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OBJECTIVE To identify lifestyle-related, sociodemographic, and mental health characteristics of people with insomnia symptoms and people without insomnia during the pandemic. METHODS A case-control study was conducted with data collected by snowball sampling using an online questionnaire. From November 2020 to April 2021, 6,360 people with a mean age of 43.5 years (SD = 14.3) participated in the survey. For this study, we considered 158 cases of insomnia disorder and 476 controls (three controls per case) randomly selected from the participants without sleep problems. RESULTS The results of the comparative analysis between cases and controls showed that sleeping less than six hours daily (OR = 3.89; 95%CI 2.50–6.05), feeling sadness frequently (OR = 2.95; 95%CI 1.69–5.17), residing in metropolitan areas (OR = 1.71; 95%CI 1.04–2.84), being 40 years or older (OR = 1.93; 95%CI 1.22–3.06), and the interaction between occupation and poorer education (OR = 2.12; 95%CI 1.22–3.69) were predictors for symptoms of insomnia disorder during the pandemic. CONCLUSIONS In addition to confirming the hypothesis that mental health problems are associated with insomnia symptoms, the results point to insomnia as an important outcome for studies on the effects of unemployment, vulnerability and low education of the population, especially in large cities, highlighting that the effects of the crisis on health and the economy are extremely unequally distributed. RESUMO OBJETIVO Identificar características relacionadas ao estilo de vida, sociodemográficas e saúde mental de pessoas com sintomas de insônia e pessoas sem insônia durante a pandemia. MÉTODOS A partir de dados coletados por amostragem em bola de neve, por meio de um questionário online foi realizado um estudo caso-controle. Durante o período de novembro de 2020 a abril de 2021, 6.360 pessoas com idade média de 43,5 anos (DP = 14,3) participaram da pesquisa. No presente estudo, foram considerados 158 casos de transtorno de insônia e 476 controles (três controles por caso) selecionados aleatoriamente dentre os participantes sem problemas de sono. RESULTADOS Os resultados da análise comparativa entre casos e controles mostraram que dormir menos de seis horas diárias (OR = 3,89; IC95% 2,50–6,05), sentir tristeza frequentemente (OR = 2,95; IC95% 1,69–5,17), residir em metrópoles (OR = 1,71; IC95% 1,04–2,84), estar com 40 anos ou mais (OR = 1,93; IC95% 1,22–3,06) e a interação entre ocupação e escolaridade mais precária (OR = 2,12; IC95% 1,22–3,69) foram fatores preditores para sintomas de transtorno de insônia durante a pandemia. CONCLUSÕES Além da confirmação da hipótese de que problemas de saúde mental estão associados a sintomas de insônia, os resultados apontam para a insônia como um desfecho importante para estudos sobre efeitos do desemprego, vulnerabilidade e baixa escolaridade da população, sobretudo nas grandes metrópoles, ressaltando que os efeitos da crise sobre a saúde e a economia são distribuídos de forma extremamente desiguais.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to the suspension or postponement of care for non-urgent conditions worldwide. Regula Mais Brasil is an initiative of the Unified Health System (SUS) in Brazil to optimize the management of referrals to specialized care by using telehealth. Objectives: To report the expansion of telehealth activities of Regula Mais Brasil in response to COVID-19 and to assess qualification of referrals in primary health care (PHC) units as well as the added value of teleconsultation in qualifying referral cases. Methods: Descriptive study of the teleconsultations carried out as an additional strategy to the remotely operated referral management system, responsible for navigating cases from PHC units to specialized care in Recife, Brazil, between May 6, 2020 and September 30, 2020. Teleconsultation was implemented as a tool for reducing delays in the access to health care due to COVID-19 and ultimately allowed for reclassification of the referral adequacy and priority. Changes in referral priority ratings and referral decisions after teleconsultation were analyzed. Results: A total of 622 referral cases were analyzed. Approved referrals represented 51.9% of cases. The main reason for approved referrals was the need for diagnostic resources. There was a reduction in priority ratings in 449 cases (72.2%) after teleconsultation. There was a statistically significant association between the change of priority ratings and the decision on referral (Pearson's χ2, p-value

Study Objectives:To evaluate the impact of COVID-19 pandemic on insomnia and other sleep disturbances in health care professionals. Methods:A survey was distributed using social media and organizat...

SUMMARY OBJECTIVE: This study aimed to characterize teleconsultations in neurology executed by Regula+Brasil project in Recife, a capital city in northeastern Brazil. METHODS: A descriptive study carried out by four private hospitals, in a partnership with the Ministry of Health in Brazil. Teleconsultation was performed preferably in the video modality. Conditions eligible for teleconsultation were headache, epilepsy, and cerebrovascular disorders. Period of analysis was May to September 2020. RESULTS: A total of 243 teleconsultations were analyzed, of which 76.95% was a first appointment. In 48.97% of cases, the teleconsultation represented the first opportunity for the patient to be consulted with the specialist. Among cases of first appointment, 20.16% were further referred to a face-to-face consultation and 21.81% could be redirected to primary health care. Headache disorders were the most predominant clinical conditions. CONCLUSIONS: The implementation and development of telemedicine by Regula+Brasil during the COVID-19 pandemic represented an opportunity to assess the value of having teleconsultations added along the line of care from primary care to a medical specialty, promoting the coordination of care across different levels of complexity of care in the health system and improving access to specialized care.

Objective: To describe and critically appraise the economic evaluations of antineoplastic drugs submitted to the ANS during the process of updating its 2020’ list of procedures. Methods: Cross-sectional study of critical analysis of the economic evaluation studies included in the documentation submitted to the ANS with the aim of incorporating them into the list of procedures. The methodological quality assessment was carried out using the Methodology Checklist 6: Economic Evaluations Version 3.0 of the Scottish Intercollegiate Guidelines Network. Results: Overall, 49 economic evaluations were included: 22 cost-effectiveness studies, 10 cost-utility studies, three cost-minimization studies and 14 mixed economic studies. Methodological quality was mostly considered as acceptable or low quality. Conclusion: Economic evaluation studies are fundamental in the decision-making process of incorporating technologies into supplementary health care. This critical appraisal suggests that the quality of the economic studies presented within the proposals to incorporate antineoplastics during the process of updating the ANS 2020 roll was limited. Methodological inconsistencies and lack of transparent reporting reduce the validity and applicability of findings for decision-making

Referral of cases from primary to secondary care in the Brazilian public healthcare system is one of the most important issues to be tackled. Telehealth strategies have been shown effective in avoiding unnecessary referrals. The objective of this study was to estimate cost per referred case by a remotely operated referral management system to further inform the decision making on the topic. Analysis of cost by applying time-driven activity-based costing. Cost analyses included comparisons between medical specialties, localities for which referrals were being conducted, and periods of time. Cost per referred case across localities ranged from R$ 5.70 to R$ 8.29. Cost per referred case across medical specialties ranged from R$ 1.85 to R$ 8.56. Strategies to optimize the management of referral cases to specialized care in public healthcare systems are still needed. Telehealth strategies may be advantageous, with cost estimates across localities ranging from R$ 5.70 to R$ 8.29, with additional observed variability related to the type of medical specialty. Resumo O encaminhamento de casos da atenção primária para a secundária no Sistema Único Brasileiro é uma das questões mais importantes a ser enfrentada. As estratégias de telessaúde têm se mostrado eficazes para evitar encaminhamentos desnecessários. O objetivo deste estudo foi estimar o custo por caso encaminhado por meio de um sistema de gerenciamento de referenciamentos operado remotamente para subsidiar a tomada de decisão sobre o tema. Análise de custo por meio da aplicação de custeio baseado em atividades orientado pelo tempo (time-driven activity-based costing ou TDABC). As análises de custo incluíram comparações entre especialidades médicas, localidades para as quais os encaminhamentos estavam sendo conduzidos e períodos de tempo. O custo por referenciamento em todas as localidades variou entre R$ 5,70 a R$ 8,29. O custo por referenciamento nas especialidades médicas variou entre R$ 1,85 a R$ 8,56. Estratégias para otimizar a gestão dos referenciamentos para a atenção especializada nos sistemas públicos de saúde ainda são necessárias. As estratégias de telessaúde podem ser vantajosas, com estimativas de custo entre as localidades variando entre R$ 5,70 a R$ 8,29, com variabilidade adicional observada relacionada ao tipo de especialidade médica.

Background Obstructive sleep apnoea syndrome (OSAS) is associated with several chronic diseases, including erectile dysfunction (ED). The association of OSAS and ED is far more common than might be found by chance; the treatment of OSAS with non-invasive positive airway pressure therapy is associated with improvement of respiratory symptoms, and may contribute to the improvement of associated conditions, such as ED. Objectives To assess the effectiveness and acceptability of non-invasive positive airway pressure therapy for improving erectile dysfunction in OSAS. Search methods We identified studies from the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, AMED EBSCO, and LILACS, the US National Institutes of Health ongoing trials register ClinicalTrials.gov, and the World Health Organisation international clinical trials registry platform to 14 June 2021, with no restriction on date, language, or status of publication. We checked the reference lists of all primary studies, and review articles for additional references, and relevant manufacturers' websites for study information. We also searched specific conference proceedings for the British Association of Urological Surgeons; the European Association of Urology; and the American Urological Association to 14 June 2021. Selection criteria We considered randomised controlled trials (RCTs) with a parallel or cross-over design, or cluster-RCTs, which included men aged 18 years or older, with OSAS and ED. We considered RCTs comparing any non-invasive positive airway pressure therapy (such as continuous positive airways pressure (CPAP), bilevel positive airway pressure (BiPAP), variable positive airway pressure (VPAP), or similar devices) versus sham, no treatment, waiting list, or pharmacological treatment for ED. The primary outcomes were remission of ED and serious adverse events; secondary outcome were sex-related quality of life, health-related quality of life, and minor adverse events. Data collection and analysis Two review authors independently conducted study selection, data extraction, and risk of bias assessment. A third review author solved any disagreement. We used the Cochrane RoB 1 tool to assess the risk of bias of the included RCTs. We used the GRADE approach to assess the certainty of the body of evidence. To measure the treatment effect on dichotomous outcomes, we used the risk ratio (RR); for continuous outcomes, we used the mean difference (MD). We calculated 95% confidence intervals (CI) for these measures. When possible (data availability and homogeneous studies), we used a random-effect model to pool data with a meta-analysis. Main results We included six RCTs (all assessing CPAP as the non-invasive positive airway pressure therapy device), with a total of 315 men with OSAS and ED. All RCTs presented some important risk of bias related to selection, performance, assessment, or reporting bias. None of included RCTs assessed the ED remission rate, and we used the provided ED mean scores as a proxy. CPAP versus no CPAP There is uncertainty about the effect of CPAP on mean ED scores after 4 weeks, using the International index of erectile function (IIEF-5, higher = better; MD 7.50, 95% CI 4.05 to 10.95; 1 RCT; 27 participants; very low-certainty evidence), and after 12 weeks (IIEF-ED, ED domain; MD 2.50, 95% CI -1.10 to 6.10; 1 RCT; 57 participants; very low-certainty evidence, downgraded due to methodological limitations and imprecision). There is uncertainty about the effect of CPAP on sex-related quality of life after 12 weeks, using the Self-esteem and relationship test (SEAR, higher = better; MD 1.00, 95% CI -8.09 to 10.09; 1 RCT; 57 participants; very low-certainty evidence, downgraded due to methodological limitations and imprecision); no serious adverse events were reported after 4 weeks (1 RCT; 27 participants; very low-certainty evidence, downgraded due to methodological limitations and imprecision). CPAP versus sham CPAP One RCT assessed this comparison (61 participants), but we were unable to extract outcomes for this comparison due to the factorial design and reporting of this trial. CPAP versus sildenafil (phosphodiesterase type 5 inhibitors) Sildenafil may slightly improve erectile function at 12 weeks when compared to CPAP, measured with the IIEF-ED (MD -4.78, 95% CI -6.98 to -2.58; 3 RCTs; 152 participants; I² = 59%; low-certainty evidence, downgraded due to methodological limitations). There is uncertainty about the effect of CPAP on sex-related quality of life after 12 weeks, measured with the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire (EDITS, higher = better; MD -1.24, 95% CI -1.80 to -0.67; 2 RCTs; 122 participants; I² = 0%; very low-certainty evidence, downgraded due to methodological limitations). No serious adverse events were reported for either group (2 RCTs; 70 participants; very low-certainty evidence, downgraded due to methodological limitations and imprecision). There is uncertainty about the effects of CPAP when compared to sildenafil for the incidence of minor adverse events (RR 1.33, 95% CI 0.34 to 5.21; 1 RCT; 40 participants; very low-certainty evidence, downgraded due to methodological limitations and imprecision). The confidence interval was wide and neither a significant increase nor reduction in the risk of minor adverse events can be ruled out with the use of CPAP (4/20 men complained of nasal dryness in the CPAP group, and 3/20 men complained of transient flushing and mild headache in the sildenafil group). Authors' conclusions When compared with no CPAP, we are uncertain about the effectiveness and acceptability of CPAP for improving erectile dysfunction in men with obstructive sleep apnoea. When compared with sildenafil, there is some evidence that sildenafil may slightly improve erectile function at 12 weeks.

Objetivo: discutir o processo regulatório de medicamentos para doenças raras no Brasil, com base no caso Zolgensma®, e avaliar criticamente as evidências disponíveis até o momento sobre a eficácia e a segurança do Zolgensma® no tratamento da atrofia muscular espinhal (AME). Metodologia: estudo descritivo realizado no Núcleo de Avaliação de Tecnologias em Saúde do Hospital Sírio-Libanês (NATS-HSL) em junho de 2019. Resultados: em abril de 2019, o uso do Zolgensma® para AME foi regulamentado nos Estados Unidos com base em dois estudos clínicos abertos (sem mascaramento), sem grupo comparador paralelo (e, portanto, não randomizados). Essas limitações metodológicas aumentam a incerteza nos resultados encontrados. A Agência Nacional de Vigilância Sanitária (Anvisa) aprovou estratégias para regulamentar o processo e os prazos de análise das submissões de registro de novos medicamentos para doenças raras, caso do Zolgensma®. Conclusão: faz-se necessário ampliar o debate em torno do processo de regulamentação e de incorporação de medicamentos órfãos para doenças raras no Brasil. O debate deve incluir as evidências relacionadas aos efeitos – benefícios e riscos – desses medicamentos, e maior clareza nos critérios para concessão de registro e recomendação de incorporação em sistemas de saúde.

A review of systematic reviews (SRs) and a critical appraisal study was conducted at Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp). The objectives of this review are (1) to identify all published SRs comparing the effectiveness and safety of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) for carotid artery stenosis, (2) to assess their methodological quality and (3) to compare the primary studies contained in each SR. We included 17 SRs published between 2005 and 2017. None of the SRs fulfilled all items of AMSTAR-2. The overall confidence in the results was graded as critically low for 16 SRs (94%) and low for 1 SR (6%). Five items were judged inadequate in all SRs: reference to a published protocol, explanation to the selection of study design, comprehensive search of the literature, methods for statistical combination of findings and consideration of the risk of bias on the results of meta-analysis. In total, 15 randomised clinical trials (RCTs) were included at least in one SR. The number of included RCTs in each SR was inconsistent (4 to 15) and was not related to the year of publication of the SR. Our study found redundant and low methodological quality SR comparing CAS versus CEA for carotid stenosis.

Aim:To assess the effects of neurodevelopmental treatment for children with cerebral palsy.Methods:We conducted a systematic review following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and reported in accordance to PRISMA Statement. Through a comprehensive literature search we considered all randomized clinical trials that compared neurodevelopmental treatment with conventional physical therapy for children with cerebral palsy. We used the Cochrane Risk of Bias Table to assess the risk of bias of the included randomized clinical trial, and the GRADE approach to evaluate the certainty of the body of the evidence.Results:We found 3 randomized clinical trials (2 published and 1 ongoing) comprising 66 children. Published randomized clinical trials presented methodological and reporting limitations and only 1 provided data for outcomes of interest. No difference between neurodevelopmental treatment and conventional physical therapy was found for gross motor function (mean difference 1.40; 95% confidence interval –5.47 to 8.27, low certainty evidence).Conclusion:This review found that the effects of neurodevelopmental treatment for children with cerebral palsy are still uncertain. Further studies are required to assess the efficacy and safety of neurodevelopmental treatment for this purpose and until there, current evidence do not support its routinely use in practice. Number of protocol registration in PROSPERO database: CRD42017082817 (available from https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=82817 ).

Background Management of patient flow within a healthcare network, allowing equitable and qualified access to healthcare, is a major challenge for universal health systems. Implementation of telehealth strategies to support referral management has been shown to increase primary care resolution and to promote coordination of care. The objective of this study was to assess the impact of telehealth strategies on waiting lists and waiting times for specialized care in Brazil. Methods Before-and-after study with measures obtained between January 2019 and February 2020. Baseline measurements of waiting lists were obtained immediately before the implementation of a remotely operated referral management system. Post-interventional measurements were obtained monthly, up to six months after the beginning of operation. Data was extracted from the database of the project. General linear models were applied to assess interaction of locality and time over number of cases on waiting lists and waiting times. Results At baseline, the median number of cases on waiting lists ranged from 2961 to 12,305 cases. Reductions of the number of cases on waiting lists after six months of operation were observed in all localities. The magnitude of the reduction ranged from 54.67 to 88.97 %. Interaction of time measurements was statistically significant from the second month onward. Median waiting times ranged from 159 to 241 days at baseline. After six months, there was a decrease of 100 and 114 waiting days in two localities, respectively, with reduction of waiting times only for high-risk cases in the third locality. Conclusions Adoption of telehealth strategies resulted in the reduction of number of cases on waiting lists. Results were consistent across localities, suggesting that telehealth interventions are viable in diverse settings.

Highlights • We analysed estimates of effect of long working hours on alcohol use and disorders. • Overall body of evidence was of low certainty. • Exposure to long working hours potentially increased alcohol consumption. • The effect of long working hours on risky drinking is unclear. • We found no eligible studies on the effect on alcohol use disorder., Background The World Health Organization (WHO) and the International Labour Organization (ILO) are developing Joint Estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic data suggests that exposure to long working hours may increase alcohol consumption and cause alcohol use disorder. In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from alcohol consumption and alcohol use disorder that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. Objectives We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41–48, 49–54 and ≥55 h/week), compared with exposure to standard working hours (35–40 h/week), on alcohol consumption, risky drinking (three outcomes: prevalence, incidence and mortality) and alcohol use disorder (three outcomes: prevalence, incidence and mortality). Data sources We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic bibliographic databases for potentially relevant records from published and unpublished studies, including the WHO International Clinical Trials Register, Ovid MEDLINE, PubMed, Embase, and CISDOC on 30 June 2018. Searches on PubMed were updated on 18 April 2020. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts. Study eligibility and criteria We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (

To synthesize findings of economic evaluations investigating cost-effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) and of strategies of organization of care related to CPAP therapy. Scoping review with searches conducted in MEDLINE, CRD, LILACS, and Embase in August 2020. Eligible studies were economic evaluations comparing CPAP to other alternative or assessing strategies of care for CPAP therapy. Results were presented narratively, and incremental cost-effectiveness ratios (ICER) were presented in evidence maps. Of 34 studies, 3 concluded that CPAP is less costly and more effective when compared to usual care. Most studies indicated that CPAP is associated with better health outcomes, but at higher prices. ICER ranged from USD 316 to 98,793 per quality-adjusted life years (QALY) gained (median 16,499; IQR 8267 to 33,119). One study concluded that CPAP is more costly and less effective, when treatment is applied to all patients, regardless of disease severity. Variability of ICER was mainly due to definition of population and applied time horizons. When CPAP was compared to mandibular advancement device, ICER ranged from USD 21,153 to 361,028 (median 89,671; IQR 26,829 to 295,983), which represents the investment in CPAP therapy required to obtain one extra QALY. Three studies assessed the effects of organizing CPAP therapy in primary care, which was cost-effective or cost-saving. Compared to usual care, CPAP is cost-effective after the second year of treatment, when indicated for moderate-to-severe OSA. CPAP therapy may be even more cost-effective by using different strategies of organization of care. These findings may inform decision making related to CPAP reimbursement in health systems. Not applicable

Study objectivesTo evaluate the impact of COVID-19 pandemic on sleep, anxiety, and Burnout in healthcare professionals.MethodsA survey was distributed using social media and organizational emails to Brazilian active healthcare professionals during the COVID-19 outbreak. We explored potential associated factors including age, gender, occupation, workplace, work hours, income, previous infection with COVID-19, recent/current contact with COVID-19 patients, regional number of incident deaths due to COVID-19, anxiety, and burnout. We evaluated new-onset or previous insomnia worsening (primary outcome), sleep quality, and duration (secondary outcomes).ResultsA total of 4,384 health professionals from all regions of the country were included in the analysis (mean age: 44±12 years, 76% females, 53.8% physicians). Overall, 55.7% were assisting patients with COVID-19, and 9.2% had a previous COVID-19 infection. New-onset insomnia symptoms or previous insomnia worsening occurred in 41.4% of respondents in parallel to 13% (n=572) new pharmacological treatments for insomnia. Prevalent anxiety and burnout during the pandemic were observed in 44.2% and 21% of participants, respectively. Multivariate analyses showed that females (OR:1.756; 95% CI 1.487-2.075), weight change (decrease: OR:1.852; 95% CI 1.531-2.240; increase: OR:1.542; 95% CI 1.323-1.799), prevalent anxiety(OR:3.209; 95% CI 2.796-3.684), new-onset burnout (OR:1.986; 95% CI 1.677-2.352), family income reduction >30% (OR:1.366; 95% CI 1.140-1.636) and assisting patients with COVID-19 (OR:1.293; 95% CI 1.104-1.514) were independently associated with new-onset or worsening of previous insomnia.ConclusionsWe observed a huge burden of insomnia in healthcare professionals during the COVID-19 pandemic. In this scenario, dedicated approaches for sleep health are highly desirable.Statement of SignificanceConsidering the stressful routine and risk of infection by COVID-19 among healthcare professionals, it is conceivable that sleep disturbances are significantly impaired during the pandemic. This nationwide survey conducted in Brazil found that 41.4% developed new-onset or worsening of previous insomnia symptoms. Moreover, 572 (13%) of respondents initiated pharmacological treatments for insomnia. Females, weight change, anxiety, Burnout development, family income reduction >30%, and recent/current care of patients with COVID-19 were independently associated with the development of insomnia or exacerbated previous insomnia symptoms. Considering the potential impact of insomnia on work performance/healthcare decisions as well as the potential long-term dependence of pharmacological treatments for insomnia, this study underscores the need for dedicated sleep and mental health programs for healthcare professionals.

BackgroundThe World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of individual experts. Evidence from mechanistic data and prior studies suggests that exposure to long working hours may cause stroke. In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from stroke that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates.ObjectivesWe aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41–48, 49–54 and ≥55 h/week), compared with exposure to standard working hours (35–40 h/week), on stroke (three outcomes: prevalence, incidence, and mortality).Data sourcesA protocol was developed and published, applying the Navigation Guide to systematic reviews as an organizing framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including Ovid MEDLINE, PubMed, EMBASE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines, and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts.Study eligibility and criteriaWe included working-age (≥15 years) individuals in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged < 15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of exposure to long working hours (41–48, 49–54 and ≥55 h/week), compared with exposure to standard working hours (35–40 h/week), on stroke (prevalence, incidence or mortality).Study appraisal and synthesis methodsAt least two review authors independently screened titles and abstracts against the eligibility criteria at a first review stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. Missing data were requested from principal study authors. We combined relative risks using random-effects meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using the Navigation Guide and GRADE tools and approaches adapted to this project.ResultsTwenty-two studies (20 cohort studies, 2 case-control studies) met the inclusion criteria, comprising a total of 839,680 participants (364,616 females) in eight countries from three WHO regions (Americas, Europe, and Western Pacific). The exposure was measured using self-reports in all studies, and the outcome was assessed with administrative health records (13 studies), self-reported physician diagnosis (7 studies), direct diagnosis by a physician (1 study) or during a medical interview (1 study). The outcome was defined as an incident non-fatal stroke event in nine studies (7 cohort studies, 2 case-control studies), incident fatal stroke event in one cohort study and incident non-fatal or fatal (“mixed”) event in 12 studies (all cohort studies). Cohort studies were judged to have a relatively low risk of bias; therefore, we prioritized evidence from these studies, but synthesised evidence from case-control studies as supporting evidence. For the bodies of evidence for both outcomes with any eligible studies (i.e. stroke incidence and mortality), we did not have serious concerns for risk of bias (at least for the cohort studies).Eligible studies were found on the effects of long working hours on stroke incidence and mortality, but not prevalence. Compared with working 35–40 h/week, we were uncertain about the effect on incidence of stroke due to working 41–48 h/week (relative risk (RR) 1.04, 95% confidence interval (CI) 0.94–1.14, 18 studies, 277,202 participants, I2 0%, low quality of evidence). There may have been an increased risk for acquiring stroke when working 49–54 h/week compared with 35–40 h/week (RR 1.13, 95% CI 1.00–1.28, 17 studies, 275,181participants, I2 0%, p 0.04, moderate quality of evidence). Compared with working 35–40 h/week, working ≥55 h/week may have led to a moderate, clinically meaningful increase in the risk of acquiring stroke, when followed up between one year and 20 years (RR 1.35, 95% CI 1.13 to 1.61, 7 studies, 162,644 participants, I2 3%, moderate quality of evidence).Compared with working 35–40 h/week, we were very uncertain about the effect on dying (mortality) of stroke due to working 41–48 h/week (RR 1.01, 95% CI 0.91–1.12, 12 studies, 265,937 participants, I2 0%, low quality of evidence), 49–54 h/week (RR 1.13, 95% CI 0.99–1.29, 11 studies, 256,129 participants, I2 0%, low quality of evidence) and 55 h/week (RR 1.08, 95% CI 0.89–1.31, 10 studies, 664,647 participants, I2 20%, low quality of evidence).Subgroup analyses found no evidence for differences by WHO region, age, sex, socioeconomic status and type of stroke. Sensitivity analyses found no differences by outcome definition (exclusively non-fatal or fatal versus “mixed”) except for the comparison working ≥55 h/week versus 35–40 h/week for stroke incidence (p for subgroup differences: 0.05), risk of bias (“high”/“probably high” ratings in any domain versus “low”/“probably low” in all domains), effect estimate measures (risk versus hazard versus odds ratios) and comparator (exact versus approximate definition).ConclusionsWe judged the existing bodies of evidence for human evidence as “inadequate evidence for harmfulness” for all exposure categories for stroke prevalence and mortality and for exposure to 41–48 h/week for stroke incidence. Evidence on exposure to 48–54 h/week and ≥55 h/week was judged as “limited evidence for harmfulness” and “sufficient evidence for harmfulness” for stroke incidence, respectively. Producing estimates for the burden of stroke attributable to exposures to working 48–54 and ≥55 h/week appears evidence-based, and the pooled effect estimates presented in this systematic review could be used as input data for the WHO/ILO Joint Estimates.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. In this paper, we present the protocol for two systematic reviews of parameters for estimating the number of deaths and disability-adjusted life years from alcohol consumption and alcohol use disorder attributable to exposure to long working hours, to inform the development of the WHO/ILO joint methodology. OBJECTIVES: We aim to systematically review studies on exposure to long working hours (Systematic Review 1) and systematically review and meta-analyse estimates of the effect of exposure to long working hours on alcohol consumption and alcohol use disorder (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework. DATA SOURCES: Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, including MEDLINE, Embase, Web of Science, CISDOC and PsychINFO. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand-search reference list of previous systematic reviews and included study records; and consult additional experts. STUDY ELIGIBILITY AND CRITERIA: We will include working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but exclude children (

BACKGROUND: Varicose veins affect nearly 30% of the world’s population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence. DESIGN AND SETTING: Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP). METHODS: Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date. RESULTS: 51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality. CONCLUSIONS: There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.

Introduction Major concerns regarding the use of medication during pregnancy justify the need for safer interventions. Acupuncture is an emerging alternative for several clinical conditions during this period. The objective of this study is to summarise evidence derived from systematic reviews (SRs) focusing on acupuncture for pregnancy-related acute conditions. Methods Review of SRs. A systematic literature search was carried out in several electronic databases, aiming to include all SRs assessing the effects of acupuncture for acute conditions during pregnancy. Methodological quality and quality of the publication/reporting of each SR were assessed by the application of AMSTAR (Assessing the Methodological Quality of Systematic Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), respectively. Results The initial search retrieved 11 492 records, of which 16 SRs met our inclusion criteria. The average AMSTAR score was 7.3, the lowest score being 3 and the highest 11. The lowest PRISMA score was 12, the highest 25, and the average PRISMA score was 19.9. The results support the proposal that acupuncture might be considered an option for alleviating pain during labour, for correcting breech presentation, and for managing pelvic and back pain during pregnancy. There is insufficient evidence to recommend acupuncture for inducing labour, managing nausea and vomiting in early pregnancy, improving sleep quality, controlling nausea and vomiting associated with Caesarean delivery, and managing urinary infection. Conclusions Acupuncture might be an option for alleviating pain during labour, for correcting breech presentation, and for managing pelvic and back pain during pregnancy. More studies are needed to confirm the effects of acupuncture for other pregnancy-related acute conditions.

A alocação de recursos em saúde é contingenciada pela desproporção entre as numerosas demandas da população e a relativa insuficiência de recursos para atendê-las. Esta desproporção faz com que processos decisórios sobre incorporação ou desinvestimento de tecnologias tenham que ser conduzidos, visando a garantir a eficiência dos sistemas de saúde. A velocidade em que as tecnologias em saúde são desenvolvidas e disponibilizadas no mercado, aliada ao alto custo das tecnologias emergentes, torna o processo decisório essencial para a garantia da viabilidade financeira dos sistemas de saúde, públicos ou privados, ao longo do tempo. O objetivo do presente estudo é discutir, com base em um caso específico, a magnitude do impacto orçamentário relacionado à incorporação de tecnologias de alto custo para o tratamento de condições de saúde com alta prevalência e potenciais consequências. O caso relatado foi selecionado a partir das propostas de incorporação da próxima atualização do rol de cobertura da Agência Nacional de Saúde Suplementar (ANS), por seu expressivo impacto epidemiológico e orçamentário. O cenário em análise envolveu a avaliação do impacto orçamentário da incorporação da toxina onabotulínica A como tratamento profilático da migrânea crônica, em relação ao cenário alternativo, no qual não existe oferta de tratamento para esta situação clínica pelas operadoras de saúde. A migrânea (ou enxaqueca) é um distúrbio neurológico caracterizado por episódios recorrentes de cefaleia de intensidade moderada a grave, localização unilateral, caráter pulsátil e agravada por esforço físico. O quadro crônico de migrânea é definido pela presença de cefaleia em 15 dias ou mais dias ao mês, por pelo menos três meses, levando ao comprometimento de qualidade de vida e a impacto econômico relevante para sistemas de saúde e sociedade. A análise de impacto orçamentário foi desenvolvida para a perspectiva da saúde suplementar, levando em consideração os aspectos epidemiológicos a partir de revisão de dados de literatura. A prevalência de migrânea crônica aplicada na análise foi de 1,8% da população total a proporção de pacientes em uso de tratamento de tratamento profilático foi de 33,3%. Custos diretos envolveram a toxina onabotulínica A (Botox® 200 UI), valorada a R$ 3608,99/ unidade (PF, ICMS 18%), e o procedimento de aplicação, valorado a R$ 721,90 /aplicação (CBHPM 2.01.03.14-0, Porte 4A, Custo operacional 1,950). O número de unidades anuais por caso foi de 4,89 (estudo PREEMPT). Custos associados envolveram a proporção de pacientes com migrânea crônica com visita ao pronto-socorro (9,6% no grupo toxina onabotulínica A e 20,2% no grupo comparador, Rothrock 2014) e proporção de pacientes com hospitalização (7,4% no grupo toxina onabotulínica A e 15,7% no grupo comparador, Rothrock 2014). Os custos da internação e de visita ao pronto socorro foram obtidos a partir de estudo da literatura. Por fim, assumiu-se a premissa de market share inicial de 5%, com incrementos de 5% ao ano, atingindo 25% ao final do horizonte temporal da análise de cinco anos. Foi realizada análise de sensibilidade determinística multivariada, do tipo pior cenário e melhor cenário, com variação simultânea dos parâmetros de custo da toxina onabotulínica A e da aplicação (+/- 15%), assim como variação do número de aplicações (4 a 5 unidades). Todas as análises foram realizadas no software Microsoft Excel®. Os resultados das análises foram apresentados, considerando-se o impacto orçamentário incremental, definido pelo impacto da incorporação da toxina onabotulínica em relação ao cenário atual. O impacto orçamentário incremental para o ano de 2021 foi de R$ 232.086.504,69; para o ano de 2022 de R$ 469.356.673,15; para 2023 de R$ 711.564.324,51; para 2024 de R$ 958.374.943,11 e para 2025 de R$ 1.209.289.462,12. O total acumulado em cinco anos foi de R$ 3.580.671.907,58. As estimativas para o melhor cenário, com redução dos custos de aplicação e da toxina em 15% e utilização de quatro aplicações anuais evidenciaram impacto orçamentário incremental para o ano de 2021 de R$ 159.777.475,73, e para o acumulado de cinco anos foi de R$ 2.465.075.337,17. As estimativas para o pior cenário, com elevação dos custos da toxina e da aplicação em 15% e utilização de cinco aplicações anuais, evidenciaram impacto orçamentário incremental para o ano de 2021 de R$ 273.821.917,38 e para o acumulado de cinco anos de R$ 4.224.573.283,79. A análise do presente caso evidencia a magnitude do impacto orçamentário relacionado à incorporação de tecnologias de alto custo em sistemas de saúde, comumente já desafiados em relação à necessidade de manutenção de seu equilíbrio financeiro, em virtude da diversidade de demandas a serem atendidas e do alto custo das tecnologias em saúde. O impacto orçamentário incremental estimado é de tal magnitude que, caso haja incorporação da tecnologia, alguns efeitos seriam esperados. Em primeiro lugar, outras tecnologias em avaliação para incorporação pelo rol poderiam ser preteridas, pela ausência de margem para acomodar incrementos orçamentários adicionais, refletindo o custo de oportunidade. Em segundo lugar, esperar-se-ia um maior risco operacional para a manutenção de pequenas operadoras, o que, em última instância poderia se refletir na redução da oferta de planos de saúde, prejudicando o equilíbrio do mercado. Poderia ainda ser esperado o repasse para o consumidor final, aumentando os custos da contratação dos planos de saúde, acarretando a migração de indivíduos para o sistema de saúde público. Uma implicação adicional da incorporação de tecnologias no rol da saúde suplementar é a pressão de stakeholders para que também ocorra a incorporação da tecnologia pelo Sistema Único de Saúde (SUS). O alinhamento entre a cobertura de tecnologias pelo rol da ANS e a incorporação de tecnologias pela Comissão Nacional de Incorporação de Tecnologias em Saúde no SUS (Conitec) tem sido observado pela coerência entre as Diretrizes de Utilização para Cobertura de Procedimentos na Saúde Suplementar da ANS (DUT) e os Protocolos Clínicos e Diretrizes Terapêuticos (PCDT) do SUS. Esta consistência visa promover equidade em relação ao acesso aos serviços e recursos de saúde, porém, o alinhamento dos sistemas de saúde público e suplementar pode incorrer em desequilíbrios orçamentários graves, frente às peculiaridades de cada sistema.

The healthcare service in Brazil comprises a public and universal system (Sistema Unico de Saude, SUS), but a considerable part of the population (59.7 million) also maintains a private health insurance as a supplementary care.1 The supplementary system is regulated by an autonomous governmental agency, formally Agencia Nacional de Saude Suplementar (ANS), which regulates the relationship between users and health operators and plans, including financial, legal and coverage aspects. The catalogue of drugs, devices and procedures that should be offered by health plans to their users is updated by ANS every other year for adding, replacing or excluding technologies through a complex process. The process was revisited and has been …

Nausea and vomiting are common and distressing adverse events of chemotherapy. This review focuses on the findings and quality of systematic reviews (SRs) of cannabinoids for chemotherapy-induced nausea and vomiting (CINV). Review of SRs, a systematic literature search, was conducted in several electronic databases and included SRs evaluating cannabinoids for CINV in cancer patients. Methodological quality and quality of reporting were evaluated by AMSTAR and PRISMA, respectively. Initial search retrieved 2,206 records, and 5 SRs were included. On the basis of findings of the sole SR judged as high methodological quality, cannabinoids seem to be more effective than placebo, equal to prochlorperazine for reducing CINV, and to be preferred by patients. The response to different combinations of antiemetic agents seems to be equal to 1 antiemetic alone. The average of AMSTAR score was 5, and the average of PRISMA score was 13.2. Cannabinoids represent a valuable option for treating CINV, despite the adverse events related to treatment, such as drowsiness and cognitive impairment. There is no good quality evidence to recommend or not the use of cannabinoids for CINV. More studies are still needed to evaluate the effectiveness of cannabinoids when compared with modern antiemetics.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing Joint Estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic data suggests that exposure to long working hours may cause ischaemic heart disease (IHD). In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from IHD that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. OBJECTIVES: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on IHD (three outcomes: prevalence, incidence and mortality). DATA SOURCES: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including MEDLINE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. STUDY ELIGIBILITY AND CRITERIA: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged

RESUMO Introdução: Há diversas terapias sendo utilizadas, consideradas ou propostas para o tratamento da COVID-19, muitas carecendo de apropriada avaliação de efetividade e segurança. O propósito deste documento é fornecer recomendações baseadas nas evidências científicas disponíveis e em sua interpretação transparente, para subsidiar decisões sobre o tratamento farmacológico da COVID-19 no Brasil. Métodos: Um grupo de 27 especialistas e metodologistas integraram a força-tarefa formada pela Associação de Medicina Intensiva Brasileira (AMIB), pela Sociedade Brasileira de Infectologia (SBI) e pela Sociedade Brasileira de Pneumologia e Tisiologia (SBPT). Foram realizadas revisões sistemáticas rápidas, atualizadas até 28 de abril de 2020. A qualidade das evidências e a elaboração das recomendações seguiram o sistema GRADE. As recomendações foram elaboradas nos dias 5, 8 e 13 de maio de 2020. Resultados: Foram geradas 11 recomendações, embasadas em evidência de nível baixo ou muito baixo. Não há indicação para uso de rotina de hidroxicloroquina, cloroquina, azitromicina, lopinavir/ritonavir, corticosteroides ou tocilizumabe no tratamento da COVID-19. Heparina deve ser utilizada em doses profiláticas no paciente hospitalizado, mas não deve ser realizada anticoagulação na ausência de indicação clínica específica. Antibacterianos e oseltamivir devem ser considerados somente nos pacientes em suspeita de coinfecção bacteriana ou por influenza, respectivamente. Conclusão: Até o momento, não há intervenções farmacológicas com efetividade e segurança comprovada que justifiquem seu uso de rotina no tratamento da COVID-19, devendo os pacientes serem tratados preferencialmente no contexto de pesquisa clínica. As recomendações serão revisadas continuamente, de forma a capturar a geração de novas evidências. ABSTRACT Introduction: Different therapies are currently used, considered, or proposed for the treatment of COVID-19; for many of those therapies, no appropriate assessment of effectiveness and safety was performed. This document aims to provide scientifically available evidence-based information in a transparent interpretation, to subsidize decisions related to the pharmacological therapy of COVID-19 in Brazil. Methods: A group of 27 experts and methodologists integrated a task-force formed by professionals from the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB), the Brazilian Society of Infectious Diseases (Sociedad Brasileira de Infectologia - SBI) and the Brazilian Society of Pulmonology and Tisiology (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT). Rapid systematic reviews, updated on April 28, 2020, were conducted. The assessment of the quality of evidence and the development of recommendations followed the GRADE system. The recommendations were written on May 5, 8, and 13, 2020. Results: Eleven recommendations were issued based on low or very-low level evidence. We do not recommend the routine use of hydroxychloroquine, chloroquine, azithromycin, lopinavir/ritonavir, corticosteroids, or tocilizumab for the treatment of COVID-19. Prophylactic heparin should be used in hospitalized patients, however, no anticoagulation should be provided for patients without a specific clinical indication. Antibiotics and oseltamivir should only be considered for patients with suspected bacterial or influenza coinfection, respectively. Conclusion: So far no pharmacological intervention was proven effective and safe to warrant its use in the routine treatment of COVID-19 patients; therefore such patients should ideally be treated in the context of clinical trials. The recommendations herein provided will be revised continuously aiming to capture newly generated evidence.

Background The World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates). For this, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors will be conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methods is to assess risk of bias (RoB) of individual studies. In this article, we present and describe the development of such a tool, called the Risk of Bias in Studies estimating Prevalence of Exposure to Occupational risk factors (RoB-SPEO) tool; report results from RoB-SPEO's pilot testing; note RoB-SPEO's limitations; and suggest how the tool might be tested and developed further. Methods Selected existing RoB tools used in environmental and occupational health systematic reviews were reviewed and analysed. From existing tools, we identified domains for the new tool and, if necessary, added new domains. For each domain, we then identified and integrated components from the existing tools (i.e. instructions, domains, guiding questions, considerations, ratings and rating criteria), and, if necessary, we developed new components. Finally, we elicited feedback from other systematic review methodologists and exposure scientists and agreed upon RoB-SPEO. Nine experts pilot tested RoB-SPEO, and we calculated a raw measure of inter-rater agreement (Pi) for each of its domain, rating Pi 0.80 as almost perfect agreement. Results Our review found no standard tool for assessing RoB in prevalence studies of exposure to occupational risk factors. We identified six existing tools for environmental and occupational health systematic reviews and found that their components for assessing RoB differ considerably. With the new RoB-SPEO tool, assessors judge RoB for each of eight domains: (1) bias in selection of participants into the study; (2) bias due to a lack of blinding of study personnel; (3) bias due to exposure misclassification; (4) bias due to incomplete exposure data; (5) bias due to conflict of interest; (6) bias due to selective reporting of exposures; (7) bias due to difference in numerator and denominator; and (8) other bias. The RoB-SPEO's ratings are low, probably low, probably high, high or no information. Pilot testing of the RoB-SPEO tool found substantial inter-rater agreement for six domains (range of Pi for these domains: 0.51–0.80), but poor agreement for two domains (i.e. Pi of 0.31 and 0.33 for biases due to incomplete exposure data and in selection of participants into the study, respectively). Limitations of RoB-SPEO include that it has not yet been fully performance-tested. Conclusions We developed the RoB-SPEO tool for assessing RoB in prevalence studies of exposure to occupational risk factors. The tool will be applied and its performance tested in the ongoing systematic reviews for the WHO/ILO Joint Estimates., Highlights • WHO and ILO are systematically reviewing occupational exposure prevalence studies. • Assessing risk of bias (RoB) in individual studies is a core step of systematic reviews. • We developed RoB-SPEO, a tool to assess RoB in occupational exposure prevalence studies. • The performance of RoB-SPEO will be tested in the WHO/ILO systematic reviews.

BACKGROUND: People with multiple sclerosis (MS) have complex symptoms and different types of needs. These demands include how to manage the burden of physical disability as well as how to organise daily life, restructure social roles in the family and at work, preserve personal identity and community roles, keep self‐sufficiency in personal care, and how to be part of an integrated care network. Palliative care teams are trained to keep open full and competent lines of communication about symptoms and disease progression, advanced care planning, and end‐of‐life issues and wishes. Teams create a treatment plan for the total management of symptoms, supporting people and families on decision‐making. Despite advances in research and the existence of many interventions to reduce disease activity or to slow the progression of MS, this condition remains a life‐limiting disease with symptoms that impact negatively the lives of people with it and their families. OBJECTIVES: To assess the effects (benefits and harms) of palliative care interventions compared to usual care for people with any form of multiple sclerosis: relapsing‐remitting MS (RRMS), secondary‐progressive MS (SPMS), primary‐progressive MS (PPMS), and progressive‐relapsing MS (PRMS) We also aimed to compare the effects of different palliative care interventions. SEARCH METHODS: On 31 October 2018, we conducted a literature search in the specialised register of the Cochrane MS and Rare Diseases of the Central Nervous System Review Group, which contains trials from CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Clinical trials.gov and the World Health Organization International Clinical Trials Registry Platform. We also searched PsycINFO, PEDro and Opengrey. We also handsearched relevant journals and screened the reference lists of published reviews. We contacted researchers in palliative care and multiple sclerosis. SELECTION CRITERIA: Randomised controlled trials (RCTs) and cluster randomised trials were eligible for inclusion, as well as the first phase of cross‐over trials. We included studies that compared palliative care interventions versus usual care. We also included studies that compared palliative care interventions versus another type of palliative interventions. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. We summarised key results and certainty of evidence in a 'Summary of Finding' table that reported outcomes at six or more months of post‐intervention. MAIN RESULTS: Three studies (146 participants) met our selection criteria. Two studies compared multidisciplinary, fast‐track palliative care versus multidisciplinary standard care while on a waiting‐list control, and one study compared a multidisciplinary palliative approach versus multidisciplinary standard care at different time points (12, 16, and 24 weeks). Two were RCTs with parallel design (total 94 participants) and one was a cross‐over design (52 participants). The three studies assessed palliative care as a home‐based intervention. One of the three studies included participants with 'neurodegenerative diseases', with MS people being a subset of the randomised population. We assessed the risk of bias of included studies using Cochrane's 'Risk of Bias' tool. We found no evidence of differences between intervention and control groups in long‐time follow‐up (> six months post‐intervention) for the following outcomes: mean change in health‐related quality of life (SEIQoL ‐ higher scores mean better quality of life; MD 4.80, 95% CI ‐12.32 to 21.92; participants = 62; studies = 1; very low‐certainty evidence), serious adverse events (RR 0.97, 95% CI 0.44 to 2.12; participants = 76; studies = 1, 22 events, low‐certainty evidence) and hospital admission (RR 0.78, 95% CI 0.24 to 2.52; participants = 76; studies = 1, 10 events, low‐certainty evidence). The three included studies did not assess the following outcomes at long term follow‐up (> six months post intervention): fatigue, anxiety, depression, disability, cognitive function, relapse‐free survival, and sustained progression‐free survival. We did not find any trial that compared different types of palliative care with each other. AUTHORS' CONCLUSIONS: Based on the findings of the RCTs included in this review, we are uncertain whether palliative care interventions are beneficial for people with MS. There is low‐ or very low‐certainty evidence regarding the difference between palliative care interventions versus usual care for long‐term health‐related quality of life, adverse events, and hospital admission in patients with MS. For intermediate‐term follow‐up, we are also uncertain about the effects of palliative care for the outcomes: health‐related quality of life (measured by different assessments: SEIQoL or MSIS), disability, anxiety, and depression.

Objectives To describe the experience of building a teaching partnership between the Oxford CEBM and leading Brazilian Medical Schools, thus aiming to increase the effectiveness and quality of EBM teaching in Brazil. Brazil is the 5th largest country in the world, with a population of approximately 210 million people. There are 336 active medical schools in Brazil, which graduate an average of 34,000 medical professionals each year. Of these schools, less than 20% have in their curricula a formal Evidence-Based Medicine (EBM) discipline. The lack of formal EBM integration into medical school curricula is not exclusively a national challenge for Brazil. Data from the USA and UK suggests that only 60% of curricula include formal EBM content. Despite the recognition of the importance of EBM education and its influence on medical training around the world, challenges remain in integrating EBM education into the medical curriculum, facilitating communication between practitioners, increasing the capacity for EBM’s meaningful use in clinical practice, and ensuring medical professionals have the knowledge and skills to support evidence-based practice. Concerned about these issues, two Oxford post-graduate students of Evidence-Based Health Care and a Senior Research Fellow of the Oxford Centre for Evidence-Based Medicine (CEBM) proposed the creation of a partnership between Oxford’s CEBM and the EBM Departments of leading Brazilian medical schools. This partnership, named the ‘Oxford-Brazil EBM Alliance,’ aims to provide Evidence-Based Medicine and curriculum development training to medical educators (formal professors or tutors) in Brazil, thus fostering sustainability and replicability of effective teaching and learning throughout medical schools in Brazil. Objective: To describe the experience of building a teaching partnership between the Oxford CEBM and leading Brazilian Medical Schools, thus aiming to increase the effectiveness and quality of EBM teaching in Brazil. Method: Descriptive Case Study. Results: Two prominent Brazilian medical schools already joined the Oxford-Brazil EBM Alliance: Escola Paulista de Medicina at Universidade Federal de Sao Paulo (EPM-UNIFESP) and Faculdade de Medicina de Petropolis (FMP-FASE). Training will be delivered via 3-day workshops, starting in June 2019, which will be facilitated by faculty from Oxford and Brazil. Other activities may emerge afterwards as instigated by local institutions. This project is underpinned in a concept of developing a ‘Center of Excellence in EBM Teaching and Training’, which intends to set the standard for EBM teaching in Brazil and throughout South America. It is our overarching aim that over time Brazil will have qualified faculty members to teach EBM in all its Medical Teaching Institutions. To our knowledge, a similar partnership does not exist in our region. In a second phase, we intend to extend this project to other countries in South America, offering further opportunities for international collaboration. Method Descriptive Case Study. Results Two prominent Brazilian medical schools already joined the Oxford-Brazil EBM Alliance: Escola Paulista de Medicina at Universidade Federal de Sao Paulo (EPM-UNIFESP) and Faculdade de Medicina de Petropolis (FMP-FASE). Training will be delivered via 3-day workshops, starting in June 2019, which will be facilitated by faculty from Oxford and Brazil. Other activities may emerge afterwards as instigated by local institutions. This project is underpinned in a concept of developing a ‘Center of Excellence in EBM Teaching and Training’, which intends to set the standard for EBM teaching in Brazil and throughout South America. It is our overarching aim that over time Brazil will have qualified faculty members to teach EBM in all its Medical Teaching Institutions. To our knowledge, a similar partnership does not exist in our region. In a second phase, we intend to extend this project to other countries in South America, offering further opportunities for international collaboration. Conclusions The Oxford - Brazil EBM Alliance is a promising partnership that can bring Evidence-Based Medicine training to thousands of medical professors and interdisciplinary health care teams throughout Brazil and its neighboring countries. The proposed ‘teach the teacher’ approach can facilitate EBM teaching and learning, foster future leaders, and ultimately benefit patients and healthcare systems throughout Brazil.

Introduction Platelet-rich plasma (PRP) is a blood component therapy with a supraphysiological concentration of platelets derived from allogenic or, more commonly, autologous blood. PRP has been used in different non-transfusion indications because of its role in the promotion of tissue repair and healing, in fields such as Traumatology, Dermatology and Dentistry. Objective To provide a synthesis of the efficacy of PRP for different clinical situations. Methods Systematic searches were carried out in MEDLINE, Embase, Cochrane Library and LILACS in July 2018 to identify systematic reviews (SRs) of randomized clinical trials (RCTs) focusing on PRP for non-transfusion use. Two authors independently screened all retrieved references in two stages (titles and abstracts at a first stage and full texts at a second stage). The methodological quality of SRs that met the eligibility criteria was appraised by AMSTAR 2. Conclusions were based on the most recent SRs with highest quality. Results One thousand two hundred and forty references were retrieved. After checking the inclusion criteria, 29 SRs of RCTs related to three different fields (wound care, Orthopedics and Dentistry) were included. The results suggest the benefit of PRP for different clinical situations, such as diabetic wounds, acute lesions of musculoskeletal system, rotator cuff lesions, tendinopathies, knee and hip osteoarthritis, total knee arthroplasty, allogenic bone graft for dental implants and periodontal intrabony defects. Conclusion There is low to moderate quality evidence supporting the efficacy of PRP for specific clinical situations. The low quality of the evidence limits the certainty of these findings. Well-planned and well-conducted RCTs are still needed to further assess the efficacy of PRP.

BACKGROUND: The therapeutic effects of cannabinoid compounds have been the center of many investigations. This study provides a synthesis on all Cochrane systematic reviews (SRs) that assessed the use of cannabinoids as a therapeutic approach. DESIGN AND SETTING: Review of SRs, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). METHODS: A broad search was conducted in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed the efficacy and safety of cannabinoids as a therapeutic approach. The results and key characteristics of all reviews included were summarized and discussed. RESULTS: Eight SRs were included. They assessed the use of cannabinoids for the following types of conditions: neurological (two SRs), psychiatric (two SRs), rheumatological (one SR), infectious (one SR) and oncological (two SRs). There was moderate-quality evidence showing that the use of cannabinoids reduced nausea and vomiting among adults, compared with placebo. Additionally, there was moderate-quality evidence showing that there was no difference between cannabinoids and prochlorperazine regarding the number of participants who reported vomiting, in this same population. CONCLUSIONS: This review identified eight Cochrane systematic reviews that provided evidence of unknown to moderate quality regarding the use of cannabinoids as a therapeutic intervention. Further studies are still imperative for solid conclusions to be reached regarding practical recommendations.

CONTEXT AND OBJECTIVE: Psoriasis is a common chronic inflammatory skin disease characterized by abnormal and increased growth of the cells that produce keratin and abnormal functioning of the immune system. We aimed to summarize the evidence available regarding interventions for patients with psoriasis. DESIGN AND SETTING: Review of systematic reviews, developed in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A systematic search was conducted to identify Cochrane systematic reviews that fulfilled the eligibility criteria. Two authors screened titles and abstracts that had been retrieved through the search strategy. The results from all the Cochrane systematic reviews that were included were summarized and presented in a narrative synthesis. RESULTS: We included six Cochrane systematic reviews assessing interventions for treating psoriasis. The findings from high-quality evidence were that (a) etanercept reduced the psoriasis severity index, compared with placebo and (b) steroids plus vitamin D, compared with vitamin D alone, improved the skin clearance rate, as assessed by investigators, but was associated with a higher proportion of participants who dropped out due to adverse events. For all other comparisons, the quality of the evidence ranged from moderate to very low. CONCLUSION: This review included six Cochrane systematic reviews that provided evidence ranging in quality from unknown to high, regarding management of psoriasis. Further randomized controlled trials are imperative to reduce the uncertainties relating to several treatments that are already used in clinical practice.

BACKGROUND: This study identified and summarized all Cochrane systematic reviews (SRs) on the effects of ten integrative practices that were recently added to the Brazilian public healthcare system (SUS). DESIGN AND SETTING: Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp). METHODS: Review of Cochrane SRs on the following interventions were identified, summarized and critically assessed: apitherapy, aromatherapy, bioenergetics, family constellation, flower therapy, chromotherapy, geotherapy, hypnotherapy, hand imposition or ozone therapy. RESULTS: We included a total of 16 SRs: 4 on apitherapy, 4 on aromatherapy, 6 on hypnotherapy and 2 on ozone therapy. No Cochrane SR was found regarding bioenergetics, family constellation, chromotherapy, clay therapy, flower therapy or hand imposition. The only high-quality evidence was in relation to the potential benefit of apitherapy, specifically regarding some benefits from honey dressings for partial healing of burn wounds, for reduction of coughing among children with acute coughs and for preventing allergic reactions to insect stings. CONCLUSION: Except for some specific uses of apitherapy (honey for burn wounds and for acute coughs and bee venom for allergic reactions to insect stings), the use of ten integrative practices that have recently been incorporated into SUS does not seem to be supported by evidence from Cochrane SRs.