. Demographic and epidemiological data were obtained from Brazilian official sources and international literature. Economic data were obtained from a study performed in 2007 in a public and a private hospital located in Sao Paulo. Vaccination was assumed to protect for 5 years with 60% effectiveness against bacteremic pneumococcal pneumonia (BPP) and 21% effectiveness against non bacteremic pneumococcal pneumonia (NBPP). Deterministic and sensitivity analyses were performed. The pneumococcal polysaccharide vaccination saved 5,218 life year gained (LYG). The vaccination program was found to be cost effective in the social security and public health care perspectives with a mean incremental cost-effectiveness ratio of R

Repercusses cardiorrespiratrias da dilise peritoneal em crianas graves

10,887 and R

Slowing down hypermetabolism: first follow the basic steps.

8,281 per LYG respectively. Results were sensitive to the vaccine effectiveness against NBPP, the incidence and case-fatality rate of NBPP. From a societal perspective, PPV23 program for adults 60 and older was found to be cost-saving. Pneumococcal polysaccharide vaccination is clinically and economically favored over the present vaccination strategy, in which persons aged over 59 years in Sao Paulo, have not been vaccinated.