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Drager LF, Santos RB, Pachito D, Albertini CS, Sert Kuniyoshi FH, Eckeli AL. Inequalities in the access to diagnosis and treatment of obstructive sleep apnea in Brazil: a cross-sectional study. J Clin Sleep Med 2024; 20:735-742. [PMID: 38169439 PMCID: PMC11063704 DOI: 10.5664/jcsm.10976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is highly prevalent, and positive airway pressure (PAP) therapy is the primary treatment. This study aimed to assess the diagnostic and PAP treatment resources for OSA within Brazil's Unified Health System and to identify potential inequalities and gaps. METHODS A structured survey was sent to members of the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine to identify sleep laboratories providing OSA diagnosis and/or treatment within Brazil's Unified Health System. The numbers of centers, care team structure, sleep studies availability, PAP accessibility, and follow-up services were characterized in all 5 Brazilian regions. RESULTS Forty-seven centers were identified: Midwest (n = 4), Northeast (n = 10), North (n = 3), Southeast (n = 22), and South (n = 8). Most centers (70%) provided both OSA diagnosis and treatment, mainly in capitals and/or metropolises (87%). Ten out of 27 Brazilian Federal Units lacked sleep services for OSA management, with the North having the highest proportion of states without a sleep service (71%). The annual number of diagnostic exams for OSA was 14,932, with significant heterogeneity across regions (Midwest: 240; North: 400; Northeast: 3,564; South: 4,380; Southeast: 6,348). Mean waiting times for diagnosis and treatment were 11 and 8 months, respectively. Only 46% of PAP treatments were publicly funded, making legal injunctions and out-of-pocket expenditure common practices. CONCLUSIONS This study revealed significant disparities in OSA diagnosis and treatment resources across Brazil, with the North region being particularly underserved. The findings underscore an urgent need for strategies to improve sleep care nationwide. CITATION Drager LF, Santos RB, Pachito D, Albertini CS, Sert Kuniyoshi FH, Eckeli AL. Inequalities in the access to diagnosis and treatment of obstructive sleep apnea in Brazil: a cross-sectional study. J Clin Sleep Med. 2024;20(5):735-742.
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Affiliation(s)
- Luciano F. Drager
- Unidades de Hipertensão, Instituto do Coração (InCor) e Disciplina de Nefrologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
- Brazilian Sleep Association (ABS), Sao Paulo, Brazil
| | - Ronaldo B. Santos
- Hospital Universitário, Universidade de São Paulo, Sao Paulo, Brazil
| | | | - Claudia S. Albertini
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Fatima H. Sert Kuniyoshi
- ResMed Science Center, San Diego, California
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alan L. Eckeli
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Sao Paulo, Brazil
- Brazilian Association of Sleep Medicine (ABMS), Sao Paulo, Brazil
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Pega F, Momen NC, Gagliardi D, Bero LA, Boccuni F, Chartres N, Descatha A, Dzhambov AM, Godderis L, Loney T, Mandrioli D, Modenese A, van der Molen HF, Morgan RL, Neupane S, Pachito D, Paulo MS, Prakash KC, Scheepers PTJ, Teixeira L, Tenkate T, Woodruff TJ, Norris SL. Assessing the quality of evidence in studies estimating prevalence of exposure to occupational risk factors: The QoE-SPEO approach applied in the systematic reviews from the WHO/ILO Joint Estimates of the Work-related burden of disease and Injury. Environ Int 2022; 161:107136. [PMID: 35182944 PMCID: PMC8885428 DOI: 10.1016/j.envint.2022.107136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 01/05/2022] [Accepted: 02/04/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND The World Health Organization (WHO) and the International Labour Organization (ILO) have produced the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates). For these, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors have been conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methodology is to assess the quality of evidence across studies. In this article, we present the approach applied in these WHO/ILO systematic reviews for performing such assessments on studies of prevalence of exposure. It is called the Quality of Evidence in Studies estimating Prevalence of Exposure to Occupational risk factors (QoE-SPEO) approach. We describe QoE-SPEO's development to date, demonstrate its feasibility reporting results from pilot testing and case studies, note its strengths and limitations, and suggest how QoE-SPEO should be tested and developed further. METHODS Following a comprehensive literature review, and using expert opinion, selected existing quality of evidence assessment approaches used in environmental and occupational health were reviewed and analysed for their relevance to prevalence studies. Relevant steps and components from the existing approaches were adopted or adapted for QoE-SPEO. New steps and components were developed. We elicited feedback from other systematic review methodologists and exposure scientists and reached consensus on the QoE-SPEO approach. Ten individual experts pilot-tested QoE-SPEO. To assess inter-rater agreement, we counted ratings of expected (actual and non-spurious) heterogeneity and quality of evidence and calculated a raw measure of agreement (Pi) between individual raters and rater teams for the downgrade domains. Pi ranged between 0.00 (no two pilot testers selected the same rating) and 1.00 (all pilot testers selected the same rating). Case studies were conducted of experiences of QoE-SPEO's use in two WHO/ILO systematic reviews. RESULTS We found no existing quality of evidence assessment approach for occupational exposure prevalence studies. We identified three relevant, existing approaches for environmental and occupational health studies of the effect of exposures. Assessments using QoE-SPEO comprise three steps: (1) judge the level of expected heterogeneity (defined as non-spurious variability that can be expected in exposure prevalence, within or between individual persons, because exposure may change over space and/or time), (2) assess downgrade domains, and (3) reach a final rating on the quality of evidence. Assessments are conducted using the same five downgrade domains as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach: (a) risk of bias, (b) indirectness, (c) inconsistency, (d) imprecision, and (e) publication bias. For downgrade domains (c) and (d), the assessment varies depending on the level of expected heterogeneity. There are no upgrade domains. The QoE-SPEO's ratings are "very low", "low", "moderate", and "high". To arrive at a final decision on the overall quality of evidence, the assessor starts at "high" quality of evidence and for each domain downgrades by one or two levels for serious concerns or very serious concerns, respectively. In pilot tests, there was reasonable agreement in ratings for expected heterogeneity; 70% of raters selected the same rating. Inter-rater agreement ranged considerably between downgrade domains, both for individual rater pairs (range Pi: 0.36-1.00) and rater teams (0.20-1.00). Sparse data prevented rigorous assessment of inter-rater agreement in quality of evidence ratings. CONCLUSIONS We present QoE-SPEO as an approach for assessing quality of evidence in prevalence studies of exposure to occupational risk factors. It has been developed to its current version (as presented here), has undergone pilot testing, and was applied in the systematic reviews for the WHO/ILO Joint Estimates. While the approach requires further testing and development, it makes steps towards filling an identified gap, and progress made so far can be used to inform future work in this area.
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Affiliation(s)
- Frank Pega
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland.
| | - Natalie C Momen
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Diana Gagliardi
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Rome, Italy
| | - Lisa A Bero
- Charles Perkins Centre, The University of Sydney, Sydney, Australia; General Internal Medicine/Public Health/Center for Bioethics and Humanities, University of Colorado-Anschutz Medical Campus, Denver, CO, United States
| | - Fabio Boccuni
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Rome, Italy
| | - Nicholas Chartres
- Program on Reproductive Health and the Environment, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, United States
| | - Alexis Descatha
- AP-HP (Paris Hospital "Assistance Publique Hôpitaux de Paris"), Occupational Health Unit, University Hospital of West Suburb of Paris, Poincaré Site, Garches, France /Versailles St-Quentin Univ - Paris Saclay Univ (UVSQ), UMS 011, UMR-S 1168, France; Univ Angers, CHU Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S1085, CAPTV CDC, Angers, France
| | - Angel M Dzhambov
- Department of Hygiene, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria; Institute for Highway Engineering and Transport Planning, Graz University of Technology, Graz, Austria
| | - Lode Godderis
- Centre for Environment and Health, KU Leuven, Leuven, Belgium; KIR Department (Knowledge, Information & Research), IDEWE, External Service for Prevention and Protection at Work, Leuven, Belgium
| | - Tom Loney
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Daniele Mandrioli
- Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bologna, Italy
| | - Alberto Modenese
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Henk F van der Molen
- Coronel Institute of Occupational Health, Amsterdam UMC, location AMC, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Subas Neupane
- Faculty of Social Science (Health Sciences), University of Tampere, Tampere, Finland
| | - Daniela Pachito
- Evidence-based Health, Universidade Federal de São Paulo, Sao Paulo, Brazil; Cochrane Brazil, Sao Paulo, Brazil
| | - Marilia S Paulo
- Institute of Public Health, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - K C Prakash
- Faculty of Social Science (Health Sciences), University of Tampere, Tampere, Finland
| | - Paul T J Scheepers
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Liliane Teixeira
- Workers' Health and Human Ecology Research Center, National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Thomas Tenkate
- School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada
| | - Tracey J Woodruff
- Program on Reproductive Health and the Environment, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, United States
| | - Susan L Norris
- Oregon Health & Science University, Portland, OR, United States; Department of Quality Assurance, Norms and Standards, World Health Organization, Geneva, Switzerland
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Momen NC, Streicher KN, da Silva DTC, Descatha A, Frings-Dresen MHW, Gagliardi D, Godderis L, Loney T, Mandrioli D, Modenese A, Morgan RL, Pachito D, Scheepers PTJ, Sgargi D, Paulo MS, Schlünssen V, Sembajwe G, Sørensen K, Teixeira LR, Tenkate T, Pega F. Assessor burden, inter-rater agreement and user experience of the RoB-SPEO tool for assessing risk of bias in studies estimating prevalence of exposure to occupational risk factors: An analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury. Environ Int 2022; 158:107005. [PMID: 34991265 PMCID: PMC8685606 DOI: 10.1016/j.envint.2021.107005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 05/08/2023]
Abstract
BACKGROUND As part of the development of the World Health Organization (WHO)/International Labour Organization (ILO) Joint Estimates of the Work-related Burden of Disease and Injury, WHO and ILO carried out several systematic reviews to determine the prevalence of exposure to selected occupational risk factors. Risk of bias assessment for individual studies is a critical step of a systematic review. No tool existed for assessing the risk of bias in prevalence studies of exposure to occupational risk factors, so WHO and ILO developed and pilot tested the RoB-SPEO tool for this purpose. Here, we investigate the assessor burden, inter-rater agreement, and user experience of this new instrument, based on the abovementioned WHO/ILO systematic reviews. METHODS Twenty-seven individual experts applied RoB-SPEO to assess risk of bias. Four systematic reviews provided a total of 283 individual assessments, carried out for 137 studies. For each study, two or more assessors independently assessed risk of bias across the eight RoB-SPEO domains selecting one of RoB-SPEO's six ratings (i.e., "low", "probably low", "probably high", "high", "unclear" or "cannot be determined"). Assessors were asked to report time taken (i.e. indicator of assessor burden) to complete each assessment and describe their user experience. To gauge assessor burden, we calculated the median and inter-quartile range of times taken per individual risk of bias assessment. To assess inter-rater reliability, we calculated a raw measure of inter-rater agreement (Pi) for each RoB-SPEO domain, between Pi = 0.00, indicating no agreement and Pi = 1.00, indicating perfect agreement. As subgroup analyses, Pi was also disaggregated by systematic review, assessor experience with RoB-SPEO (≤10 assessments versus > 10 assessments), and assessment time (tertiles: ≤25 min versus 26-66 min versus ≥ 67 min). To describe user experience, we synthesised the assessors' comments and recommendations. RESULTS Assessors reported a median of 40 min to complete one assessment (interquartile range 21-120 min). For all domains, raw inter-rater agreement ranged from 0.54 to 0.82. Agreement varied by systematic review and assessor experience with RoB-SPEO between domains, and increased with increasing assessment time. A small number of users recommended further development of instructions for selected RoB-SPEO domains, especially bias in selection of participants into the study (domain 1) and bias due to differences in numerator and denominator (domain 7). DISCUSSION Overall, our results indicated good agreement across the eight domains of the RoB-SPEO tool. The median assessment time was comparable to that of other risk of bias tools, indicating comparable assessor burden. However, there was considerable variation in time taken to complete assessments. Additional time spent on assessments may improve inter-rater agreement. Further development of the RoB-SPEO tool could focus on refining instructions for selected RoB-SPEO domains and additional testing to assess agreement for different topic areas and with a wider range of assessors from different research backgrounds.
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Affiliation(s)
- Natalie C Momen
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland.
| | - Kai N Streicher
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland.
| | - Denise T C da Silva
- Workers' Health and Human Ecology Research Center, National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Alexis Descatha
- UNIV Angers, CHU Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Angers, France; AP-HP (Paris Hospital), Occupational Health Unit, Poincaré University Hospital, Garches, France; Versailles St-Quentin Univ-Paris Saclay Univ (UVSQ), UMS 011, UMR-S 1168, France; Inserm, U1168 UMS 011, Villejuif, France.
| | - Monique H W Frings-Dresen
- Amsterdam UMC, University of Amsterdam, Department Public and Occupational Health/Coronel Institute of Occupational Health, Amsterdam Research Institute, Amsterdam, the Netherlands.
| | - Diana Gagliardi
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Rome, Italy.
| | - Lode Godderis
- Centre for Environment and Health, KU Leuven, Leuven, Belgium; KIR Department (Knowledge, Information & Research), IDEWE, External Service for Prevention and Protection at Work, Leuven, Belgium.
| | - Tom Loney
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates.
| | - Daniele Mandrioli
- Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bologna, Italy.
| | - Alberto Modenese
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Daniela Pachito
- Núcleo de Avaliação de Tecnologias em Saúde, Hospital Sírio-Libanês, Bela Vista, São Paulo, SP, Brazil; Fundação Getúlio Vargas, Bela Vista, São Paulo, SP, Brazil.
| | - Paul T J Scheepers
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands.
| | - Daria Sgargi
- Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bologna, Italy
| | - Marília Silva Paulo
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.
| | - Vivi Schlünssen
- Aarhus University, Aarhus, Denmark; National Research Center for the Working Environment, Copenhagen, Denmark.
| | - Grace Sembajwe
- Department of Environmental, Occupational, and Geospatial Health Sciences, CUNY Graduate School of Public Health and Health Policy, CUNY Institute for Implementation Science in Population Health, New York, NY, United States.
| | - Kathrine Sørensen
- National Research Center for the Working Environment, Copenhagen, Denmark.
| | - Liliane R Teixeira
- Workers' Health and Human Ecology Research Center, National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil.
| | - Thomas Tenkate
- School of Occupational and Public Health, Ryerson University, Toronto, ON, Canada.
| | - Frank Pega
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland.
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4
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Descatha A, Sembajwe G, Pega F, Ujita Y, Baer M, Boccuni F, Di Tecco C, Duret C, Evanoff BA, Gagliardi D, Godderis L, Kang SK, Kim BJ, Li J, Magnusson Hanson LL, Marinaccio A, Ozguler A, Pachito D, Pell J, Pico F, Ronchetti M, Roquelaure Y, Rugulies R, Schouteden M, Siegrist J, Tsutsumi A, Iavicoli S. The effect of exposure to long working hours on stroke: A systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury. Environ Int 2020; 142:105746. [PMID: 32505015 DOI: 10.1016/j.envint.2020.105746] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 05/21/2023]
Abstract
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 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. 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 stroke (three outcomes: prevalence, incidence, and mortality). DATA SOURCES A 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 CRITERIA We 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 METHODS At 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. RESULTS Twenty-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). CONCLUSIONS We 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. PROTOCOL IDENTIFIER: https://doi.org/10.1016/j.envint.2018.06.016. PROSPERO REGISTRATION NUMBER CRD42017060124.
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Affiliation(s)
- Alexis Descatha
- UNIV Angers, CHU Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-49000 Angers, France; AP-HP (Paris Hospital), Occupational Health Unit, Poincaré University Hospital, Garches, France; Versailles St-Quentin Univ-Paris Saclay Univ (UVSQ), UMS 011, UMR-S 1168, France; Inserm, U1168 UMS 011, Villejuif, France.
| | - Grace Sembajwe
- Department of Occupational Medicine Epidemiology and Prevention, Zucker School of Medicine at Hofstra University, Feinstein Institutes for Medical Research, Northwell Health, NY, USA.
| | - Frank Pega
- Environment, Climate Change and Health Department, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland.
| | - Yuka Ujita
- Labour Administration, Labour Inspection and Occupational Safety and Health Branch, International Labour Organization, Route des Morillons 4, 1211 Geneva, Switzerland.
| | - Michael Baer
- AP-HP (Paris Hospital), SAMU92, Poincaré University Hospital, Garches, France.
| | - Fabio Boccuni
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone (Rome), Italy.
| | - Cristina Di Tecco
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone (Rome), Italy.
| | - Clement Duret
- AP-HP (Paris Hospital), Occupational Health Unit, Poincaré University Hospital, Garches, France.
| | - Bradley A Evanoff
- Division of General Medical Sciences, Washington University School of Medicine, Campus Box 8005, 660 South Euclid Ave, St. Louis, MO 63110, United States.
| | - Diana Gagliardi
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone (Rome), Italy.
| | - Lode Godderis
- Environment and Health, Kapucijnenvoer 35 blok d - box 7001, 3000 Leuven, Belgium; IDEWE, External Service for Prevention and Protection at Work, Interleuvenlaan 58, 3001 Leuven, Belgium.
| | - Seong-Kyu Kang
- Department of Occupational and Environmental Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea.
| | - Beon Joon Kim
- Seoul National University Bundang Hospital, Bundang-gu, Republic of Korea.
| | - Jian Li
- Department of Environmental Health Sciences, Fielding School of Public Health, School of Nursing, University of California, Los Angeles, United States.
| | | | - Alessandro Marinaccio
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone (Rome), Italy.
| | - Anna Ozguler
- AP-HP (Paris Hospital), SAMU92, Poincaré University Hospital, Garches, France; Inserm UMS 011, Villejuif, France.
| | - Daniela Pachito
- Núcleo de Avaliação de Tecnologias em Saúde, Hospital Sírio-Libanês, 142 Barata Ribeiro, Sao Paulo, Brazil.
| | - John Pell
- Hunter College Libraries, Social Work and Public Health Library, 2180 3rd Avenue, 110D, New York, NY 10035, United States.
| | - Fernando Pico
- Neurology and Stroke Unit, Versailles Hospital, Le Chesnay, France.
| | - Matteo Ronchetti
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone (Rome), Italy.
| | - Yves Roquelaure
- UNIV Angers, CHU Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-49000 Angers, France.
| | - Reiner Rugulies
- National Research Centre for the Working Environment, Lersø Parkallé 105, DK-2100 Copenhagen, Denmark; Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, DK-1014 Copenhagen, Denmark; Department of Psychology, University of Copenhagen, Øster Farimagsgade 2A, DK-1353 Copenhagen, Denmark.
| | - Martijn Schouteden
- IDEWE, External Service for Prevention and Protection at Work, Interleuvenlaan 58, 3001 Leuven, Belgium.
| | - Johannes Siegrist
- Life Science Centre, University of Düsseldorf, Merowingerplatz 1a, Düsseldorf 40225, Germany.
| | - Akizumi Tsutsumi
- Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara 252-0374, Japan.
| | - Sergio Iavicoli
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone (Rome), Italy.
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5
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Pega F, Norris SL, Backes C, Bero LA, Descatha A, Gagliardi D, Godderis L, Loney T, Modenese A, Morgan RL, Pachito D, Paulo MBS, Scheepers PTJ, Schlünssen V, Sgargi D, Silbergeld EK, Sørensen K, Sutton P, Tenkate T, Torreão Corrêa da Silva D, Ujita Y, van Deventer E, Woodruff TJ, Mandrioli D. RoB-SPEO: A tool for assessing risk of bias in studies estimating the prevalence of exposure to occupational risk factors from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury. Environ Int 2020; 135:105039. [PMID: 31864023 PMCID: PMC7479507 DOI: 10.1016/j.envint.2019.105039] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 05/20/2023]
Abstract
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 < 0.4 as poor, 0.4 ≤ Pi ≥ 0.8 as substantial and 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.
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Affiliation(s)
- Frank Pega
- Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland.
| | - Susan L Norris
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Claudine Backes
- Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland
| | - Lisa A Bero
- Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Alexis Descatha
- AP-HP (Paris Hospital "Assistance Publique Hôpitaux de Paris"), Occupational Health Unit, University Hospital of West Suburb of Paris, Poincaré Site, Garches, France; Versailles St-Quentin Univ - Paris Saclay Univ (UVSQ), UMS 011, UMR-S 1168, France; Inserm, U1168 (VIMA: Aging and chronic diseases. Epidemiological and public health approaches), UMS 011 (Population-based Epidemiologic Cohorts Unit), Villejuif, France
| | - Diana Gagliardi
- Inail, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Rome, Italy
| | - Lode Godderis
- Centre for Environment and Health, KU Leuven, Leuven, Belgium; KIR Department (Knowledge, Information & Research), IDEWE, External Service for Prevention and Protection at Work, Leuven, Belgium
| | - Tom Loney
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Alberto Modenese
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Daniela Pachito
- Evidence-based Health, Universidade Federal de São Paulo, Sao Paulo, Brazil; Cochrane Brazil, Sao Paulo, Brazil
| | - Marilia B S Paulo
- Institute of Public Health, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Paul T J Scheepers
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Vivi Schlünssen
- Department of Public Health, Aarhus University, Aarhus, Denmark; National Research Center for the Working Environment, Copenhagen, Denmark
| | - Daria Sgargi
- Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bologna, Italy
| | - Ellen K Silbergeld
- Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Kathrine Sørensen
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Patrice Sutton
- Program on Reproductive Health and the Environment, University of California San Francisco, San Francisco, United States of America
| | - Thomas Tenkate
- School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada
| | - Denise Torreão Corrêa da Silva
- Workers' Health and Human Ecology Research Center, National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Yuka Ujita
- Labour Administration, Labour Inspection and Occupational Safety and Health Branch, International Labour Organization, Geneva, Switzerland
| | - Emilie van Deventer
- Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland
| | - Tracey J Woodruff
- Program on Reproductive Health and the Environment, University of California San Francisco, San Francisco, United States of America
| | - Daniele Mandrioli
- Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bologna, Italy
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6
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Alóe F, Alves RC, Araújo JF, Azevedo A, Bacelar A, Bezerra M, Bittencourt LRA, Bustamante G, Cardoso TAMDO, Eckeli AL, Fernandes RMF, Goulart L, Pradella-Hallinan M, Hasan R, Sander HH, Pinto LR, Cecília Lopes M, Minhoto GR, Moraes W, Moreira GA, Pachito D, Pedrazolli M, Poyares D, Prado L, Rizzo G, Nonato Rodrigues R, Roitman I, Ademir Baptista S, Tavares SMA. [Brazilian guidelines for the treatment of narcolepsy]. Braz J Psychiatry 2010; 32:305-314. [PMID: 20945021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 04/09/2010] [Indexed: 05/30/2023]
Abstract
This manuscript contains the conclusion of the consensus meeting of the Brazilian Sleep Association with Brazilian sleep specialists on the treatment of narcolepsy based on the review of medical literature from 1980 to 2010. The manuscript objectives were to reinforce the use of agents evaluated in randomized placebo-controlled trials and to issue consensus opinions on the use of other available medications as well as to inform about safety and adverse effects of these medications. Management of narcolepsy relies on several classes of drugs, namely, stimulants for excessive sleepiness, antidepressants for cataplexy and hypnotics for disturbed nocturnal sleep. Behavioral measures are likewise valuable and universally recommended. All therapeutic trials were analyzed according to their class of evidence. Recommendations concerning the treatment of each single symptom of narcolepsy as well as general recommendations were made. Modafinil is the first-line pharmacological treatment of excessive sleepiness. Second-line choices for the treatment of excessive sleepiness are slow-release metylphenidate followed by mazindol. The first-line treatments of cataplexy are the antidepressants, reboxetine, clomipramine, venlafaxine, desvenlafaxine or high doses of selective serotonin reuptake inibitors antidepressants. As for disturbed nocturnal sleep the best option is still hypnotics. Antidepressants and hypnotics are used to treat hypnagogic hallucinations and sleep paralysis.
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Affiliation(s)
- Flávio Alóe
- Hospital das Clínicas, Universidade de São Paulo, SP, Brasil.
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7
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Alóe F, Alves RC, Araújo JF, Azevedo A, Bacelar A, Bezerra M, Bittencourt LRA, Bustamante G, Cardoso TAMDO, Eckeli AL, Fernandes RMF, Goulart L, Pradella-Hallinan M, Hasan R, Sander HH, Pinto LR, Lopes MC, Minhoto GR, Moraes W, Moreira GA, Pachito D, Pedrazolli M, Poyares D, Prado L, Rizzo G, Rodrigues RN, Roitman I, Silva AB, Tavares SMA. [Brazilian guidelines for the diagnosis of narcolepsy]. ACTA ACUST UNITED AC 2010; 32:294-304. [PMID: 20585744 DOI: 10.1590/s1516-44462010005000014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 04/09/2010] [Indexed: 11/21/2022]
Abstract
This manuscript contains the conclusion of the consensus meeting on the diagnosis of narcolepsy based on the review of Medline publications between 1980-2010. Narcolepsy is a chronic disorder with age at onset between the first and second decade of life. Essential narcolepsy symptoms are cataplexy and excessive sleepiness. Cataplexy is defined as sudden, recurrent and reversible attacks of muscle weakness triggered by emotions. Accessory narcolepsy symptoms are hypnagogic hallucinations, sleep paralysis and nocturnal fragmented sleep. The clinical diagnosis according to the International Classification of Sleep Disorders is the presence of excessive sleepiness and cataplexy. A full in-lab polysomnography followed by a multiple sleep latency test is recommended for the confirmation of the diagnosis and co-morbidities. The presence of two sleep-onset REM period naps in the multiple sleep latency test is diagnostic for cataplexy-free narcolepsy. A positive HLA-DQB1*0602 with lower than 110pg/mL level of hypocretin-1 in the cerebrospinal fluid is required for the final diagnosis of cataplexy- and sleep-onset REM period -free narcolepsy.
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Affiliation(s)
- Flávio Alóe
- Hospital das Clínicas, Universidade de São Paulo, SP, Brasil.
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