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Papers by Anna Buehler

Como Avaliar Criticamente Revisões Sistemáticas e Metanálises?* How to Critically Assess Systematic Reviews and Meta-Analyses?

SUMMARYBACKGROUND AND OBJECTIVES : Systematic reviews are important knowledge generating tools to... more SUMMARYBACKGROUND AND OBJECTIVES : Systematic reviews are important knowledge generating tools to help the deci -sion making process in the Critical Care Unit. This narrative aims to describe the important elements used to critically appraise intensive care-related systematic reviews. CONTENTS : When critically assessing systematic re-views, one should pay particular attention to the impor-tance and appropriateness of the research question, the search strategy, the inclusion criteria and methodo-logical quality of the studies included, and the methods of data extraction. In addition, a relevant systematic review must have consistent data (in case of a meta-analysis) or the cause of the heterogeneity must have been adequately explored, and results must be appli-cable in critical patients. CONCLUSIONS : To apply correctly the available scien-tific evidence, one should critically assess data quality of systematic reviews, selecting the relevant informa-tion to manage the critically ill...

Cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole or letrozole as monotherapy in first-line treatment of postmenopausal women with HR+/HER2− locally advanced or metastatic breast cancer: a Brazilian private payer perspective

Therapeutic Advances in Medical Oncology, 2021

Background: The global burden of breast cancer (BC) is high, especially in advanced stages. CDK 4... more Background: The global burden of breast cancer (BC) is high, especially in advanced stages. CDK 4/6 inhibitors represent a paradigm shift in the treatment of advanced BC HR+/HER2−, given the clinically and statistically significant gain in overall survival associated with this new class of medications. Nevertheless, as an innovation, the incorporation of these drugs impacts healthcare budgets, requiring cost-effectiveness analyses for decision-making. The aim of this study was to evaluate the cost-effectiveness of ribociclib plus letrozole compared with palbociclib plus letrozole or letrozole as monotherapy for first-line treatment of postmenopausal women with HR+/HER2− locally advanced or metastatic BC (aBC) from a Brazilian private healthcare system perspective. Methods: A model including progression-free survival (PFS), progressed disease, and death health states was used to simulate lifetime costs and outcomes. PFS and overall survival were derived from the MONALEESA-2 trial (li...

Health Research Policy and Systems

In Brazil, governmental and non-governmental organisations develop practice guidelines (PGs) in o... more In Brazil, governmental and non-governmental organisations develop practice guidelines (PGs) in order to optimise patient care. Although important improvements have been made over the past years, many of these documents still lack transparency and methodological rigour. In order to conduct a critical analysis and define future steps in PG development in Brazil, we carried out a structured assessment of strengths, weaknesses, opportunities and threats (SWOT analysis) for the development of a national guideline programme. Participants consisted of academia, methodologists, medical societies and healthcare system representatives. In summary, the PG development process has improved in Brazil and current investments in methodological research and capacity-building are ongoing. Despite the centralised processes for public PGs, standardised procedures for their development are not well established and human resources are insufficient in number and capacity to develop the amount of trustworthy documents needed. Brazil's capacity could be strengthened and initial efforts have been made such as the adoption of standards proposed by world-renowned institutions in PG development and enhancement of the involvement of key stakeholders. Further steps involve the alignment between health technology assessment and PG processes for synergy and the development of a national network to promote the interaction between groups involved in the development of PGs. The lessons learned from this paper could be used to foster debate on guideline development, especially for countries facing similar threats on this topic.

Prevalência De Comorbidades Psiquiátricas Em Mulheres Usuárias De Drogas Ilícitas Durante O Período Periparto: Uma Revisão Sistemática

Proceedings of JBI Brazil Conference of the Americas

Can Enhanced Techniques Improve the Diagnostic Accuracy of Transvaginal Sonography and Magnetic Resonance Imaging for Rectosigmoid Endometriosis? A Systematic Review and Meta-analysis

Journal of Obstetrics and Gynaecology Canada

OBJECTIVE Our aim was to perform a systematic review and meta-analysis of the most commonly used ... more OBJECTIVE Our aim was to perform a systematic review and meta-analysis of the most commonly used examinations for rectosigmoid lesions of deeply infiltrating endometriosis, transvaginal sonography (TVS) and magnetic resonance imaging (MRI), to compare their diagnostic accuracy and enhanced or non-enhanced techniques. METHODS A systematic search was performed until March 2018 without time or language restrictions. Eligibility criteria included studies that compared the accuracy of TVS and MRI for diagnosis of rectosigmoid endometriosis. The quality of the studies was assessed by means of Quality Assessment of Diagnostic Accuracy Studies-2 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Bivariate and hierarchical analysis were performed. The difference in the accuracy of TVS and MRI was tested, and heterogeneity was addressed by means of meta-regression, sensitivity, or subgroup analysis. RESULTS A total of 1754 studies were screened; 105 studies were eligible, and 11 studies were included in the meta-analysis. Overall pooled sensitivity, specificity, and area under the receiver operating characteristic curve were 0.80, 0.94, and 0.95, respectively. The measures for MRI were 0.82, 0.94, and 0.95, respectively. There was no statistical difference between the accuracy values of TVS and MRI (P = 0.90). The use of bowel preparation and vaginal contrast could enhance the accuracy of MRI. Along with rectosigmoid prevalence, bowel and vaginal contrast explained a significant proportion of the statistical heterogeneity. CONCLUSIONS Both TVS and MRI showed high diagnostic accuracy for rectosigmoid deeply infiltrating endometriosis lesions. There is no strong evidence suggesting that the two diagnostic methods might differ in specificity or sensitivity, but enhanced techniques may increase the accuracy measures.

The Overt and Hidden Use of Animal-derived Products in Alternative Methods for Skin Sensitisation: A Systematic Review

Alternatives to Laboratory Animals

In vitro methods that can replace animal testing in the identification of skin sensitisers are no... more In vitro methods that can replace animal testing in the identification of skin sensitisers are now a reality. However, as cell culture and related techniques usually rely on animal-derived products, these methods may be failing to address the complete replacement of animals in safety assessment. The objective of this study was to identify the animal-derived products that are used as part of in vitro methods for skin sensitisation testing. Thus, a systematic review of 156 articles featuring 83 different in vitro methods was carried out and, from this review, the use of several animal-derived products from different species was identified, with the use of fetal bovine serum being cited in most of the methods (78%). The use of sera from other animals, monoclonal antibodies and animal proteins were also variously mentioned. While non-animal alternatives are available and methods free of animal-derived products are emerging, most of the current methods reported used at least one animal-d...

Arquivos Brasileiros de Cardiologia

Background: The choice of a mechanical (MP) or biological prosthesis (BP) for patients with valvu... more Background: The choice of a mechanical (MP) or biological prosthesis (BP) for patients with valvular heart disease undergoing replacement is still not a consensus. Objective: We aimed to determine the clinical outcomes of MP or BP placement in those patients. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared biological prostheses and mechanical prostheses in patients with valvular heart diseases and assessed the outcomes. RCTs were searched in the MEDLINE, EMBASE, LILACS, CENTRAL, SCOPUS and Web of Science (from inception to November 2014) databases. Meta-analyses were performed using inverse variance with random effects models. The GRADE system was used to rate the quality of the evidence. A P-value lower than 0.05 was considered significant. Results: A total of four RCTs were included in the meta-analyses (1,528 patients) with follow up ranging from 2 to 20 years. Three used old generation mechanical and biological prostheses, and one used contemporary prostheses. No significant difference in mortality was found between BP and MP patients (risk ratio (RR = 1.07; 95% CI 0.99-1.15). The risk of bleeding was significantly lower in BP patients than MP patients (RR = 0.64; 95% CI 0.52-0.78); however, reoperations were significantly more frequent in BP patients (RR = 3.60; 95% CI 2.44-5.32). There were no statistically significant differences between BP and MP patients with respect to systemic arterial embolisms and infective endocarditis (RR = 0.93; 95% CI 0.66-1.31, RR = 1.21; CI95% 0.78-1.88, respectively). Results in the trials with modern and old prostheses were similar. Conclusions: The mortality rate and the risk of thromboembolic events and endocarditis were similar between BP and MP patients. The risk of bleeding was approximately one third lower for BP patients than for MP patients, while the risk of reoperations was more than three times higher for BP patients.

Viscosupplementation for hip osteoarthritis: a systematic review and meta-analysis of the efficacy for pain, disability and adverse events

Archives of Physical Medicine and Rehabilitation

To assess the efficacy of viscosupplementation (HA) in hip osteoarthritis (OA) pain, disability a... more To assess the efficacy of viscosupplementation (HA) in hip osteoarthritis (OA) pain, disability and adverse events. Pubmed, EMBASE, Cochrane Library, ClinicalTrials.gov database and specific journals up to March 2017. Randomized controlled trials comparing HA with any other intra-articular injection. Performed according to Cochrane/GRADE criteria. Two authors extracted data, assessed risk of bias and quality of evidence. Random-effects meta-analysis was conducted. Protocol registered on PROSPERO under CRD42015017312 DATA SYNTHESIS: Eight RCTs were retrieved (n=807): four comparing HA to placebo (PBO); three with platelet-rich plasma (PRP), three with methylprednisolone (MPA), and one mepivacaine (MPV). Some RCTs had three arms. There is VERY LOW evidence that HA is not superior to PBO in pain at 3 months (SMD=-0.06 [95% CI -0.38; 0.25], p=0.69), and HIGH evidence that is not superior in adverse events (RR=1.21 [95%CI 0.79; 1.86], p=0.38). There is LOW evidence that HA is not superior to PRP for pain at 1 month. There is VERY LOW evidence that HA is not superior to PRP for pain at 6 and 12 months (mean difference in VAS in cm= -0.05 [95%CI -0.81, 0.71]; 1.0 [95%CI -1.5, 3.50]; 0.81 [95%CI -1.11, 2.73], respectively). There is HIGH evidence that HA is no different from MPA for pain at 1 month (SMD=0.02 [95% CI -0.18; 0.22], p=0.85). There is LOW evidence HA is no different from MPA for OMERACT-OARSI responders index at 1 month (RR=0.44 [95%CI 0.10; 1.95], p=0.28; There is HIGH evidence HA is no different from MPA for adverse events (RR=1.21 [95%CI 0.79; 1.87], p=0.38). We do not recommend viscosupplementation for hip OA. Compared to placebo, data shows scarce evidence of its efficacy up to 3 months, and suggests no difference at 6 months. However, future RCTs could present HA as an alternative to MPA for short-term symptom relief.

Jornal Brasileiro de Pneumologia

Objective: To determine whether long-acting muscarinic antagonists (LAMAs) provide superior thera... more Objective: To determine whether long-acting muscarinic antagonists (LAMAs) provide superior therapeutic effects over long-acting β2 agonists (LABAs) for preventing COPD exacerbations. Methods: This was a systematic review and meta-analysis of randomized clinical trials involving patients with stable, moderate to severe COPD according to the Global Initiative for Chronic Obstructive Lung Disease criteria, treated with a LAMA (i.e., tiotropium bromide, aclidinium, or glycopyrronium), followed for at least 12 weeks and compared with controls using a LABA in isolation or in combination with a corticosteroid. Results: A total of 2,622 studies were analyzed for possible inclusion on the basis of their title and abstract; 9 studies (17,120 participants) were included in the analysis. In comparison with LABAs, LAMAs led to a greater decrease in the exacerbation rate ratio (relative risk [RR] = 0.88; 95% CI: 0.84-0.93]; a lower proportion of patients who experienced at least one exacerbation...

Short-term effects of fine particulate matter pollution on daily health events in Latin America: a systematic review and meta-analysis

International journal of public health, Jan 2, 2017

Ambient air pollution is among the leading risks for health worldwide and by 2050 will largely ov... more Ambient air pollution is among the leading risks for health worldwide and by 2050 will largely overcome deaths due to unsafe sanitation and malaria, but local evidence from Latin America (LA) is scarce. We aimed to summarize the effect of short-term exposure to fine particulate air pollution (PM2.5) on morbidity and mortality in Latin America and evaluate evidence coverage and quality, using systematic review and meta-analysis. The comprehensive search (six online databases and hand-searching) identified studies investigating the short-term associations between PM2.5 and daily health events in LA. Two reviewers independently accessed the internal validity of the studies and used random-effect models in the meta-analysis. We retrieved 1628 studies. Nine were elected for the qualitative analysis and seven for the quantitative analyses. Each 10 µg/m(3) increments in daily PM2.5 concentrations was significantly associated with increased risk for respiratory and cardiovascular mortality ...

International Journal of Food Sciences and Nutrition, 2016

Como avaliar criticamente um ensaio cl�nico de aloca��o aleat�ria em terapia intensiva

Revista Brasileira De Terapia Intensiva, 2009

The long-term outcome of biological or mechanical prostheses for heart valve surgery: a meta-analysis of randomised clinical studies

European Heart Journal, 2013

Letter to the editor: naltrexone sustained-release/bupropion sustained-release for the management of obesity: review of the data to date

Drug design, development and therapy, 2015

Rev Bras Cardiol Invas, 2008

Métodos como angiografias coronárias representam inquestionáveis avanços no diagnóstico, no manej... more Métodos como angiografias coronárias representam inquestionáveis avanços no diagnóstico, no manejo e na estratificação de risco de uma série de condições clínicas, sendo, por isso, crescente o número de pacientes submetidos a esses exames 1-4. A nefropatia induzida por contraste (NIC) representa uma potencial complicação bem conhecida em angiografia e intervenções coronárias e essas interven-SUMMARY Acetylcysteine for Prevention of Contrast-Induced Nephropathy: Is the Evidence Definitive or Do We Need More Clinical Trials? Background: Contrast-induced nephropathy (CIN) is a potential complication of angiography and coronary interventions that use radiological contrast, especially in high-risk patients. Acetylcysteine may have a protective effect on the development of this pathology. Objectives: Narrative review which has the following objectives: to define the development context of CIN and the risk factors; to define the mechanism of action proposed for CIN prevention and the compilation of the main and current randomized trials and systematic reviews and meta-analyses conducted to sustain this idea. Methods: Bibliographic research of MEDLINE, EMBASE, Cochrane CENTRAL to screen the most relevant randomized trials and systematic reviews and meta-analyses. Results: The randomized trial results are conflictive and the results of all systematic reviews and meta-analyses are controversial, despite most studies suggesting beneficial use of acetylcysteine for CIN prevention. Conclusion: It will be necessary to conduct better designed randomized clinical trials with adequate sample size population to obtain more consistent results. DESCRIPTORS: Kidney diseases/chemically induced. Acetylcysteine. Contrast media/adverse effects. Angiography. Clinical trials.

Revista da Associação Médica Brasileira

SUMMARY OBJECTIVE: To assist clinicians to make adequate interpretation of scientific evidence fr... more SUMMARY OBJECTIVE: To assist clinicians to make adequate interpretation of scientific evidence from studies that evaluate diagnostic tests in order to allow their rational use in clinical practice. METHODS: This is a narrative review focused on the main concepts, study designs, the adequate interpretation of the diagnostic accuracy data, and making inferences about the impact of diagnostic testing in clinical practice. RESULTS: Most of the literature that evaluates the performance of diagnostic tests uses cross-sectional design. Randomized clinical trials, in which diagnostic strategies are compared, are scarce. Cross-sectional studies measure diagnostic accuracy outcomes that are considered indirect and insufficient to define the real benefit for patients. Among the accuracy outcomes, the positive and negative likelihood ratios are the most useful for clinical management. Variations in the study's cross-sectional design, which may add bias to the results, as well as other domai...

Acetylcysteine for prevention of contrast-induced nephropathy: is the evidence definitive or do we need more clinical trials?

INTRODUÇÃO: A nefropatia induzida por contraste (NIC) representa uma potencial complicação em ang... more INTRODUÇÃO: A nefropatia induzida por contraste (NIC) representa uma potencial complicação em angiografia e outras intervenções que utilizam contraste radiológico, principalmente em pacientes com fatores de risco. A Nacetilcisteína parece exercer efeito protetor no desenvolvimento dessa afecção. OBJETIVOS: Revisão narrativa que tem como objetivos definir o contexto do desenvolvimento da NIC e seus fatores de risco, definir o mecanismo de ação proposto para a prevenção da NIC pela N-acetilcisteína, e compilar os principais e atuais ensaios clínicos randomizados e revisões sistemáticas com metanálise desenvolvidos para sustentar essa hipótese. MÉTODO: Revisão bibliográfica no MEDLINE, EMBASE e Cochrane CENTRAL para seleção dos ensaios clínicos randomizados e revisões sistemáticas com metanálise mais relevantes. RESULTADOS: Os resultados dos ensaios clínicos randomizados são conflitantes e os das revisões sistemáticas são inconclusivos, embora a maioria aponte para o benefício da N-ace...

Como avaliar criticamente revis�es sistem�ticas e metan�lises?

Revista Brasileira De Terapia Intensiva, 2007

Endovascular thrombectomy for the treatment of acute ischemic stroke

Arquivos de Neuro-Psiquiatria, 2015

Few patients benefit from the current standard treatment for acute ischemic stroke (AIS), encoura... more Few patients benefit from the current standard treatment for acute ischemic stroke (AIS), encouraging the development of new treatments. Objective To systematically review the literature on the efficacy and/or safety of endovascular thrombectomy in AIS compared to standard treatment and to identify ongoing randomized controlled trials (RCTs). Method Searches for RCTs were performed in Medline/Embase, and for ongoing trials: International Clinical Trial Registry Platform, Clinicaltrials.gov and ISRCTN registry (to June 15th, 2015). Results From the eight published RCTs, five showed the superiority of treatment that includes thrombectomy compared to standard care alone. From the 13 ongoing RCTs, 3 have been halted, one has not started, one has unknown status and eight will end between 2016 - 2020. Conclusion Evidence favours a combination of the standard therapy with endovascular thrombectomy. The selection criteria however limit the number of people who can benefit. Further studies are needed to prove its cost-effectiveness.

Avaliação de Metanálises em Medicina de Urgência