Strength Of Recommendation Taxonomy Research Articles

Coach-led prevention programs are effective in reducing anterior cruciate ligament injury risk in female athletes: A number-needed-to-treat analysis.

The purpose of this study was to determine whether the effectiveness of an anterior cruciate ligament (ACL) prevention program is impacted by the individual(s) directing the program. A number-needed-to-treat analysis compared the effectiveness of injury prevention measures when either directed by a coach or a mixed leadership group consisting of coach and healthcare providers. Eleven studies were included for analysis. Number-needed-to-treat and relative risk reduction (RRR) were calculated for each study and data sets were pooled based on the intervention leader. Quality of evidence was determined by assessing individual studies (PEDro score x¯=4.55±1.97, range=2-7), applying the Oxford Centre for Evidence-Based Medicine Levels of Evidence (CEBM=2a), and the Strength of Recommendation Taxonomy (SORT=Level B). The mixed leadership group studies' RRR=48.2% (95% confidence interval (CI)=22-65) and a number-needed-to-benefit of 120 (CI=73-303) while the coach-led group's RRR=58.4% (CI=40-71) and a number-needed-to-benefit=133 (CI=96-217). These results demonstrate that a coach-led ACL injury prevention program approach is as effective as a mixed group leadership approach. Coach-led prevention programs can be more widely implemented; however, it is imperative to ensure adequate training is in place prior to implementation of such intervention.

Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features.

Context:Evaluation of groin pain in athletes may be challenging as pain is typically poorly localized and the pubic symphyseal region comprises closely approximated tendons and muscles. As such, magnetic resonance imaging (MRI) and ultrasound (US) may help determine the etiology of groin pain.Evidence Acquisition:A PubMed search was performed using the following search terms: ultrasound, magnetic resonance imaging, sports hernia, athletic pubalgia, and groin pain. Date restrictions were not placed on the literature search.Study Design:Clinical review.Level of Evidence:Level 4.Results:MRI is sensitive in diagnosing pathology in groin pain. Not only can MRI be used to image rectus abdominis/adductor longus aponeurosis and pubic bone pathology, but it can also evaluate other pathology within the hip and pelvis. MRI is especially helpful when groin pain is poorly localized. Real-time capability makes ultrasound useful in evaluating the pubic symphyseal region, as it can be used for evaluation and treatment.Conclusion:MRI and US are valuable in diagnosing pathology in athletes with groin pain, with the added utility of treatment using US-guided intervention.Strength-of Recommendation Taxonomy:C

Ácido acetilsalicílico na prevenção da pré-eclâmpsia: uma revisão baseada na evidência

Objectives: To review the current evidence for the effectiveness of aspirin in preventing preeclampsia. Data sources: MEDLINE and evidence-based medicine websites. Methods: We searched for clinical practice guidelines (CPG), randomized controlled trials (RCT), systematic reviews (SR) and meta-analyzes (MA), published between 13/11/2005 and 13/11/2015, using the MESH terms ‘pre-eclampsia’ and ‘aspirin’ and the Portuguese DeCS terms ‘pre-eclâmpsia’ and ‘aspirina’. The Strength of Recommendation Taxonomy (SORT) of American Academy of Family Physicians was used for the assignment of levels of evidence (LE) and the strength of recommendations (SOR). Results: A total of 14 articles were selected for this review out of 296 articles found. These included seven MA, three SR, three CPG and one RCT. The SR and MA found benefits for aspirin in the prevention of preeclampsia, particularly in women at high-risk. One SR with LE 2 found no evidence to support the use of aspirin prophylaxis in women at risk for preeclampsia. Studies that analyzed women at low-risk separately found no benefit from the use of aspirin in this group of women. The CPG recommend the use of aspirin in the prevention of preeclampsia in high-risk women and discouraged its use in low-risk women. The RCT supported the same recommendation for high-risk women. Conclusions: The available evidence suggests that low-dose aspirin is effective for the prevention of preeclampsia in women at risk. There is clear evidence of its benefit in high-risk women (SOR A) and its use is discouraged in low-risk women (SOR A). There is still a need for more high quality studies with similar methods conducted in relevant populations to support these recommendations.

Surgical treatment vs. conservative treatment in intravenous bisphosphonate-related osteonecrosis of the jaws. Systematic review.

AimsTo determine the success rates of the surgical and non-surgical treatments in the management of bisphosphonate-related osteonecrosis of the jaws (BRONJ).Material and MethodsA systematic review of the literature was made. A PubMed Medline database search was performed in order to include clinical studies published in English,between2004 and 2014 with the following key-words: “BRONJ AND treatment” and “NOT osteoporosis”. The following data was gathered: authors, title, year of publication, aim of study, level of evidence, sample size, treatment performed, treatment outcomes and follow-up. Studies including more than 20 patients with at least 6 months of follow-up, and that specify the different treatment approaches and their outcomes were included. Systematic reviews were excluded.All studies were classified according to the SORT criteria (Strength of Recommendation Taxonomy).ResultsThe initial electronic search yielded 169 papers, and 13 studies were added after a manual search (total of 182 studies). After analysing the title and abstract and removing duplicates, 31 full-texts were obtained. A total of 12 papers were finally included. Two were classified as level 3 evidence and 9 as level 2. The quality of the selected studies and the risk of bias were also reported.ConclusionsSurgical treatments like sequestrectomy, surgical debridement and bone osteotomies provide successful treatment outcomes, with success rates ranging from 58 to 100%. Controlled randomized clinical trials with larger samples and longer follow-up are needed to support these findings. Key words:BRONJ, treatment.

Clinical practice guidelines for Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a common psychiatric illness with lifetime prevalence of 1-3% [1]. It is the fourth-most common psychiatric illness and a leading cause of disability. OCD is associated with significant impairment in functioning, quality of life and disability. If untreated, OCD is a chronic illness with a waxing and waning of symptoms. A recent meta-analysis of long-term naturalistic prospective studies demonstrated that nearly a half of patients experience remission with much higher rates of remission in Indian patients compared to those in the west [2]. Early diagnosis and appropriate treatment may improve outcomes. Despite OCD being a common mental illness, most seek treatment after several years of suffering. Those who suffer from OCD tend to be secretive about their symptoms and suffer from shame and embarrassment. Less than a third of OCD sufferers receive appropriate pharmacotherapy and even less receive evidence-based psychotherapy. Symptoms The hallmarks of OCD are presence of obsessions and compulsions. Obsessions are repetitive, unwanted, intrusive thoughts, images or urges that are mostly ego-dystonic and cause severe distress or anxiety. Compulsions (or rituals) are repetitive behaviours or mental acts that are performed in response to an obsession to reduce anxiety/distress or prevent a dreaded consequence. Obsessions and compulsions are time consuming, distressing and are often resisted unsuccessfully. Clinical manifestations of OCD are remarkably similar across cultures and geographic locations. Common obsessions and compulsions and symptom dimensions identified through factor-analytical studies are shown in Table 1. Table 1 Common symptoms of OCD

Opioid-Induced Constipation and Bowel Dysfunction: A Clinical Guideline.

ObjectiveTo formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction.SettingConstipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term “opioid-induced bowel dysfunction.”MethodsA literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system.ResultsFrom a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction.ConclusionsIn recent years, more insight has been gained in the pathophysiology of this “entity”; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.

Is hyponatraemia a major or a trivial issue in endurance sports?

Exercise-associated hyponatraemia (EAH) is a potentially serious and occasionally fatal outcome in marathons and other long duration events. In the last 30 years, there have been more than 500 publications on hyponatraemia and exercise. Some studies, who point to the fatalities that have occurred, consider this as a major concern while others dismiss it as a rare and unimportant condition. This work critically assessed and summarized the main evidence on the prevalence and aetiology of the condition and on possible preventive measures. Hence, more than 400 relevant articles were identified by a search in PubMed and other secondary sources like NICE and 112 abstracts and 42 full text were reviewed. Level and strength of evidence supporting the conclusions were assessed by Strength of Recommendation Taxonomy (SORT). EAH is more frequently asymptomatic. If its frequency through finishers of an endurance event is estimated from 0 to 51%, the incidence of symptomatic EAH in marathon is estimated to less than 1% of all participants. Actual evidence correlates EAH incidence to 2 major etiologies: an overhydration by excessive fluid intake and a persistent secretion of arginine vasopressin. The prevention consists primarily of avoiding overdrinking. In this context, the key recommendation is to drink according to thirst to avoid dehydration and overhydration. To provide such prevention, besides educating athletes, education for the supporting event staff is recommended to avoid errors in fluid supplementation advices. Furthermore, the medical staff covering such events should be familiar with early recognition and diagnosis of EAH to avoid complications and improper real-time drink supplementation. In conclusion, EAH is a life threatening condition during endurance sport events. Besides a limited incidence, the increasing numbers of participants in events like marathons induce a higher rate of symptomatic EAH. It seems, according to actual evidence to be a serious concern in endurance sports.

Musicoembriologia – qual o impacto no neurodesenvolvimento infantil

Introduction: Musicembriology is music listening during pregnancy, in order to improve maternal-fetal relationship and child neurodevelopment. However, their relationship is not well established, so it remains a controversial issue.Objective: Review of the available evidence on the impact of music listening during pregnancy on children’s neurodevelopment.Methods: Meta-analysis research, systematic reviews, randomized controlled trials, and standards of clinical orientation, in English and Portuguese languages, published between 01/2004 and 04/2014, on the basis Pubmed / Medline, medical sites based on evidence and Portuguese Index of Medical Journal, using the MeSH terms: music; pregnancy; child; neurodevelopment. For the assessment of levels of evidence (NE) and award recommendation forces (FR) scale SORT was used (Strength of Recommendation Taxonomy) of the American Family Physician.Results: Eleven articles were found, four of which were selected: three randomized controlled trials and one systematic review. A randomized controlled trial (NE 1) showed significant improvement in neonatal behavior in children whose mothers listened to music during pregnancy. A randomized controlled trial (NE 2) showed an improvement of maternal-fetal relationship with musicoembriology. Another randomized controlled trial (NE3) and a systematic review (B FR) showed that the intrauterine environment is important in the neonatal brain development, especially the development of the motor and sensorineural cerebral cortex.Conclusion: The available evidence showed that music listening during the embryonic period shows benefit in children’s neurodevelopment. (FR B) However, those obtained studies are few in number and have great heterogeneity in methodological terms. Further studies are needed with controlled populations and similar methodology for the overall recommendation of this measure

Factors Influencing Removable Partial Denture Patient-Reported Outcomes of Quality of Life and Satisfaction: A Systematic Review.

A systematic search of the literature was performed to identify and characterize articles reporting the influence of removable partial denture (RPD) therapy on satisfaction and quality of life (QoL). The literature search for relevant articles published between January 1983 and March 30, 2013 was conducted using keyword searches of electronic databases and complimentary hand searches. The search strategy included the following keyword combinations (MeSH and free-text terms): fail, complication, surviv*, longevity, outcome, patient satisfaction or QoL, and denture or prosthes*, and partial and removable. Based on inclusion and exclusion criteria, articles focused on the effect of RPD therapy were reviewed and classified according to Strength-of-Recommendation Taxonomy (SORT) criteria. The combined search identified 997 publications; 198 duplicates were identified and removed, leaving 799 references for further evaluation. After abstract review, 209 articles were selected and read; 18 reports representing findings from 4002 patients were included. While two studies were prospective comparative investigations, the majority of studies represented cross-sectional and retrospective studies. Different instruments were used to measure oral health-quality of life (OHQoL) and satisfaction. Several investigations reported a significant association of satisfaction and QoL with either (a) age of the patient, (b) number of occluding dental units replaced, (c) replacement of anterior teeth, and (d) nature of the opposing arch. A paucity of detailed investigations concerning outcomes of RPD therapy was noted. Improvement in OHQoL or satisfaction following provision of RPDs was not consistently reported. There is little evidence supporting any association between patient-reported QoL or satisfaction with technical or biological parameters of therapy. Therapeutic success of tooth replacement using RPDs should be carefully considered and compared with alternatives.

The Emerging Role of Mindfulness Meditation as Effective Self-Management Strategy, Part 2: Clinical Implications for Chronic Pain, Substance Misuse, and Insomnia

Mindfulness-based interventions have been increasingly utilized in the management of chronic pain since 1982. This second review of a two-part series evaluates the efficacy, mechanism, and safety of mindfulness meditation for chronic pain, substance use disorder, tobacco use disorder, and insomnia frequently co-occurring after return from deployment. Standard databases were searched until August 4, 2015. 72 relevant systematic reviews and clinical trials met the inclusion criteria. The Strength of Recommendation Taxonomy was used to assess the quality of individual studies and to rate the strength of recommendation (SOR) for each clinical condition. Mindfulness-based interventions effectively and durably reduce pain intensity, improve functional status, pain-related psychological consequences, quality of life (SOR B). They can also be utilized as an adjunctive intervention aimed at improving health-related quality of life in individuals with substance use disorders interested in self-management strategies (SOR B). Mindfulness training for smokers used adjunctively with pharmacotherapy shows efficacy in maintaining abstinence comparable to that of the current standard of care (SOR B). Future large, well-designed randomized clinical trials using active controls in service members and veterans with co-occurring pain and psychological health conditions are necessary to provide more precise clinical guidance.

Pharmacotherapy of conduct disorder: Challenges, options and future directions.

There is a critical need for evaluation of the pharmacotherapies used in conduct disorder (CD), due to the high incidence of off-label prescribing. The aim of this review was to identify concerns associated with the safety, efficacy and impact on quality of life (QOL) that pharmacotherapy has in children and adolescents with CD. A systematic review was undertaken using pre-defined search criteria and four databases, including reference searches. We assessed these studies using the Strength of Recommendation Taxonomy, Grading of Recommendations Assessment, Development and Evaluation, and Review Manager Risk of Bias (RevMan®) tools. There were 12 randomised controlled trials that met our inclusion criteria. antipsychotics, atomoxetine, lithium, clonidine, divalproex sodium and psychostimulants. The antipsychotics demonstrated efficacy, but were associated with adverse effects. Other agents demonstrated mixed responses, highlighting the lack of clinical significance and increased incidence of adverse effects. The management of related adverse effects was addressed to assist with clinical gaps. Overall, there is limited evidence regarding the role of pharmacotherapy in CD. More research is needed that takes into account the heterogeneity of CD and analysis of pharmacotherapy in pure CD.

O papel dos inibidores da fosfodiesterase 5 no tratamento dos sintomas do trato urinário inferior: revisão baseada na evidência

Aim: The aim of this study was to review the evidence for the efficacy and safety of monotherapy with phosphodiesterase 5 inhibitors (PDE5I) in the treatment of lower urinary tract symptoms (LUTS) due to prostatic hyperplasia in men with or without erectile dysfunction. Data Sources: MEDLINE and evidence-based medicine sites. Review methods: We searched clinical guidelines, meta-analyses, systematic reviews and randomized clinical trials using the MeSH terms: ‘Phosphodiesterase 5 inhibitors’, ‘Lower urinary tract symptoms’, ‘Prostatic hyperplasia’. To assess the quality and strength of recommendation of the trials we used the Strength of Recommendation Taxonomy (SORT) scale, from the American Family Physician. Results: We found 172 articles and selected eight for this review. One clinical guideline, five meta-analyses, one systematic review, and one randomized clinical trial met the inclusion criteria. The use of PDE5I resulted in significant improvement in the International Prostatic Symptom Score (IPSS) and International Index of Erectile Function (IIFE) score. They were associated with a higher overall incidence of mild to moderate adverse events, with no differences in serious adverse events, providing a favorable safety profile. Conclusions: There is strong evidence for the efficacy and safety of the PDE5I in the treatment of LUTS, with or without associated erectile dysfunction (SORT A). We suggest conducting further studies to evaluate the long-term efficacy and safety of this treatment, their effect on the progression of disease and their cost-effectiveness in the treatment of LUTS.

Papel da memantina no tratamento das perturbações da ansiedade: uma revisão baseada na evidência

RESUMO Objetivo Avaliar a eficácia da memantina no tratamento das perturbações da ansiedade. Métodos Foi realizada uma revisão sistemática na Medline, outras bases de dados baseadas na evidência e Índex das Revistas Médicas Portuguesas, nos últimos 10 anos, em inglês, espanhol e português, utilizando os seguintes termos “MESH memantine”, “treatment” e “anxiety disorders”. Para avaliar a qualidade dos estudos e a força de recomendação, foi utilizada a escala de Strength of Recommendation Taxonomy da American Family Physician. Resultados Obtiveram-se 131 artigos, dos quais seis cumpriam os critérios de inclusão: dois ensaios clínicos aleatorizados e controlados (ECAC), uma revisão sistemática (RS), uma norma de orientação clínica (NOC) e dois ensaios clínicos não controlados (ECNC). A NOC não recomenda o uso de memantina no tratamento da perturbação generalizada da ansiedade (PGA) (SOR C), mas recomenda o uso da memantina como tratamento adjuvante de segunda linha na perturbação obsessivo-compulsiva (POC) e como terceira linha na perturbação do estresse pós-traumático (SORT C). Os dois ECAC sugerem que o tratamento adjuvante com memantina melhorou a sintomatologia dos pacientes com POC severa. A RS revelou que o uso da memantina tem alguns benefícios na diminuição dos sintomas da POC. Os dois ECNC sugerem que a memantina pode ser eficaz como tratamento adjuvante em pacientes sintomáticos apesar de tratamento adequado com antidepressivos convencionais. Conclusão A evidência atual sugere que o uso de memantina como adjuvante no tratamento da POC parece ser eficaz (SORT B). O uso de memantina no tratamento da PGA não é recomendado (SORT C).

Health-Related Quality of Life in Athletes: A Systematic Review With Meta-Analysis.

Assessment of health-related quality of life (HRQOL) after injury is important. Differences in HRQOL between nonathletes and athletes and between injured and uninjured athletes have been demonstrated; however, the evidence has not been synthesized. To answer the following questions: (1) Does HRQOL differ among adolescent and collegiate athletes and nonathletes? (2) Does HRQOL differ between injured adolescent and collegiate athletes or between athletes with a history of injury and uninjured athletes or those without a history of injury? We systematically searched CINAHL, MEDLINE, SPORTDiscus, and PubMed. A hand search of references was also conducted. Studies were included if they used generic instruments to compare HRQOL outcomes between athletes and nonathletes and between uninjured and injured athletes. Studies were excluded if they did not use a generic instrument, pertained to instrument development, or included retired athletes or athletes with a chronic disease. We assessed study quality using the modified Downs and Black Index Tool. Bias-corrected Hedges g effect sizes and 95% confidence intervals (CIs) were calculated. The Strength of Recommendation Taxonomy (SORT) was used to determine the overall strength of the recommendation. A random-effects meta-analysis was performed for all studies using the composite or total score. Eight studies with modified Downs and Black scores ranging from 70.6% to 88.4% were included. For question 1, the overall random-effects meta-analysis was weak (effect size = 0.27, 95% confidence interval = 0.14, 0.40; P < .001). For question 2, the overall random-effects meta-analysis was moderate (effect size = 0.68, 95% confidence interval = 0.42, 0.95; P < .001). Grade A evidence indicates that athletes reported better HRQOL than nonathletes and that uninjured athletes reported better HRQOL than injured athletes. However, the overall effect for question 1 was weak, suggesting that the differences between athletes and nonathletes may not be clinically meaningful. Clinicians should monitor HRQOL after injury to ensure that all dimensions of health are appropriately treated.

Quais os benefícios para o doente da associação de metformina com dapagliflozina comparativamente a outros antidiabéticos orais? Uma revisão baseada na evidência

Objectives: To compare the effect of the combination of metformin and dapagliflozin compared with metformin and other oral anti-diabetics as an add-on therapy in patients inadequately controlled with metformin alone. Data sources: MEDLINE and other evidence-based medicine databases Review methods: A review was made of meta-analyses, systematic reviews, randomized controlled clinical trials and clinical guidelines, published between January 2007 and March 2017, in Portuguese, English and Spanish, using the MeSH terms ‘dapagliflozin’, ‘diabetes mellitus type 2’, and ‘metformin’. The American Family Physician Strength of Recommendation Taxonomy (SORT) was used to establish the quality of the studies and to define the strength of recommendations. Results: There were 59 articles found. Eight met the inclusion criteria. These included one meta-analysis, one systematic review, five randomized controlled clinical trials, and one clinical guideline. There is evidence that dual therapy with metformin and dapagliflozin is effective in reducing glycosylated haemoglobin and body weight, when compared to other oral anti-diabetics, without increasing the risk of hypoglycemic episodes. The most frequent adverse effects related to this drug were urinary tract and genital infections, especially in women (SORT C). Dapagliflozin seems to be neutral regarding cardiovascular risk and its association with cancer is yet to be clarified. Conclusions: There was not enough evidence to support the claim that dapagliflozin combined with metformin is more effective or better for the patient when compared to other oral anti-diabetics (SORT C). Given these limitations, we conclude that more controlled studies are required to determine the effects of dapagliflozin in terms of efficacy, safety, morbidity and mortality, as well as the maintenance of the results with this combination of drugs.

Strength of recommendation for single-visit root canal treatment: grading the body of the evidence using a patient-centred approach.

To identify, search for and critically interpret the results from clinical studies on single- versus multiple-visit root canal treatment in the light of an evidence-based paradigm. For that purpose, the quality of the available body of evidence was assessed using the SORT 'grade' - Strength of Recommendation Taxonomy. A protocol was followed including all aspects of the review methods: (i) search strategy, (ii) inclusion criteria for studies, (iii) screening methods, (iv) quality assessment, (v) data synthesis of the selected studies, and (vi) the assessment of quality of the body of evidence available by the means of the SORT 'grade'. An extensive search of recent biomedical literature was performed in PubMed (up to May, 2014), EMBASE (dating from 1980 to May 2014) and Cochrane databases with appropriate headings and keywords related to single- and multiple-visit root canal treatment. Selected studies were stratified according to their level of evidence using the SORT criteria: (i) quality - Level A high-quality evidence, Level B medium/low-quality evidence and Level C noevidence; (ii) degree of consistency - consistent, when most studies found a similar conclusion, or inconsistent, when there was considerable variation amongst study findings. After the digital and manual searches, 246 studies were indentified. Two hundred and seven studies were eliminated by exclusion criteria, resulting in a yield of 39 articles that were selected for retrieval. Of the 39 articles, only 11 could be classified as Level 2 (B); the other 28 articles did not obey the criteria to be considered as real patient-oriented evidence; thus, they were classified as Level 3 (C). No studies were ranked as Level 1 because they did not obey the minimum standard to be considered as both good-quality research and patient-oriented evidence. Despite this, all of the selected Level B studies reported no significant differences between single- and multiple-visit treatments. There is B-level (mid-level) evidence to confirm there is no difference between the two different treatments, based on research addressing clinical outcomes and using some consistent but limited-quality methods of scientific investigation. More studies focused on evaluating patient-centred outcomes are urgently required.

Diabetes mellitus e cancro colorretal: uma revisão baseada na evidência

Objective: Diabetes mellitus (DM) and colorectal cancer (CRC) are diseases with increasing incidence and high mortality. In 2014, DM accounted for 4.9 million deaths worldwide according to the International Diabetes Federation. Some studies suggest that DM is a risk factor for CRC. However, this association is inconsistent. The aim of this study was to review the evidence for the association between DM and increased incidence and mortality from CRC. Data sources: National Guideline Clearing House, NICE, Canadian Medical Association Practice Guidelines, Cochrane, PubMed, and Direcao-Geral da Saude. Methods: We searched for meta-analyses (MA), systematic reviews (SR), observational studies, and clinical guidelines based on evidence published in the last five years in Portuguese, Spanish and English, using the MeSH terms ‘diabetes mellitus’ and ‘cancer, colorectal’ and the corresponding DeCS (Portuguese search terms). We used the Strength of Recommendation Taxonomy (SORT) scale of the American Academy of Family Physicians to assign levels of evidence and strength of recommendations. Results: From the 48 articles obtained, 6 MA and 1 observational study met the inclusion criteria. Included studies found statistically significant results showing increased mortality and incidence of CRC in diabetic individuals. Four MA conducted an independent analysis by site of cancer (colon and rectum) and found a statistically significant increase in incidence and mortality of both types of cancer in diabetic population. Similarly, four MA conducted a subgroup analysis by gender showing, in most studies, a positive association between diabetes and increased incidence of CRC in both genders. Conclusion: The currently available evidence shows a statistically significant and moderate increase in incidence and mortality from CRC in diabetic individuals (SORT A). We need studies with more homogeneous methodology, regarding subtypes of DM, ethnicity, and the effects of confounding factors such as diet, obesity, smoking, sedentary lifestyle, antidiabetic medication and duration of the disease. These results are clinically relevant and may have public health implications, given the high prevalence and morbidity of DM and CRC and the possible common pathophysiological basis of these diseases.

O papel do exercício físico na prevenção das quedas nos idosos: uma revisão baseada na evidência

Objectives: Falls are defined as events in which a person comes to rest inadvertently on the ground or floor or other lower level. They do not happen by chance, but can be predicted through the assessment of risk factors. The elderly population is more vulnerable. It is estimated that 30% of people aged 65 or more fall at least once a year. This represents a potentially preventable cause of disability and high health care costs. The aim of this study is to determine the benefits of physical exercise (PE) in the prevention of falls in the elderly. Data sources: MEDLINE and evidence-based medicine databases. Review methods: Research of clinical guidelines, meta-analyses (MA), systematic reviews (SR) and randomized controlled clinical trials, published between January 2010 and September 2014, using the MeSH terms: ACCIDENTAL FALLS, ACCIDENT PREVENTION, AGED and EXERCISE. Strength of Recommendation Taxonomy (SORT) was utilized for the assignment of levels of evidence and strength of recommendations. Results: We found 203 articles. Five met the inclusion criteria, including three MA and two SR. There is evidence that exercise programs to prevent falls in older people not only reduce the incidence of falls but also prevent injuries arising from falls. Many of the risk factors for falls are correctable by well-designed exercise programs. These are equally effective if practiced at home. The most effective type of PE in the prevention of falls in the elderly is balance training. PE programs are more effective if prolonged in time and of greater intensity (a greater number of hours and at least twice a week). Conclusions: PE programs should be recommended because they are effective in decreasing the number and risk of falls in the elderly (Strength of Recommendation A).

Levedura vermelha do arroz e berberina no tratamento da dislipidemia: qual a evidência?

Aim: To determine if red yeast rice (RYR) and berberine (BBR) are effective in lowering serum levels of LDL-cholesterol (LDL-C) and triglycerides (TG). Data sources: PubMed and databases of evidence-based medicine. Review methods: Guidelines, meta-analyses (MA), systematic reviews (SR), randomized controlled trials (RCT) and observational studies in English, Portuguese and Spanish were searched, using the MeSH terms (cholesterol, LDL, triglycerides, red yeast rice and berberine). Articles published between January of 2003 and January of 2014, including patients aged 18 years old and older without familial dyslipidemia were selected. The level of evidence (LE) and the strength of recommendation (SR) were assessed using the Strength of Recommendation Taxonomy (SORT) scale from the American Academy of Family Physicians. Results: Of the 34 articles found, 10 met the inclusion criteria. One MA, two SR, four RCT and one retrospective observational study described the effectiveness of RYR for the reduction of LDL-C levels (LE 3). Triglycerides were also effectively decreased by RYR in the MA, in one of the SR and in the RCT (LE 3). The MA and SR that analysed BBR showed its benefit in reducing LDL-C and TG (LE 3). The association of both substances, evaluated in a RCT, was also effective in lowering the levels of LDL-C. Conclusions: The available evidence regarding the reduction of LDL-C and TG levels with administration of RYR and/ or BBR was considered limited (SR C). Thus, before recommending these substances in the treatment of dyslipidemia, more studies of higher quality are needed to demonstrate their beneficial effects and safety. Better control in their production and marketing is also required.

Recent Advances in Pharmacotherapeutic Paradigm of Mild to Recalcitrant Atopic Dermatitis.

Atopic dermatitis (AD) is a common, chronic skin inflammatory disorder characterized by perivascular infiltration of immunoglobulin E (IgE), T lymphocytes, and mast cells. The key factors responsible for the pathophysiology of this disease are immunological disorders and defects in epidermal barrier properties. Pruritus, intense itching, psychological stress, deprived physical and mental performance, and sleep disturbance are the hallmark features of this dermatological disorder. Preventive interventions such as educational programs, avoidance of allergens, and exclusive care toward the skin could play a partial role in suppressing the symptoms. Based on the available clinical evidence, topical corticosteroids (TCs) are among the most commonly prescribed agents; however, these should be selected with care. In cases of steroid phobia, persistent adverse effects or chronic use, topical calcineurin inhibitors can be considered as a promising adjunct to TCs. Recent advances in the pharmacotherapeutic paradigm of atopic diseases exploring the therapeutic dominance of nanocarrier-mediated delivery is also discussed in this evidence-based review with regard to the treatment of AD. The present review summarizes the available clinical evidence, highlighting the current and emerging trends in the treatment of AD and providing evidence-based recommendations for the clinicians and health care professionals. Available evidence for the management of pediatric and adult atopic dermatitis (AD; atopic eczema) of all severities is explored. The management of other types of dermatitis, such as irritant contact dermatitis, seborrheic dermatitis, neurodermatitis, perioral dermatitis, stasis dermatitis, and allergic contact dermatitis are outside the scope of current review article. The presented studies were appraised using a unified system called the "Strength of Recommendation Taxonomy (SORT)", which was developed by the editors of several US family medicine and primary care journals (i.e., American Family Physician, Family Medicine, Journal of Family Practice, and BMJ USA).1 The searched studies were graded using a 3-point scale based on the quality of methodology (e.g., randomized control trial, case control series, clinical cohort studies, case series, etc.) and key emphasis of the trial (i.e., diagnosis, treatment/prevention/ screening, or prognosis) as follows: I. Good-quality patient-oriented evidence (i.e., evidence assessing consequences that matter to patients: mortality, morbidity, improvement in signs and symptom, quality of life, and socioeconomic factors); II. Limited-quality patient-oriented evidence; and III. Other evidence such as consensus guidelines, expert opinion, case control trial, or disease-related information. Recommendations for nonpharmacological and pharmacological approaches were established based on the best available evidence and are graded as follows: A. Recommendations based on consistent and good-quality patient-oriented evidence; B. Recommendations based on inconsistent or limited-quality patient-oriented evidence; and C. Recommendations based on consensus, expert opinion, case control evidence, or disease-related information.