Wanderley Marques Bernardo

Effectiveness of probiotics in the prophylaxis of necrotizing enterocolitis in preterm neonates: a systematic review and meta-analysis

OBJECTIVE To elucidate the benefits of using probiotics in the prevention of necrotizing enterocolitis (NEC) and its complications in preterm newborns. METHOD This was a systematic review of randomized controlled trials, which included studies retrieved from three databases (MEDLINE, Embase, and LILACS), using a combination of the terms (necrotizing enterocolitis) AND (probiotics). RESULTS 11 randomized trials were included, totaling 2,887 patients, 1,431 in the probiotic group and 1,456 in the control group. There was a reduction in the incidence of NEC (NNT=25), overall death (NNT=34), and neonatal sepsis (NNT=34) in the probiotic group compared to the control group. Patients that received probiotic supplementation had lower food reintroduction time (p<0.001) and hospitalization time (p<0.001) when compared to those not receiving probiotics. There was no difference in mortality caused by NEC. CONCLUSION In premature newborns, the use of probiotics is effective as a prophylaxis for NEC and its complications.

O uso adjuvante da imunoglobulina endovenosa no tratamento da sepse neonatal: uma revisão sistemática com metanálise

OBJECTIVE To evaluate whether intravenous immunoglobulin reduces mortality and length of hospital stay in the treatment of neonatal sepsis. SOURCES The MEDLINE database was searched. The keywords were combined using the following search strategy: [(sepsis OR shock, septic OR infection) AND immunoglobulins, intravenous] AND infant, newborn. Only randomized clinical trials (RCTs) showing good methodological quality and assessing the effect of adjuvant intravenous immunoglobulin in the treatment of neonatal sepsis were selected for inclusion and data analysis. SUMMARY OF THE FINDINGS Seven RCTs were selected. All of them evaluated the mortality rate, including 3,756 patients. The global effect of this outcome showed no statistically significant difference between the groups. Only five studies evaluated the mean length of hospital stay, including 3,672 patients. Although there is a statistically significant reduction of 1.24 days in the length of hospital stay with the use of intravenous immunoglobulin, such difference is clinically irrelevant and its high cost does not warrant its routine use in medical practice. The data reported in the present review contradict the review by Ohlsson et al., which was updated in 2010 and showed significant benefit with the use of intravenous immunoglobulin on both outcomes. CONCLUSIONS We concluded that the use of adjuvant intravenous immunoglobulin shows no benefit regarding mortality, whereas the reduction in the length of hospital stay is irrelevant.

Early oral feeding after total laryngectomy: A systematic review.

Early oral feeding for patients who underwent total laryngectomy is still controversial. The purpose of this study was to evaluate the safety of initiating early oral feeding after total laryngectomy regarding pharyngocutaneous fistula. The survey included research in MEDLINE, EMBASE, and LILACS.

The importance of analysis in published evidence levels

“Critical analysis of the use of statistical tests in Brazilian publications related to digestive tract surgery”1 analyzes the strength of evidence and use of statistical tests in two periods, 1987 and 2007, in national gastroenterological surgical publications. It concluded that: an increase in animal studies (from 3.33% to 19.7%) was observed; the distribution of studies according to the strength of the evidence remained intact (randomized assays [less than 3%] and non-randomized, prospective or historical cohorts, and case control studies); and the use of statistical tests increased from 40% to 70%, despite a significant impact in the adequate use having not been observed. Despite implicit limitations in the evaluation of the two periods, this analysis indicates how scientific information generation in surgical gastroenterology has been among us. This is done with an explicit and reproducible method, in a clear, objective, and understandable way, providing elements for a few reflections, which are exposed below. Whenever we approach the subject “level or strength of the evidence published”, it should be done with at least two points of view: regarding the consequences of the clinical decision and the consequences of the evaluation of the publisher. The strength of the evidence translates the level of uncertainty, inherent to the inferences of publications regarding the effects on patients by described or executed interventions2. Statistical tests should only be useful when the level of uncertainty is small, confirming or not the applicability, with expectations of practical results similar to those of the study. The consequences of publication-based decision making is directly proportional to the level of their uncertainties and, therefore, the lower the strength the greater the risk of an unpredictable result regarding the effects on patients. Currently, assessing the quality of the publisher and/or author is limited to a series of superficial indicators3, such as the number of quotes obtained along a determined period of time or publication in international journals, regardless of the strength of the evidence of said publications or the strength of evidence of the publications that quote them. Proposals of analysis like that of the work of Orso IRB et al.1, reach some stakeholders and have a few consequences:

Is laparoscopic cholecystectomy safe in patients with liver cirrhosis

The incidence of cholelithiasis in cirrhotic patients is two-fold higher when compared to that of the general popula-tion. That is due to intravascular hemolysis, hypersplen-ism, increased estrogen levels and decreased gallbladder motility and emptying. Cholecystectomy in cirrhotic patients is associated with a high rate of morbimortality, related to excessive blood loss, postoperative liver failure and sepsis. Since the introduction of the videolaparoscopy technique to treat cholelithiasis, it has been debated whether cirrhotic pa-tients would benefit from this technique. The objective of the present study is to compare the laparoscopic cholecystectomy to the open surgery in cir-rhotic patients with symptomatic cholelithiasis.

Is inhaled nitric oxide therapy more effective or safer than the conventional treatment for the treatment of vaso-occlusive crises in sickle-cell anemia?

IntroductIon Sickle-cell diseases (SCD) constitute a group of hereditary anemias that occur together with chronic hemolytic anemia, vasculopathy, vaso-occlusive phenomena, and acute and generalized chronic organ lesion. One of these diseases is sickle-cell anemia, a recessive autosomal disease that results from a mutation in the beta (ß) globin (chromosome 11), originating hemoglobin S, of which its homozygous form characterizes this pathology. According to the World Health Organization (WHO), there are approximately 20 million individuals with sicklecell anemia worldwide. Although SCD are more common in Africa, the migratory flows have disseminated the gene around the world1. Although the physiopathology of vaso-occlusion is not completely understood, it is known that the interactions between sickled red blood cells, endothelial alterations, vascular muscle tonus deregulation, activation of monocytes and adhesion molecules secondary to frequent hemolysis have an important role in the development of the disorder. Certain complications such as cerebrovascular accident, pulmonary hypertension, priapism and leg ulcers are related to the intensity of hemolysis, whereas painful crises, acute chest syndrome (ACS) and osteonecrosis are associated with the high blood viscosity and the interactions between sickle cells, leukocytes and endothelium. Due to the high morbidity and elevated complication treatment costs, there is an interest regarding the study of new therapies, such as the therapeutic use of inhaled nitric oxide. Nitric oxide (NO) is a vasodilating substance, in addition to inhibiting platelet aggregation, decreasing cell adhesion molecules and also modulating ischemic lesions with reperfusion. The objective of this systematic review was to evaluate the safety and effectiveness of inhaled NO to treat vaso-occlusive crises in sickle-cell anemia.

O óxido nítrico inalatório nas crises vaso-oclusivas da anemia falciforme é mais eficaz ou seguro que o tratamento convencional?

As doencas falciformes (DF) constituem um grupo de anemias hereditarias que cursam com anemia hemolitica cronica, vasculopatia, fenomenos vaso-oclusivos e lesao orgânica aguda e cronica generalizada. Entre elas esta a anemia falciforme, uma doenca autossomica recessiva que resulta de uma mutacao do gene da beta (s) globina (cro-mossomo 11), originando a hemoglobina S, que, em sua forma homozigota, caracteriza tal patologia.De acordo com a Organizacao Mundial da Saude (OMS), ha cerca de 20 milhoes de pessoas com doencas falciformes em todo o planeta. Apesar de as doencas falci-formes serem mais comuns na Africa, os fluxos migrato-rios disseminaram o gene ao redor do mundo

A colecistectomia laparoscópica é segura em pacientes com cirrose hepática

367 Rev Assoc Med Bras 2011; 57(4):367-368 Introdução A incidência de colelitíase em pacientes cirróticos está duas vezes aumentada quando comparada à população em geral. Isso ocorre devido a hemólise intravascular, hiperesplenismo, aumento dos níveis de estrogênio e redução da motilidade e do esvaziamento vesicular. A colecistectomia em pacientes cirróticos está associada à elevada taxa de morbimortalidade, relacionada a perda excessiva de sangue, insuficiência hepática pósoperatória e sepse. Desde a introdução da videolaparoscopia para o tratamento da litíase vesicular, tem-se discutido se os pacientes cirróticos se beneficiariam dessa técnica. O objetivo deste estudo é comparar a colecistectomia laparoscópica à aberta em pacientes cirróticos com colelitíase sintomática.

Tratamento do cisto pilonidal: cicatrização por segunda intenção ou sutura primária em linha média?

A doença pilonidal sacrococcígea é uma inflamação crônica dos seios pós-sacrais que afeta a área da pele posterior ao ânus, recobrindo o sacro na região da fenda interglútea. A melhor opção de tratamento cirúrgico tem por finalidade alcançar a cura por meio de operações de pequena envergadura e pouca complexidade, que permitam rápida integração dos doentes às suas atividades habituais, além de baixas taxas de recorrência. Embora a doença pilonidal seja conhecida há muito tempo e diversas variedades terapêuticas tenham sido propostas, visto que não há consenso sobre a melhor estratégia para abordar a doença pilonidal sacrococcígea, realizou-se uma revisão com o objetivo de comparar a técnica de cicatrização por segunda intenção à técnica de fechamento primário em linha média. Foi realizada uma busca na literatura eletrônica na base de dados MEDLINE, utilizando os termos “Pilonidal sinus” e “Randomized Controlled Trial”. As buscas foram encerradas em maio de 2009. Apenas ensaios clínicos controlados e randomizados publicados em inglês, espanhol ou português foram selecionados para análise. Procedeu-se ainda uma avaliação mais apurada da qualidade dos ensaios, com o objetivo de avaliar a força da evidência produzida por cada estudo e a validade de sua inclusão na revisão. Para isso, utilizamos os critérios elaborados a partir do trabalho de Jadad et al.1. Apenas estudos com pontuação igual ou superior a três foram incluídos. Os desfechos analisados foram: tempo para obter cura, tempo para retomar atividades e recorrência.