Marcus Tolentino Silva

Prevalence of depression morbidity among Brazilian adults: a systematic review and meta-analysis

OBJECTIVE To estimate the prevalence of depressive symptoms and major depressive disorder, as assessed in population-based cross-sectional studies of Brazilian adults. METHODS We performed a systematic review of the literature. The major databases were searched up through October 2013. Two researchers selected the studies, extracted the data, and assessed their methodological quality. Meta-analyses were performed using random effects. RESULTS Of the 2,971 records retrieved, we selected 27 studies that assessed the prevalence of depression morbidity in 464,734 individuals (66% women). Eleven different screening tools were used to assess depression morbidity. The prevalence of depressive symptoms was 14% (95% confidence interval [95%CI] 13-16; I2 = 99.5%), whereas the 1-year prevalence of major depressive disorder was 8% (95%CI 7-10; I2 = 86.7%), and the lifetime prevalence of major depressive disorder was 17% (95%CI 14-19; I2 = 91.6%). All rates were higher in women than in men. No causes of heterogeneity could be identified. CONCLUSION Depression morbidity was common among Brazilian adults, and affects more women than men. Inconsistencies across studies highlight the need for standardization of future research. Clinicians should routinely investigate for the presence of depression morbidity in this population.

Antioxidants for Preventing Preeclampsia: A Systematic Review

Objective. To investigate the efficacy of antioxidants for preventing preeclampsia and other maternal and fetal complications among pregnant women with low, moderate, or high risk of preeclampsia. Methods. We searched MEDLINE, Embase, CENTRAL, mRCT, and other databases, with no language or publication restrictions. Two independent reviewers selected randomized controlled trials that evaluated the use of antioxidants versus placebo and extracted the relevant data. Relative risks (RRs) and 95% confidence intervals (95% CIs) were calculated. The data were compiled through the random effects model. Main Results. Fifteen studies were included (21,012 women and 21,647 fetuses). No statistically significant difference was found between women who received antioxidant treatment and women who received placebo for preeclampsia (RR  = 0.92; 95% CI: 0.82–1.04), severe preeclampsia (RR  = 1.03; 95% CI: 0.87–1.22), preterm birth (RR  = 1.03; 95% CI: 0.94–1.14), and small for gestational age <10th centile (RR  = 0.92; 95% CI: 0.80–1.05). Side effects were numerically more frequent in the antioxidants group compared to placebo, but without significant statistical difference (RR  = 1.24; 95% CI: 0.85–1.80). Conclusions. The available evidence reviewed does not support the use of antioxidants during pregnancy for the prevention of preeclampsia and other outcomes.

Pubertal timing in girls and depression: A systematic review

BACKGROUND Because the incidence of depression increases after puberty, it is possible that pubertal timing in girls influences the onset of depression. Our objective was to assess the effect of early and late puberty in girls on the incidence of depression. METHODS We systematically searched relevant databases for controlled studies that assessed the impact of pubertal timing in girls on the incidence of depression or depressive symptoms. The last search was completed in August 2013. Two authors selected the studies, extracted the data, and assessed the quality of the evidence. Meta-analyses of the adjusted and unadjusted results were calculated using random effects. RESULTS Four cohort studies were included (n=8055 participants). Early puberty significantly increased the risk of new cases of depression in the unadjusted meta-analysis (RR=1.33; CI 95%: 1.02, 1.73) but not in the adjusted estimate of two of the included studies (RR=1.48; CI 95%: 0.69, 2.28). For late puberty, no significant associations were found (unadjusted RR=1.28; CI 95%: 0.87, 1.88). Two studies assessed the effect of early puberty on depressive symptoms and found positive associations. The quality of the available evidence was rated as very low. LIMITATIONS The polled results had wide confidence intervals, and the available evidence was of very low quality. CONCLUSIONS The available evidence supports little confidence regarding the impact of pubertal timing on the onset of depression in girls but suggests that early puberty in girls may increase the risk of depression. Further higher quality studies are needed to clarify the association between pubertal timing and the incidence of depression in girls and women.

Safety of Benzathine Penicillin for Preventing Congenital Syphilis: A Systematic Review

Objective To estimate the risk of serious adverse reactions to benzathine penicillin in pregnant women for preventing congenital syphilis. Methods We searched for clinical trials or cohorts that assessed the incidence of serious adverse reactions to benzathine penicillin in pregnant women and the general population (indirect evidence). MEDLINE, EMBASE, Scopus and other databases were searched up to December 2012. The GRADE approach was used to assess quality of evidence. Absolute risks of each study were calculated along with their 95% confidence intervals (95% CI). We employed the DerSimonian and Laird random effects model in the meta-analyses. Results From 2,765 retrieved studies we included 13, representing 3,466,780 patients. The studies that included pregnant women were conducted to demonstrate the effectiveness of benzathine penicillin: no serious adverse reactions were reported among the 1,244 pregnant women included. In the general population, among 2,028,982 patients treated, 4 died from an adverse reaction. The pooled risk of death was virtually zero. Fifty-four cases of anaphylaxis were reported (pooled absolute risk = 0.002%; 95% CI: 0%–0.003% I2 = 12%). From that estimate, penicillin treatment would be expected to result in an incidence of 0 to 3 cases of anaphylaxis per 100,000 treated. Any adverse reactions were reported in 6,377 patients among 3,465,322 treated with penicillin (pooled absolute risk = 0.169%; 95% CI: 0.073%–0.265% I2 = 97%). The quality of evidence was very low. Conclusion Studies that assessed the risk of serious adverse events due to benzathine penicillin treatment in pregnant women were scarce, but no reports of adverse reactions were found. The incidence of severe adverse outcomes was very low in the general population. The risk of treating pregnant women with benzathine penicillin to prevent congenital syphilis appears very low and does not outweigh its benefits. Further research is needed to improve the quality of evidence.

Prevalence of dementia among elderly Brazilians: a systematic review

CONTEXT AND OBJECTIVE The rapid growth of the elderly population in Brazil has implied a significant rise in the number of individuals with dementia. The real prevalence of this disease needs to be ascertained in order to establish appropriate measures for improving the quality of life of those affected. The aim of this study was to estimate the prevalence of dementia among elderly Brazilians (≥ 60 years) through a systematic review of high-quality, population-based, double-blind studies published between 1990 and 2010. DESIGN AND SETTING Systematic review of prevalence studies. The manuscript was produced in the School of Medicine, Universidade de Brasília. METHODS Database searches for articles were conducted in Medline (Medical Literature Analysis and Retrieval System Online), Embase (Excerpta Medica database), Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), SciELO (Scientific Electronic Library Online) and theses and dissertations, using specific keywords. Quality was assessed according to eight criteria for sampling and measurement of findings. RESULTS Out of 112 articles identified, eleven were included in the qualitative synthesis. In five higher-quality studies from São Paulo, the prevalence rates ranged from 5.1 to 19.0%. No meta-analysis was presented because of heterogeneity among the studies. Poor, illiterate, female and very elderly individuals were the groups most affected. CONCLUSION The findings from this review did not reflect the reality of the whole country. Although the results brought some information on the prevalence and distribution of dementia in Brazil, cross-sectional studies with consistent methodology are needed.

Treatment of American tegumentary leishmaniasis in special populations: a summary of evidence

We aimed to assess and synthesize the information available in the literature regarding the treatment of American tegumentary leishmaniasis in special populations. We searched MEDLINE (via PubMed), EMBASE, LILACS, SciELO, Scopus, Cochrane Library and mRCT databases to identify clinical trials and observational studies that assessed the pharmacological treatment of the following groups of patients: pregnant women, nursing mothers, children, the elderly, individuals with chronic diseases and individuals with suppressed immune systems. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The available evidence suggests that the treatments of choice for each population or disease entity are as follows: nursing mothers and children (meglumine antimoniate or pentamidine), patients with renal disease (amphotericin B or miltefosine), patients with heart disease (amphotericin B, miltefosine or pentamidine), immunosuppressed patients (liposomal amphotericin), the elderly (meglumine antimoniate), pregnant women (amphotericinB) and patients with liver disease (no evidence available). The quality of evidence is low or very low for all groups. Accurate controlled studies are required to fi ll in the gaps in evidence for treatment in special populations. Post-marketing surveillance programs could also collect relevant information to guide treatment decision-making.

Olanzapine plus fluoxetine for bipolar disorder: a systematic review and meta-analysis.

BACKGROUND Olanzapine plus fluoxetine combination (OFC) is one of the current approaches for treating the depressive phase of bipolar disorder. Our objective was to synthesize the evidence on the efficacy of OFC therapy in bipolar depressed patients. METHODS We searched for randomized controlled trials (RCTs) on MEDLINE, Embase and other databases. Independent researchers selected the studies and extracted the data. The GRADE approach was used to assess the quality of the evidence. The Mantel-Haenszel random effect model was used to perform the meta-analyses. RESULTS From 627 unique records retrieved, four RCTs were included (1330 patients). OFC improved the response compared to olanzapine (relative risk [RR]=1.58; 95% confidence interval [95% CI]: 1.27, 1.97) and to placebo (RR=1.99; 95% CI: 1.49, 2.65) but not to lamotrigine (low-quality evidence). Similar results were found for remission and relapse rates. No differences were identified for levels of depression and mania symptoms (low-quality evidence) and incidence of mania (moderate-quality evidence). Adverse effects were more common in patients treated with OFC than in those treated with lamotrigine (RR=1.13; 95% CI: 1.04, 1.23), but no difference was found relative to the patients treated with olanzapine (low-quality evidence). LIMITATIONS Despite the totality of the evidence included, there are few RCTs available regarding the efficacy of OFC therapy for bipolar depression. The risk of attrition and reporting bias is also a concern. CONCLUSIONS OFC therapy improved the response, remission, and relapse rates among other outcomes. However, a worse profile of adverse reactions was observed in some comparisons. These data clarify the therapeutic use of OFC as an option to olanzapine in bipolar depression. The quality of the evidence could be improved by additional comparisons and higher rates of treatment adherence.

Non-aspirin Non-steroidal Anti-inflammatory Drugs for the Primary Chemoprevention of Non-gastrointestinal Cancer: Summary of Evidence

BACKGROUND There is evidence that aspirin is effective for the chemoprevention of colorectal cancer. Due to their similar pharmacodynamics, the use of other non-steroidal anti-inflammatory drugs (NSAIDs) has been suggested for other cancer sites. Although this possibility has been discussed in the literature, uncertainty remains about the actual effects of NSAIDs other than aspirin in nongastrointestinal cancer. OBJECTIVE To summarize the best available evidence of the primary chemopreventive effects of non-aspirin NSAIDs for nongastrointestinal cancer. METHODS Our inclusion criteria were narrative or systematic reviews, clinical guidelines and, if they had not been previously included, primary controlled studies that evaluated the effectiveness of non-aspirin NSAIDs in preventing non-gastrointestinal cancer in healthy individuals. Studies were retrieved from the following databases: Guidelines.gov, BMJ Clinical Evidence, TRIP database, UpToDate, MEDLINE, CANCERLIT, Embase, CINAHL, ISI Web of Science and Scopus. Two independent reviewers selected eligible studies. Data were extracted by one reviewer and crosschecked by two others. RESULTS We found 9,984 non-duplicated articles and included 56 eligible studies. Most of these studies were observational. The studies reported conflicting results or no statistically significant associations between the use of non-aspirin NSAIDs and risk of lung, ovary, bladder, prostate, skin, and head and neck cancers. In contrast, an increased risk of renal cell carcinoma and a reduced risk of breast cancer were found to be statistically significant. The included studies had methodological limitations, which reduces our confidence in their results. CONCLUSIONS We did not find sufficient evidence to support the use of the non-aspirin NSAIDs for the primary chemoprevention of a wide variety of non-gastrointestinal cancers. This scenario suggests caution when considering the routine use of non-aspirin NSAIDs. Additional well-conducted controlled studies may provide more conclusive evidence on this issue, but there are concerns about the risks of such exposure.

Zinc supplementation for treating diarrhea in children: a systematic review and meta-analysis

OBJECTIVE To update the available evidence about zinc use for treating diarrhea in children and to assess its effect on the malnourished population, a subgroup that has not been fully explored in previous analyses. METHODS A systematic review was performed of randomized clinical trials that assessed children up to 5 years old with acute diarrhea who received zinc supplementation. Controls received a placebo or oral rehydration therapy. After searching the main databases, without language restrictions, two independent reviewers selected eligible studies, extracted the data, and assessed the risk of bias of included studies. Meta-analyses were calculated using Mantel-Haenszel or inverse variance random effects. RESULTS Eighteen of 1 041 studies retrieved were included in the review (n = 7 314 children). Zinc was beneficial for reducing the duration of diarrhea in hours (mean difference [MD] = -20.12, 95% confidence interval [CI] = -29.15 to -11.09, I² = 91%). The effect was greater in malnourished children (MD = -33.17, 95% CI = -33.55 to -27.79, I² = 0%). Diarrhea prevalence on days 3, 5, and 7 was lower in the zinc group. The incidence of vomiting was significantly greater in the group that received zinc than in the control group. Included randomized controlled trials were of low risk of bias in most domains assessed. CONCLUSIONS Oral zinc supplementation significantly decreases diarrhea duration and has a greater effect on malnourished children. Zinc supplementation seems to be an appropriate public health strategy, mainly in areas of endemic deficiencies.

Prevalence of Frailty in Latin America and the Caribbean: A Systematic Review and Meta-Analysis

Background Countries in Latin America and the Caribbean (LAC) have experienced a rapid increase in their proportion of older people. This region is marked by a high prevalence of chronic diseases and disabilities among aging adults. Frailty appears in the context of LAC negatively affecting quality of life among many older people. Aim To investigate the prevalence of frailty among community-dwelling older people in LAC through a systematic review and meta-analysis. Methods A literature search was performed in indexed databases and in the grey literature. Studies investigating the prevalence of frailty with representative samples of community-dwelling older people in Latin America and the Caribbean were retrieved. Independent investigators carried out the study selection process and the data extraction. A meta-analysis and meta-regression were performed using STATA 11 software. The systematic review was registered at the International Prospective Register of Systematic Reviews under the number CRD42014015203. Results A total of 29 studies and 43,083 individuals were included in the systematic review. The prevalence of frailty was 19.6% (95% CI: 15.4–24.3%) in the investigated region, with a range of 7.7% to 42.6% in the studies reviewed. The year of data collection influenced the heterogeneity between the studies. Conclusion Frailty is very common among older people in LAC. As a result, countries in the region need to adapt their health and social care systems to demands of an older population.