Off-label drug use in an adult intensive care unit of a Brazilian hospital

Abstract The objective of this study was to determine the prevalence and describe the factors associated with off-label drug use in an adult intensive care unit (ICU) of a Brazilian hospital. An analytical, cross-sectional, prospective study was conducted in the adult ICU population from March 2018 to May 2018. Off-label use of medication was classified by indication, dosage, route of administration, type and volume of diluent, and duration of administration. Most patients were female (57.89%), non-elderly (56.14%), and had a mean age of 54.44 ± 17.15 years. The prevalence of off-label drug use was 70.31%, but was not associated with the clinical severity of the patients. A statistically significant association was observed between label use of drugs and prescribing potentially inappropriate medicines (PIM). The most common reasons for off-label drug use were therapeutic indication (19.58%) and volume of diluent (23.30%). Drug administration by enteral tubes accounted for the largest number of off-label uses due to route of administration (90.85%). There was a higher prevalence of off-label use of systemic antimicrobials (14.44%) and norepinephrine (9.28%). Our study provided a broad characterization of off-label drug use in an adult ICU and showed why it is important for health professionals to evaluate the specific risks and benefits of this practice

Pharmaceutical services in primary health care: dissatisfaction among users, managers and pharmacists

Abstract To assess the performance indicators for pharmaceutical services (PS) in primary health care (PHC), the level of satisfaction with pharmacy services among users and managers / pharmacists' impressions in relation to the findings were evaluated. The study used mixed methods, including a retrospective and descriptive study of the performance indicators for PS in PHC, an observational study on the level of satisfaction and a qualitative study of users' perception of pharmacy services at Health Units. Managers and pharmacists' impressions of the study results were also collected. Only 44.4% of pharmacies had a full-time pharmacist. From the establishments visited, 5.3% did not have an air-conditioned environment, and only 33.3% of the items essential to the Good Practices of Storage of Medicines and Supplies criteria were fulfilled. Although 77.9% of the prescribed medicines were dispensed, it did not reach the 80% standard. The satisfaction level of users was 3.2±0.6, indicating dissatisfaction with pharmacies' services. By means of an evaluation of each item within the questionnaire, it was possible to observe that variables related to pharmaceutical care presented low scores in relation to other domains, thus evidencing the fragility of the pharmaceutical- patient relationship in users' perception. Managers and pharmacists suggested that these results were related to the inadequate physical infrastructure of pharmacies, work overload, lack of recognition and undervaluation of pharmacists, lack of interaction within the PHC team, high turnover of pharmacists, and lack of PS prioritization by the administration. PS in PHC has structural and organizational weaknesses that require changes. In general, users are dissatisfied with pharmacies' services, especially with pharmaceutical care.

Actions developed at the Instituto de Medicina Integral Prof. Fernando Figueira to confront the COVID-19 pandemic / Ações desenvolvidas no Instituto de Medicina Integral Prof. Fernando Figueira para enfrentamento à pandemia da COVID-19

Abstract The COVID-19 pandemic has brought countless challenges to the health institutions around the world, especially those located in countries such as Brazil, with large territorial dimensions and many social and economic differences. This technical report aims to publish the actions carried out and the products developed at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) before and during the pandemic - from January 31st to September 4th, 2020 - facing it efficiently and effectively, seeking institutional sustainability. The mobilization of the professional staff at the institution was fundamental to create protocols ofas-sistance, adapt the physical structures in the hospital and outpatient care, care for the health professionals, offer teaching and research activities in the distance mode, articulate management members to make decisions based on systematically collected data on the pandemic situationat real time. All actions were carried out with a single objective of assisting all the patients affected by COVID-19 admitted at the institution.

Resumo A pandemia da COVID-19 trouxe incontáveis desafios para as instituições de saúde de todo o mundo, em especial as localizadas em países como o Brasil, com grande dimensão territorial e muitas diferenças sociais e econômicas. Este informe técnico tem como objetivo publicizar as ações realizadas e os produtos desenvolvidos no Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) antes e durante a pandemia - no período de 31 de janeiro até 04 de setembro de 2020 - enfrentando-a com eficiência e eficácia, buscando a sustentabilidade institucional. A mobilização do corpo profissional da instituição foi fundamental para a construir protocolos de atendimento, adaptar as estruturas físicas na assistência ao paciente em âmbito hospitalar e ambulatorial, cuidar dos profissionais de saúde, ofertar as atividades de ensino e pesquisa na modalidade à distância, articular os membros da gestão para tomar decisões baseadas em dados sistematicamente coletados sobre a situação da pandemia em tempo real. Todas as ações foram realizadas com um uníssono objetivo de atender a todos os pacientes acometidos pela COVID-19 admitidos na instituição.

Use of Statewide Administrative Data to Assess Clinical Outcomes: A Retrospective Cohort Study of Therapeutic Anticoagulation for Isolated Calf Vein Thrombosis.

BACKGROUND: Single-center comparative effectiveness studies evaluating outcomes that can occur posthospitalization may become biased if outcomes diagnosed at other facilities are not ascertained. Administrative datasets that link patients' records across facilities may improve outcome ascertainment. OBJECTIVE: To determine whether use of linked administrative data significantly augments thromboembolic outcome ascertainment. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Patients with an acute isolated calf deep vein thrombosis (DVT) diagnosed at 1 Californian center during 2010-2013. MEASURES: Proximal DVT or pulmonary embolism (PE) within 180 days. We ascertained outcomes from linked California hospitalization, emergency department, and ambulatory surgery data and compared this information to outcomes previously identified from review of the center's medical records. RESULTS: Among 384 patients with an isolated calf DVT, 333 could be linked to longitudinal administrative data records. Ten patients had a possible proximal DVT or PE (4 more clearly so) from administrative data; all were unknown from medical record review. Eleven patients with known outcomes from medical record review had no outcome from administrative data. The adjusted odds ratio of proximal DVT or PE with therapeutic anticoagulation attenuated from 0.33 [95% confidence interval (CI), 0.12-0.87] using only medical record review to 0.64 (95% CI, 0.29-1.40) using both medical record review and possible outcomes from administrative data. Restricting the outcome to diagnoses clearly involving proximal DVT or PE, the adjusted odds ratio was 0.46 (95% CI, 0.19-1.10). CONCLUSIONS: Use of linked hospital administrative data augmented detection of outcomes but imperfect linkage, nonspecific diagnoses, and documentation/coding errors introduced uncertainty regarding the accuracy of outcome ascertainment.

From Challenges to Resources: A Qualitative Study of Cancer Coordinators' Experiences of Barriers and Facilitators to Enacting Their System-Focused Tasks.

BACKGROUND: Cancer coordinators (CCs) operate at both patient and system levels in order to provide patients with tailored and coordinated services. In common with international CCs, Norwegian CCs denote notable progress in their patient-focused work, while reporting ongoing challenges in carrying out system-focused tasks. However, little is known about the barriers and facilitators for CCs' system-level work. OBJECTIVE: The aim of this study was to explore Norwegian CCs' experiences of barriers and facilitators for enacting system-focused tasks. METHODS: The study applies a qualitative method, conducting an interpretative data inquiry of semistructured in-depth interviews with 26 Norwegian CCs. The data were analyzed using thematic analysis and discussed in light of previous research and salutogenic theory. RESULTS: The analyses revealed 3 main themes: (1) "understanding the role and local cancer care," (2) "systems for care delivery in primary healthcare," and (3) "commitment to collaboration." Where present, the themes could represent important facilitators, whereas their absence could depict notable challenges to CCs system-focused work. Over time, as CCs were able to mobilize resources, they were able to gradually turn initial challenges into facilitators in the context of system-level work. CONCLUSIONS: Cancer coordinators encounter cognitive, practical, and relational topics that impact their system-focused activities. Adopting a salutogenic focus can help CCs mobilize resources needed to turn challenges into facilitators for system-level work. IMPLICATIONS FOR PRACTICE: Cancer care coordination cannot be undertaken by CCs alone. Cancer coordinators' embedding in multidisciplinary teams, common systems for care provision, meaningful work relations, and professionals' commitment to cancer care represent important facilitators for CCs' system-focused tasks.

Saberes e práticas no gerenciamento do cuidado de enfermagem a pessoa com câncer avançado na atenção básica / Knowledge and practices in managing nursing care the person with advanced cancer in the basic attention

Dados internacionais indicam que com o crescente envelhecimento da população mundial e o aumento das doenças não transmissíveis, dentre elas o câncer, a necessidade por cuidados paliativos aumentará drasticamente nos próximos 50 anos.Tal afirmativa traz repercussões importantes para a organização da assistência no cenário das práticas em saúde. Diante desse cenário, apontou-se como objeto para esse estudo: diretrizes para o gerenciamento do cuidado de enfermagem à pessoa com câncer avançado na atenção básica, objetivando: identificar saberes e práticas de enfermeiros acerca da oferta de cuidados paliativos à pessoa com câncer avançado na atenção básica; descrever os fatores intervenientes no gerenciamento do cuidado de enfermagem à pessoa com câncer avançado na visão dos enfermeiros e propor com os enfermeiros ações e estratégias que favoreçam a oferta de cuidados paliativos à pessoa com câncer avançado no âmbito da atenção básica. Estudo descritivo, de natureza qualitativa onde foi adotado como método, a Pesquisa Convergente Assistencial (PCA). Foram entrevistados 13 profissionais, sendo 11 enfermeiros, 01 psicóloga e 01 assistente social. O cenário do estudo foi o Município de Saquarema, localizado na Baixada Litorânea do Rio de Janeiro. A técnica de coleta de dados foi a entrevista individual (para caracterização do perfil dos participantes) e a criação de um grupo de discussão mediante a apresentação de um caso mobilizador. Houve consentimento dos participantes pelo Termo de consentimento Livre e Esclarecido (TCLE) e aprovação do estudo por Comitê de Ética em Pesquisa (CAEE n. 53185416.1.0000.5238.). Os dados foram distribuídos e agrupados em Unidades temáticas e núcleos de sentidos com a discussão dos resultados contemplando os três eixos principais do estudo: saberes e práticas sobre o cuidado paliativo; fatores intervenientes e diretrizes para ações do cuidado paliativo no contexto da Atenção Básica. Os resultados apontam a existência de fatores intervenientes para o gerenciamento do cuidado de enfermagem a pessoas com câncer avançado no Município, que impactam diretamente na oferta dos cuidados paliativos. Porém, destaca ações e estratégias elaboradas e propostas pelas participantes do estudo, como ferramentas capazes de promover mudanças no cenário da prática atual.Conclui-se que o primeiro passo foi dado para articular de forma integrada os saberes e práticas as ações do cuidado de enfermagem, delineando transformações na atenção oncológica do município.(AU)

Short and long-term effects of supervised versus unsupervised exercise training on health-related quality of life and functional outcomes following lung cancer surgery - a randomized controlled trial.

OBJECTIVE: Surgical resection enhances long-term survival after lung cancer, but survivors face functional deficits and report on poor quality of life long time after surgery. This study evaluated short and long-term effects of supervised group exercise training on health-related quality of life and physical performance in patients, who were radically operated for lung cancer. METHODS: A randomized, assessor-blinded, controlled trial was performed on 78 patients undergoing lung cancer surgery. The intervention group (IG, n=41) participated in supervised out-patient exercise training sessions, one hour once a week for ten weeks. The sessions were based on aerobic exercises with target intensity of 60-80% of work capacity, resistance training and dyspnoea management. The control group (CG, n=37) received one individual instruction in exercise training. Measurements consisted of: health-related quality of life (SF36), six minute walk test (6MWT) and lung function (spirometry), assessed three weeks after surgery and after four and twelve months. RESULTS: Both groups were comparable at baseline on demographic characteristic and outcome values. We found a statistically significant effect after four months in the bodily pain domain of SF36, with an estimated mean difference (EMD) of 15.3 (95% CI:4 to 26.6, p=0.01) and a trend in favour of the intervention for role physical functioning (EMD 12.04, 95% CI: -1 to 25.1, p=0.07) and physical component summary (EMD 3.76, 95% CI:-0.1 to 7.6, p=0.06). At 12 months, the tendency was reversed, with the CG presenting overall slightly better measures. We found no effect of the intervention on 6MWT or lung volumes at any time-point. CONCLUSION: Supervised compared to unsupervised exercise training resulted in no improvement in health-related quality of life, except for the bodily pain domain, four months after lung cancer surgery. No effects of the intervention were found for any outcome after one year.

The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training.

BACKGROUND: Poor supervision of physician trainees can be detrimental not only to resident education but also to patient care and safety. Inadequate supervision has been associated with more frequent deaths of patients under the care of junior residents. We hypothesized that residents reporting more medical errors would also report lower quality of supervision scores than the ones with lower reported medical errors. The primary objective of this study was to evaluate the association between the frequency of medical errors reported by residents and their perceived quality of faculty supervision. METHODS: A cross-sectional nationwide survey was sent to 1000 residents randomly selected from anesthesiology training departments across the United States. Residents from 122 residency programs were invited to participate, the median (interquartile range) per institution was 7 (4-11). Participants were asked to complete a survey assessing demography, perceived quality of faculty supervision, and perceived causes of inadequate perceived supervision. Responses to the statements "I perform procedures for which I am not properly trained," "I make mistakes that have negative consequences for the patient," and "I have made a medication error (drug or incorrect dose) in the last year" were used to assess error rates. Average supervision scores were determined using the De Oliveira Filho et al. scale and compared among the frequency of self-reported error categories using the Kruskal-Wallis test. RESULTS: Six hundred four residents responded to the survey (60.4%). Forty-five (7.5%) of the respondents reported performing procedures for which they were not properly trained, 24 (4%) reported having made mistakes with negative consequences to patients, and 16 (3%) reported medication errors in the last year having occurred multiple times or often. Supervision scores were inversely correlated with the frequency of reported errors for all 3 questions evaluating errors. At a cutoff value of 3, supervision scores demonstrated an overall accuracy (area under the curve) (99% confidence interval) of 0.81 (0.73-0.86), 0.89 (0.77-0.95), and 0.93 (0.77-0.98) for predicting a response of multiple times or often to the question of performing procedures for which they were not properly trained, reported mistakes with negative consequences to patients, and reported medication errors in the last year, respectively. CONCLUSIONS: Anesthesiology trainees who reported a greater incidence of medical errors with negative consequences to patients and drug errors also reported lower scores for supervision by faculty. Our findings suggest that further studies of the association between supervision and patient safety are warranted. (Anesth Analg 2013;116:892-7).

Perfil sociodemográfico, de conhecimentos administrativos, em legislação sanitária de gerentes e segurança alimentar em unidades produtoras de refeições comerciais / Socio-demographic profile of restaurant managers regarding their knowledge on administration, health legislation and food safety

The objective of the present work was to investigate the socio-demographicprofi le of managers in commercial restaurants of the south central region ofBelo Horizonte, and check their knowledge about the administrative aspectsand requirements of the Brazilian health legislation in force. We also triedto verify and characterize the studied restaurants according to the hygieneconditions. The sample consisted of 16 managers from different commercialunits, registered at the Brazilian Association of Bars and Restaurants. Thedata were based on an interview with the managers and a restaurantchecklist according to the technical regulation by the Brazilian NationalHealth Surveillance Agency (ANVISA) Resolution # 216 dated September15, 2004. The results showed a management staff consisting mostly ofmen, married, aged an average 38.6 years, with a knowledge gained inspecialization technical courses not related to the food area and insuffi cientinformation on good practices. The rate of compliance with good practices inrestaurant is considered as regular. It was observed that increased workinghours of the managers were signifi cantly correlated (p <0.05) with a bettersanitary classifi cation of the restaurants. The data obtained show a challengefor the development of strategies aimed at training managers aware of theirleadership role in the context of food service.

El objetivo del trabajo fue investigar el perfil sociodemográfico de los gerentes derestaurantes comerciales de la región CentroSur de Belo Horizonte - Minas Gerais - Brasil y verificar sus conocimientos sobre los aspectosadministrativos y de la legislación sanitariavigente. Se verifi caron también las condicionessanitarias de las unidades estudiadas. El estudioincluyó 16 gerentes de unidades comercialesde la región registradas en la AsociaciónBrasilera de Cantinas y Restaurantes. Lacolecta de los datos fue conducida por mediode una entrevista modelo con los gerentes y laaplicación de una lista de verifi caciones en lasunidades comerciales, con base en el reglamentotécnico de la Resolución Nº 216 de 15 deseptiembre de 2004, de la Agencia Nacional deVigilancia Sanitaria (ANVISA). Se constato uncuadro gerencial compuesto en su mayoría porhombres, casados, edad media de 38,6 años yconocimientos adquiridos en cursos técnicosde especialización no relacionados al área dealimentos que tenían información insufi cientesobre buenas prácticas. El índice de aplicacióngeneral de las buenas prácticas en las unidadescomerciales se encuentra regular. Fue observadoque una jornada de trabajo mayor de los gerentesse correlaciona signifi cativamente (p<0,05) conuna mejor clasifi cación higiénico-sanitaria delas unidades comerciales. Los datos obtenidosrepresentan desafíos para la elaboración deestrategia direccionada a la formación degerentes concientes de su papel de líder, en elcontexto de la alimentación colectiva.

Objetivou-se investigar o perfi l sociodemográfi code gerentes de UPRs comerciais da regiãoCentro-Sul de Belo Horizonte e verifi car seusconhecimentos sobre aspectos administrativose requisitos da legislação sanitária vigente.Procurou-se, ainda, verifi car e caracterizar asunidades estudadas de acordo com as condiçõeshigiênico-sanitárias. A amostra foi de 16 gerentesde diferentes unidades comerciais da regiãoCentro-Sul de Belo Horizonte, cadastrados naAssociaçã o Brasileira de Bares e Restaurantes. Acoleta de dados seguiu um roteiro de entrevistapara os gestores e aplicação de uma lista deverifi cação nas unidades comerciais, com baseno regulamento técnico da Resolução Nº 216 de15 de setembro de 2004 da Agência Nacionalde Vigilância Sanitária (ANVISA). Verifi cou-seum quadro gerencial composto na maioria porhomens, casados, idade média de 38,6 anos,com conhecimento adquirido em cursos técnicosde especialização não relacionados à área dealimentos e com informação insufi ciente sobreboas práticas. O índice de atendimento geral àsboas práticas nas unidades comerciais encontraseregular. Foi observado que uma maiorjornada de trabalho dos gerentes correlacionousignifi cativamente (p<0,05) com uma melhorclassifi cação higiênico-sanitária das unidadescomerciais. Os dados obtidos são desafi os paraa elaboração de estratégias direcionadas àformação de gerentes conscientes do seu papelde líder, no contexto da alimentação coletiva.

A vantagem em casa no futebol: comparação entre o campeonato Brasileiro e as principais ligas nacionais do Mundo / Home advantage in the soccer: comparison between the Brazilian championship and the main national leagues of the World

A vantagem em casa é um fenômeno que tem sido investigado em muitos confrontos esportivos. Contudo, dados do futebol brasileiro e comparações entre ligas são limitados na literatura. Dessa forma, o objetivo deste estudo foi fazer um levantamento da vantagem em casa do Campeonato Brasileiro da primeira divisão (Série A), por meio do percentual de aproveitamento dos pontos em casa, e compará-la com as principais ligas nacionais do mundo nas temporadas de 2002/03 a 2006/07. Os resultados demonstraram que o Campeonato Brasileiro obteve vantagem em casa significantemente maior (64,9 ± 2,2%; p<0.05) em comparação com as ligas da Alemanha, Argentina, Espanha, Inglaterra, Itália e Portugal. Apenas na comparação com a liga francesa não houve diferença estatística (p=0,050). Conclui-se que no Campeonato Brasileiro a vantagem em casa foi maior do que as principais ligas nacionais de futebol do mundo no período analisado. Possíveis fatores que contribuíram para isso foram discutidos...

Home advantage is a phenomenon that has been investigated in many sporting competition. Nevertheless, data from Brazilian soccer and comparisons between different leagues are rare in the literature. Thus, the objective of this study was to perform a survey of the advantage of playing at home in the first division of the Brazilian Championship (Série A), by means of percentage of available points won while playing at home, and to compare this with the principal national leagues of the world for the seasons from 2002/03 to 2006/07. The results showed that there was a significantly greater advantage to playing at home for teams in the Brazilian Championship (64.9 ± 2.2%; p<0.05) than for those competing in Germany, Argentina, Spain, England, Italy or Portugal. There was no statistical difference when Brazilian results were compared with those from the French league (p=0.050). It was concluded that the advantage of playing at home was greater in the Brazilian championship than in the principal national soccer leagues of the world during the period analyzed. Factors that possibly contribute to this finding were discussed...