Enderson Miranda

DOI: 10.1136/bmjebm-2020-111377

The Oxford-Brazil EBM Alliance aims to contribute to the continued evolution of EBM in Brazil and Latin America by empowering the united actions from volunteers and EBM enthusiasts while removing language or geograph- ical barriers between countries. The detailed activities and initial projects from the Oxford-Brazil EBM Alliance will be presented in a blog in the BMJ EBM Spotlight and can be accessed at https:// blogs.bmj.com/bmjebmspotlight/.

Fontes LE, Riera R, Miranda E, Oke J, Heneghan CJ, Aronson JK, Pacheco RL, Martimbianco ALC, Nunan D

Urgent research is needed to test potential therapeutic agents against COVID-19. Several studies are evaluating the benefit and harm profiles of different pharmacological interventions such as antimalarial drugs, antiviral drugs, biologics, and interferon. The number of trial registrations for hydroxychloroquine/cholorquine as a COVID-19 therapeutic rises each day and on April 5th 2020 we… Show more

Fontes LE, Riera R, Miranda E, Oke J, Heneghan CJ, Aronson JK, Pacheco RL, Martimbianco ALC, Nunan D

Urgent research is needed to test potential therapeutic agents against COVID-19. Several studies are evaluating the benefit and harm profiles of different pharmacological interventions such as antimalarial drugs, antiviral drugs, biologics, and interferon. The number of trial registrations for hydroxychloroquine/cholorquine as a COVID-19 therapeutic rises each day and on April 5th 2020 we found three published trials and 100 ongoing studies. A first published report from Gautret et al. (1) suggested a positive effect of hydroxychloroquine (plus azithromycin, an antibiotic, in some cases) on the disappearance of COVID-19, attracting intense media coverage worldwide. Another two publications have since shown equivocal findings (2,3). All the trials have serious methodological limitations and do not permit recommendations on the use of hydroxychloroquine/cholorquine in COVID-19. Known serious adverse effects associated with hydroxychloroquine/cholorquine administration also need to be considered.

OBJECTIVE: To assess the benefits and harms of chloroquine or hydroxychloroquine for the treatment of COVID-19 infection.

METHODS: A systematic review of Individual Participant Data (IPD).

FULL PROTOCOL Download: https://www.cebm.net/wp-content/uploads/2020/04/Protocol-Chloroquine-IPD_FULL.pdf Show less

“Research-on-research” studies, also known as methodological studies, have the main purpose of evaluating certain methodological aspects of published research, which includes methodological and reporting quality characteristics from previous studies. Research-on-research studies have an important implication on helping the conception, design, and conduction of future studies. Therefore, assessing previous research is essential in avoiding unnecessary duplication and waste.

In times of uncertainty regarding #COVID19 #evidence, it’s important that people know all the biases that can exist when interpreting studies and research.

Biases may arise in any stage of healthcare research and are likely to influence the magnitude and direction of the results. Understanding where and how different biases emerge in the research process allows researchers to properly design studies that can prevent or counteract the impact of biases. Furthermore, to assess the risk of… Show more

In times of uncertainty regarding #COVID19 #evidence, it’s important that people know all the biases that can exist when interpreting studies and research.

Biases may arise in any stage of healthcare research and are likely to influence the magnitude and direction of the results. Understanding where and how different biases emerge in the research process allows researchers to properly design studies that can prevent or counteract the impact of biases. Furthermore, to assess the risk of bias within published studies is imperative when drafting any research synthesis and clinical practical guidelines.

Sackett, in a remarkable paper published in 1979, ‘Bias in Analytic Research’, was the first to propose a catalogue that would include a list of biases that ‘may distort the design, execution, analysis and interpretation of research’. Sacket’s pioneering work identified, labelled and discussed 35 biases. In the conclusion of this paper, Sackett highlighted, among others, two priorities for future researches: the continued development of the proposed catalogue and the empirical evaluation of the proposed biases.


Forty years after Sackett’s paper, a group of researchers from the University of Oxford’s Centre for Evidence-Based Medicine (CEBM) decided to continue Sackett’s mission by creating an expansion to his original catalogue of bias. Fifty-two biases have been catalogued and discussed so far. All the content related to each bias is freely available at the official catalogue’s website (https://catalogofbias.org), including any new biases that may be catalogued after the publication of this article. Show less

Fontes LES, Miranda E, Riera R, Pacheco RL, Vieira R, Martimbianco ALC, Pachito D, Nunan D

The ‘Oxford-Brazil EBM Alliance’ is a promising initiative that can bring EBM training to thousands of medical professors and interdisciplinary health care teams throughout Brazil and its neighboring countries.

Relevance to diversity:
Different countries may experience diverse barriers to implementing EBM education in medical schools. We hope that the combined experience and enthusiasm of… Show more

Fontes LES, Miranda E, Riera R, Pacheco RL, Vieira R, Martimbianco ALC, Pachito D, Nunan D

The ‘Oxford-Brazil EBM Alliance’ is a promising initiative that can bring EBM training to thousands of medical professors and interdisciplinary health care teams throughout Brazil and its neighboring countries.

Relevance to diversity:
Different countries may experience diverse barriers to implementing EBM education in medical schools. We hope that the combined experience and enthusiasm of home and international educators can together enhance and disseminate the teaching and learning of evidence-based medicine and health care in Brazil.

Relevance to patients and consumers:
The ‘Oxford-Brazil EBM Alliance’ can facilitate EBM teaching and learning, foster future leaders, and ultimately benefit patients, public and healthcare systems throughout South America. Show less

Brazil is the 5th largest country in the world, with a population of about 210 million people. Its 336 medical schools graduate an average of 34,000 medical professionals each year. Of these schools, under 20% include formal Evidence-Based Medicine teaching in their curricula. The lack of formal EBM integration into medical school curricula is not exclusively a national challenge for Brazil. Data from the USA and UK suggest that only 60% of curricula include formal EBM content. Despite the… Show more

Brazil is the 5th largest country in the world, with a population of about 210 million people. Its 336 medical schools graduate an average of 34,000 medical professionals each year. Of these schools, under 20% include formal Evidence-Based Medicine teaching in their curricula. The lack of formal EBM integration into medical school curricula is not exclusively a national challenge for Brazil. Data from the USA and UK suggest that only 60% of curricula include formal EBM content. Despite the recognition of the importance of EBM education and its influence on medical training around the world, challenges remain in integrating EBM education into the medical curriculum, facilitating communication between practitioners, increasing the capacity for EBM’s use in clinical practice, and ensuring that medical professionals have the knowledge and skills to support evidence-based practice.

Concerned about these needs, two Oxford post-graduate students and Brazilian citizens, Dr. Luis Fontes (MSc in EBHC Systematic Reviews) and Enderson Miranda (DPhil in EBHC), who met while attending Oxford’s TEBM course in 2017, have joined forces with Dr David Nunan, a Senior Research Fellow in the CEBM, to create an international partnership between Oxford’s CEBM and the EBM Departments of leading Brazilian medical schools. This partnership, named the “Oxford-Brazil EBM Alliance,” has the following principal aims:

1. To promote teaching, learning, practice, and evaluation of Evidence-Based Health Care throughout Brazil.
2. To conduct applied, patient-based and methodologically sound research, in order to generate the new knowledge required for the practice of Evidence-Based Health Care.
3. To foster national and international collaborations with like-minded academics, educators, and scientists for developing and delivering high-quality teaching, training, and research programmes in Evidence-Based Medicine and Health Care. Show less

Quality of care issues relating to potential overutilization of treatments and healthcare resources are widely discussed in the oncology field, especially near end-of-life. There are many distinct stakeholders involved, including patients, families, governments, payers, and healthcare providers. The aim of this systematic review is to identify the diverse factors that impact the appropriateness of treatment received by oncology patients near end-of-life.

2,229 studies were screened. 52… Show more

Quality of care issues relating to potential overutilization of treatments and healthcare resources are widely discussed in the oncology field, especially near end-of-life. There are many distinct stakeholders involved, including patients, families, governments, payers, and healthcare providers. The aim of this systematic review is to identify the diverse factors that impact the appropriateness of treatment received by oncology patients near end-of-life.

2,229 studies were screened. 52 were included (n=1,561,124 patients; n=19 countries). Rates of chemotherapy use across studies were 8.1% (7.4%-8.8%, P<0.001) in last 14 days of life and 18.2% (16.0-20.3%, P<0.001) in last 30 of life. Chemotherapy use in last 14 and 30 days of life varied substantially between studies. Meta-Regression models explained 43% and 73% of the variance respectively. Impacting factors included younger age (OR=2.71,2.19-3.36,p<0.00001/(OR=2.74,2.07-3.62,p<0.00001), being married (OR=1.56,1.40-1.75,p<0.00001)/(OR=1.28,1.13-1.44,p=0.0001), black race (OR=0.76,0.68-0.85,p<0.00001)/(OR=0.83,0.80-0.87,p<0.00001), and male gender (OR=1.29,1.15-1.45,p<0001)/(OR=1.11,1.01-1.23,p=0.04).

The quantification and definition of aggressiveness versus appropriateness of end-of-life cancer treatment is particularly challenging. Our criteria for defining appropriate treatment is based on predominant benchmarks and measures that have been widely adopted in existing literature.

Appropriateness of treatment varied significantly across included studies. Chemotherapy use in last 14 and 30 days of life was inappropriate and potentially overly aggressive in 34.4% and 33.3% of studies respectively. ICU admissions, ED/A&E visits, and Hospice admission were also inappropriate in most studies. Further research into novel treatments and clinical practice that is focused on patient’s values, needs, and individualized goals are vital to ensure optimum alignment of effective advanced cancer care and patient preferences. Show less

PRÓSPERO 2018 CRD42018091711

Potentially inadequate utilization of treatments and healthcare resources are critical issues in the oncology field. This is especially the case regarding end-of-life care. The quantification and definition of "aggressiveness" versus "appropriateness" of treatment is a particularly challenging aspect of this review because there are often many distinct stakeholders involved, including patients, families, governments, payers, and healthcare providers. This… Show more

PRÓSPERO 2018 CRD42018091711

Potentially inadequate utilization of treatments and healthcare resources are critical issues in the oncology field. This is especially the case regarding end-of-life care. The quantification and definition of "aggressiveness" versus "appropriateness" of treatment is a particularly challenging aspect of this review because there are often many distinct stakeholders involved, including patients, families, governments, payers, and healthcare providers. This complex scenario yields conflicting opinions, interests, and ideologies. Therefore, our review bases its criteria for defining the appropriateness of treatment on predominant measures within existing literature. As outlined by Earle et al., three major areas are typically measured: "(1) the overuse of chemotherapy very near death; (2) possible misuse of treatment resulting in high rates of emergency room visits, hospitalization, or intensive care unit stays for terminal patients; and (3) underuse of hospice services as measured both by lack of referral or very late referral to hospice" (Earle et al. 2008 and Earle et al., 2004). Therefore, this review aims to study the significant concern regarding overutilization of aggressive treatments and underutilization of palliative resources or alternative treatments for terminal oncology patients by identifying the diverse factors that impact the appropriateness of treatment they receive nearing end-of-life. Show less

DOI: 10.1016/j.mnl.2017.03.009.
Nurse Leader: Official Journal of the American Organization of Nurse Executives.

The American healthcare system has undergone several reforms and is likely to undertake another reformation soon, given the sociopolitical landscape. Shifts from Fee-For-Service (FFS) to Value-Based Reimbursement (VBR) models continue to transfer a significant percentage of clinical and financial risk from payers to providers. Value-based models aim to reduce potentially… Show more

DOI: 10.1016/j.mnl.2017.03.009.
Nurse Leader: Official Journal of the American Organization of Nurse Executives.

The American healthcare system has undergone several reforms and is likely to undertake another reformation soon, given the sociopolitical landscape. Shifts from Fee-For-Service (FFS) to Value-Based Reimbursement (VBR) models continue to transfer a significant percentage of clinical and financial risk from payers to providers. Value-based models aim to reduce potentially unnecessary healthcare costs, improve the quality of care provided, and increase efficiency.1 This aim cannot be attained unless all healthcare providers are completely clear about their accountabilities and competent in their professional roles. (...) Show less

Presentation and publication focused on how healthcare organizations are using 21st century workplace performance analytics technology to address variation in practice and follow the Institute of Medicine (IOM)’s recommendations from the Future of Nursing report regarding practice to the highest level of licensure, nurse role accountability, professional responsibilities, and authority confusion. These factors are significant contributors of a task-based vs. professional role-based focus. Study… Show more

Presentation and publication focused on how healthcare organizations are using 21st century workplace performance analytics technology to address variation in practice and follow the Institute of Medicine (IOM)’s recommendations from the Future of Nursing report regarding practice to the highest level of licensure, nurse role accountability, professional responsibilities, and authority confusion. These factors are significant contributors of a task-based vs. professional role-based focus. Study also focuses on how Performance Improvement Professionals can use human capital analytics technology to identify hidden workplace behavioral gaps in real time, thus applying ISPI’s 10 International Standards to Improve Organizational Performance in any industry. Show less