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1.
Farm. hosp ; 44(3): 109-113, mayo-jun. 2020.
Artigo em Espanhol | IBECS | ID: ibc-192343

RESUMO

Existen dimensiones relevantes desde una perspectiva de género relaciona-das con el esfuerzo terapéutico. Se pretende ilustrar y traer a debate posibles sesgos de género relacionados con los medicamentos, mediante el análisis del consumo en las mujeres, la prescripción de fármacos biológicos según sexo, la potencial desigualdad de género en las reacciones adversas a los medicamentos y la investigación con ensayos clínicos, así como las decisiones de las instituciones internacionales en la comercialización de medicamentos. mSe observa una mayor tendencia a prescribir analgésicos, con independencia del dolor, y fármacos para síntomas depresivos de baja intensidad en mujeres que en hombres. Lo contrario sucede en la prescripción de estatinas y dosis adecuadas, y con la mayor probabilidad de prescripción de antifactor de necrosis tumoral en hombres que en mujeres con espondilitis anquilosante, pese a la similar carga de la enfermedad. Las reacciones adversas a los medicamentos se observan con más frecuencia en mujeres que en hombres, donde determinantes como el peso corporal están influyendo poco en la dosificación. En la actualidad se considera escasamente en la prescripción que las mujeres presentan diferencias en la actividad de las enzimas del citocromo CYPP450, que puede afectar a la velocidad del metabolismo hepático. Incluso hay efectos inmunológicos, genéticos y epigenéticos (por la herencia y la dosificación desigual de los genes ubicados en los cromosomas X e Y) que pueden influir en estas diferencias por sexo. Por último, mediante los casos de ensayos clínicos de la terapia hormonal, un fármaco para el deseo sexual inhibido de las mujeres y un anticonceptivo para hombres, se muestran sesgos y estereotipos de género que influyen en una potencial generación de desigualdades, especialmente en las reacciones adversas a los medicamentos en perjuicio de las mujeres. Concluyendo, los profesionales sanitarios atribuyen con frecuencia a la emocionalidad de las mujeres lo que son síntomas físicos, influyendo en la mayor prescripción de fármacos sintomáticos en ellas. Debe analizarse si la misma razón influye en la menor prescripción de fármacos terapéuticos en mujeres que en hombres. Existen determinantes biológicos a considerar por su influencia en una mayor toxicidad farmacológica en las mujeres. Los ensayos clínicos deben mejorar atendiendo a las recomendaciones de género de la Food and Drug Administration


There are relevant dimensions from a gender perspective related to the-rapeutic effort. To illustrate and discuss possible gender bias related to medicines, through the consumption analysis in women, the prescription of biological drugs according to sex, the potential gender inequality in adverse drug reactions, and research with clinical trials, as well as the decisions of international institutions in the marketing of medicinal products.There is greater tendency to prescribe pain relievers, regardless of pain, and drugs for low intensity depressive symptoms in women than in men. The opposite occurs in the prescription of statins and adequate doses, and with the greater probability of prescribing anti-tumor necrosis factor in men than in women with ankylosing spondylitis, despite a similar disease burden. Adverse drug reactions are observed more frequently in women than in men, where determinants such as body weight are having little influence on the dosage. It is currently scarcely considered in the prescrip-tion that women have differences in the activity of cytochrome CYPP450 enzymes, which can affect the liver's metabolism rate. There are even immunological, genetic and epigenetic effects (due to heredity and une-ven gene dosing located in the X and Y chromosomes) that can influence these differences by sex. Finally, through cases of hormonal therapy clini-cal trials, a drug for women's inhibited sexual desire and a contraceptive for men, gender bias and stereotypes are shown to influence a potential generation of inequalities, especially in adverse drug reactions to the de-triment of women. In conclusion, health professionals frequently attribute physical symptoms to women's emotionality, influencing their greater prescription of sympto-matic drugs. Whether the same reason influences the lower prescription of therapeutic drugs in women than in men should be analyzed. There are biological determinants to consider due to their influence on a greater pharmacological toxicity in women. Clinical trials should improve accor-ding to the gender recommendations by the Food and Drugs Administration


Assuntos
Humanos , Iniquidade de Gênero , Pesquisa Biomédica , Terapêutica/métodos , Ensaios Clínicos como Assunto/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde , Preconceito , Estereotipagem de Gênero , Prescrições de Medicamentos
2.
An Real Acad Farm ; 86(1): 75-88, ene.-mar. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-190874

RESUMO

El incremento de animales de compañía y animales productores de alimentos, junto con el importante gasto sanitario que estos suponen, hacen que el sector del medicamento veterinario esté adquiriendo cada vez más peso en España. Ante esta situación, se nos plantea la duda de si los propietarios, veterinarios y especialmente farmacéuticos, estamos correctamente preparados e informados. Tal como se observa en la recopilación de leyes sobre venta y distribución de medicamentos de uso veterinario realizada en este trabajo, actualmente no existe una legislación que se adecúe a las necesidades sanitarias de estos animales pudiendo observar en su aplicación intrusiones por parte del veterinario en las funciones legalmente establecidas y propias del farmacéutico o la venta ilegal de medicamentos veterinarios por parte de establecimientos sin la debida autorización. Por lo que al farmacéutico respecta, la falta de información y formación en este campo se manifiesta en varios aspectos como la falta de atención farmacéutica o la aceptación de recetas indebidamente cumplimentadas por el veterinario. Todo ello incrementa el riesgo de realizar un mal uso de los medicamentos por parte del propietario suponiendo así un peligro no solo para el propio animal, sino también para las personas como ocurre en el caso concreto de los antibióticos. Por tanto, nos encontramos frente a un importante problema de regulación y falta de información entre propietarios y profesionales sanitarios, que hace necesaria la realización de campañas informativas y la formación de farmacéuticos y veterinarios desde los Colegios Oficiales y Universidades


The veterinary medicinal sector is gaining more and more importance in Spain because of the increasing of livestock population and pets, and the significant healthcare costs that they involve. Given this situation, are the owners, veterinarians and especially pharmacists, properly prepared and informed? As it can be seen in the compilation of laws about sale and distribution of veterinary medicaments presented in this work, nowadays there is not a legislation adapted to the health requirements of these animals. Indeed, there are some problems in the application of the law such the intrusion of veterinarians in the own and legally established pharmacist’s functions and the ilegal sale of veterinary drugs by non properly authorized establishments. Concerning the pharmacist’s role, the lack of information and training in this area, is manifested in several aspects such a limited ability of pharmaceutical advice and the admission of prescriptions improperly filled by the veterinarian. Taken together, it increases the risk of abuse or wrong use of drugs by the owner, assuming a real danger not only for the animal itself, but also for the people, as in the case of antibiotics consumption. In conclusion, we are facing a critical problem of law regulation and lack of knowledge between owners and healthcare professionals. Therefore, it would be necessary that Universities and Official Colleges carry out information campaigns and organize specific training to pharmacists and veterinarians


Assuntos
Humanos , Animais , Papel Profissional , Farmacêuticos , Assistência Farmacêutica , Prescrições de Medicamentos/normas , Legislação de Medicamentos , Drogas Veterinárias/administração & dosagem
3.
Farm. hosp ; 44(1): 3-9, ene.-feb. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-187485

RESUMO

Objetivo: Describir la situación actual de la prestación farmacéutica especializada en centros sociosanitarios en España desde una perspectiva asistencial reflejando la actividad, la atención y los servicios prestados. Método: Estudio observacional, transversal, multicéntrico realizado entre febrero y junio de 2018 mediante encuesta dirigida a todos los servicios de farmacia hospitalaria de España. Una vez valorada la versión inicial por 12 evaluadores cuya labor asistencial estaba relacionada con centros sociosanitarios, se diseñó un formulario electrónico que constó de 10 dimensiones y 66 preguntas, y se realizó un pilotaje por seis farmacéuticos de centros sociosanitarios. Los resultados se analizaron de forma descriptiva. Resultados: La tasa de respuesta global fue del 29,7% (113 de 380). El 46,0% (n = 52) atendían centros sociosanitarios (9 como servicios de farmacia de centros sociosanitarios) cuyas características concretaron un perfil de servicio de farmacia de hospital, titularidad pública, consolidado en esta actividad, con gran variabilidad en número de centros y pacientes atendidos por servicio, y con dedicación parcial del farmacéutico. En el 51,3%, las comisiones de farmacia y terapéutica tenían representación de profesionales de los centros sociosanitarios, y el 38,5% de los servicios de farmacia participó en selección de productos sanitarios. El 67,4% realizó una gestión integral del tratamiento. El 34,6% disponía de prescripción electrónica asistida, el 88,5% realizó una validación farmacéutica de la prescripción previa a la dispensación que, en el 71,2% fue en dosis unitaria individualizada. El 42,3% llevó a cabo una revisión integral del tratamiento de nivel 3 y el 25,0% participó en la valoración nutricional interdisciplinar. El 34,6% participó activamente en la valoración geriátrica integral o de casos clínicos en los equipos interdisciplinares y el 46,2% disponía de programas para el uso seguro de los medicamentos. Conclusiones: La atención farmacéutica especializada en los centros sociosanitarios es una realidad, aunque presenta diferencias importantes en aspectos esenciales para la calidad de la asistencia prestada. Es necesario profundizar en el modelo asistencial a desarrollar y en una mayor implicación de los servicios de farmacia para lograr una atención integrada y centrada en la persona


Objective: To describe the current situation regarding the specialized pharmaceutical service provision in nursing homes in Spain, from a healthcare perspective reflecting activity, care and services provided. Method: Observational, cross-sectional, multicenter study conducted between February-June 2018 through a survey aimed at all Hospital Pharmacy Units in Spain. Once the initial version was assessed by twelve evaluators whose healthcare assistance work were related to nursing homes, an electronic form was designed, consisting on 10 dimensions and 66 questions. A piloting was carried out by six nursing homes pharmacists. The results were analyzed descriptively. Results: The overall response rate was 29.7% (113 out of 380). Out of all studied hospital pharmacy units, 46.0% (n = 52) served nursing homes (9 as Nursing Homes Pharmacy Department) whose characteristics defined a profile of pharmacy unit at hospital, public ownership, consolidation in this activity, with great variability in the number of centers and patients to be attended by service, and with the pharmacist's partial dedication. In 51.3% of cases, nursing homes professionals were represented at pharmacy and therapeutic committees, while 38.5% were from pharmacy services who participated in the selection of medical devices. Also, 67.4% performed an integral management of the therapy. The study has also shown that 34.6% counted on assisted electronic prescription, while 88.5% performed a pharmaceutical validation of the prescription prior to dispensing, which in 71.2% of cases consisted of individualized unit doses. It was found that 42.3% performed a third-level treatment comprehensive review, and 25.0% participated in the interdisciplinary nutritional assessment. It also showed that 34.6% actively participated in either comprehensive geriatric assessment, or clinical cases in interdisciplinary teams, and 46.2% counted on programs for the safe use of medicines. Conclusions: The specialized pharmaceutical care at nursing homes is a reality, although it presents important differences in essential aspects for the quality of the assistance provided. It is necessary to go in-depth on the care model to be developed, as well as having a greater involvement of pharmacy services to achieve a comprehensive and person-centered care


Assuntos
Humanos , Casas de Saúde/organização & administração , Serviço de Farmácia Hospitalar/organização & administração , Prescrições de Medicamentos , Sistemas de Medicação , Casas de Saúde/estatística & dados numéricos , Farmacêuticos , Estudos Transversais , Inquéritos e Questionários , Espanha , Prescrição Eletrônica , Assistência Centrada no Paciente/métodos , Idoso Fragilizado/estatística & dados numéricos
4.
Farm. hosp ; 44(supl.1): 11-16, 2020. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-190469

RESUMO

El objetivo de este artículo es describir la experiencia del servicio de farmacia de un hospital mediano, en el período álgido de la pandemia de COVID-19, con recursos humanos y materiales más limitados que otros hospitales de su entorno de mayor tamaño. Se analiza cómo afrontó su reorganización, debido al incremento de su actividad, así como las estrategias desarrolladas y las lecciones aprendidas para afrontar el futuro. La pandemia por COVID-19 tuvo especial repercusión en el municipio de Leganés, una ciudad de 190.000 habitantes al sur de Madrid. Ante el incremento de la afluencia de pacientes entre los meses de marzo y abril de 2020, el Hospital Universitario Severo Ochoa llegó a asumir un 24,5% más de camas, incluyendo nuevas ubicaciones tanto dentro como fuera del hospital (pabellón deportivo). Siendo la media de frecuentación del Servicio de Urgencias de 70-80 pacientes, se llegó a alcanzar un pico de 286 pacientes y 652 pacientes ingresados. Esta situación de emergencia y el abordaje de una patología infecciosa, con protocolos de tratamiento en continua revisión, impactó en todas las áreas y actividades del servicio de farmacia: adquisiciones, gestión económica, elaboración de medicamentos y dispensación a pacientes hospitalizados, pacientes externos y ambulantes, domiciliaria, a centros geriátricos, hospitales de gestión privada y hospitales de campaña. Se vieron afectadas áreas como la formación, los ensayos clínicos, la farmacovigilancia y las comisiones hospitalarias. Para superar los problemas, se aplicaron dos estrategias: una centrada en los recursos humanos (reforzamiento de áreas, reasignación de responsabilidades) y otra focalizada en los procesos (procesos que se reforzaron por un aumento de la actividad, procesos que se suspendieron temporal-mente por la pandemia y procesos que se redujeron al mínimo)


The purpose of this article is to report the experience of the Department of Hospital Pharmacy of a mid-size hospital during the peak of the COVID-19 pandemic. The human and material resources available in a midsize hospital were more limited than in larger hospitals of the region. In this article, we describe how this Department of Hospital Pharmacy was reorganized to meet the increase in activity, the strategies developed and the lessons learned for future pandemics. The COVID-19 pandemic had a higher impact in Leganes, a city in the south of Madrid, with a population of 190,000. In the face of the dramatic increase in the proportion of patients attending our hospital between March and April 2020, the Severo Ochoa University Hospital increased the number of beds by 24.5% and fitted out new premises inside and outside the hospital (sports centers). The mean number of patients seen in our Emergency Department every day passed from 70-80 to a peak of 286 patients, with 652 hospitalized patients. The situation of emergency created by this infectious disease, with management protocols changing constantly, had a dramatic impact on the activity of hospital pharmacies. Thus, the pandemic has affected areas of economic management, magistral preparation, dispensing of medication to inpatients, ambulatory patients, patients monitored at home, institutionalized patients, and patients from private hospitals and field hospitals. Other areas affected include training, clinical trials, pharmacovigilance, and counseling boards. Two strategies were adopted to overcome these problems: a strategy centered on human resources (staff reinforcement, reallocation of responsibilities), and a strategy centered on processes (some processes were reinforced to meet the increase in activity, whereas other were temporarily suspended or reduced to the minimum)


Assuntos
Humanos , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Pandemias , Pneumonia Viral/tratamento farmacológico , Serviço de Farmácia Hospitalar/organização & administração , Ensaios Clínicos como Assunto , Planejamento em Desastres , Prescrições de Medicamentos/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Número de Leitos em Hospital , Sistemas de Medicação no Hospital , Desenvolvimento de Pessoal
5.
Farm. hosp ; 44(supl.1): 17-20, 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-190470

RESUMO

La crisis COVID ha irrumpido en los hospitales de forma abrupta, y ha planteado muchas dificultades de partida a todos los niveles, incluyendo la logística de adquisiciones. El aumento radical de pacientes, una aceleradísima reorganización interna y otros cambios pusieron de manifiesto un drástico incremento de necesidades, tanto de medicamentos básicos, como de aquellos específicos para soporte y tratamiento de la infección por SARS-CoV-2. Paralelamente, surgieron otras dificultades como desabastecimientos, procedimientos de compra nuevos y más complejos, etc., que podían comprometer la seguridad del proceso de utilización de medicamentos. Nuestro objetivo consistió en establecer todas las medidas necesarias dentro del proceso logístico para garantizar de forma segura y eficaz la disponibilidad de los medicamentos para los pacientes durante la crisis COVID. En primer lugar, se designaron los farmacéuticos responsables del proceso, y se realizó un análisis preliminar de los siguientes aspectos: estimación de necesidades para realizar una compra inicial, estudio de viabilidad de almacenamiento y análisis logístico global para detectar puntos críticos. Se establecieron tres circuitos de adquisiciones, según se tratase de medicamentos intervenidos por la Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), por el Servicio Madrileño de Salud (SERMAS) o medicamentos no sujetos a restricciones. Para el control de stocks se implementaron revisiones frecuentes de inventario y seguimiento de las tendencias de prescripción. En las especialidades nuevas recibidas se revisó el cumplimiento de los estándares de seguridad y se realizó reetiquetado en caso necesario. Se establecieron unos criterios para el almacenamiento de los sobre stocks y se destinó un área independiente para medicamentos en cuarentena. Los desabastecimientos fueron inevitables pero amortiguados por la gestión del SERMAS y la AEMPS. Una vez superada la crisis, consideramos que el procedimiento implantado para la gestión logística es reproducible, y sus puntos clave para aplicabilidad futura son: mantener y potenciar nuestro sistema de gestión de calidad, elaborar un plan de actuación para emergencias sanitarias y garantizar la adecuada formación de todo el personal. Asimismo, existen otros aspectos que debemos abordar: establecer estrategias de optimización del almacenamiento, enfocarnos hacia un modelo de gestión logística más avanzado, así como aprovechar la extraordinaria red multidisciplinar consolidada durante la crisis


COVID crisis has abruptly broken into our hospitals, and many difficulties have emerged, including those related to supply logistics. A huge number of new patients, a fast internal reorganization process and many other changes were suddenly established. These circumstances revealed the need to increase stocks of drugs, both for basic treatment as well as for specific SARS-CoV-2 infection management. At the same time, other problems (shortages, new and complex purchasing procedures, etc.) surfaced, so they could risk safety along the pharmacotherapeutic process. The main objective was to develop and implement all the necessary measures within the logistics circuit in order to ensure the availability of medicines for patients, as safely and effectively as possible, during the Coronavirus crisis. Firstly, two pharmacists were appointed to coordinate the whole process, and a preliminary analysis of the following aspects was carried out an estimation of needs to make an initial drug provisioning, a storage feasibility study and a global analysis of the logistics process to detect critical points. Three different circuits for medicines supply were established as some drugs were operated by Agencia Española de Medicamentos y Productos Sanitarios (AEMPS) or Servicio Madrileño de Salud (SERMAS), and others were under no restrictions. For stocks control, inventory was frequently reviewed and monitoring of prescription trends was implemented. For all new medicinal products, compliance with security standards was reviewed and relabeling was carried out if necessary. Criteria were defined for the storage of overstocks and it was placed an isolated area for quarantined drugs. Shortages inevitably occurred but their effects were partly mitigated by AEMPS and SERMAS. After all, we consider that the implemented procedure for logistics management may be reproducible, and the key points we have identified are the following: to enhance our quality management system, to develop an Action Plan for Healthcare Emergencies and to ensure the adequate training for all pharmacy staff. Furthermore, we also should address other aspects: to establish storage optimization strategies, to focus on a more advanced logistics management model, as well as to take advantage of the extraordinary multidisciplinary network, which has been consolidated during this COVID pandemic


Assuntos
Humanos , Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Pandemias , Preparações Farmacêuticas/provisão & distribução , Serviço de Farmácia Hospitalar/organização & administração , Pneumonia Viral/complicações , Pneumonia Viral/tratamento farmacológico , Antivirais/provisão & distribução , Antivirais/uso terapêutico , Planejamento em Desastres , Prescrições de Medicamentos , Armazenamento de Medicamentos , Educação Continuada em Farmácia , Comunicação Interdisciplinar , Inventários Hospitalares , Necessidades e Demandas de Serviços de Saúde , Gestão da Qualidade Total
6.
Farm. hosp ; 44(supl.1): 53-56, 2020.
Artigo em Espanhol | IBECS | ID: ibc-190479

RESUMO

Ante la pandemia por SARS-CoV-2, los servicios de farmacia de los hospitales se han adaptado rápidamente para dar respuesta a una situación muy grave caracterizada por el ingreso constante y continuo de pacientes con neumonía que necesitaban tratamiento, siendo necesaria una transformación del hospital para poder aumentar el número de camas de hospitalización y de críticos que se requerían. Asimismo, otros dispositivos extrahospitalarios se han transformado en unidades de hospitalización para absorber el elevado número de pacientes que debían tratarse y aislarse. Para garantizar la distribución de los medicamentos y la calidad de la atención farmacéutica, los sistemas de distribución de fármacos, como la unidosis y los sistemas automatizados de dispensación, han sufrido a su vez transformaciones. Se diseñaron stocks estándar para las plantas COVID, y circuitos de dispensación diferentes para evitar el riesgo de contaminación cruzada entre plan-tas COVID y no-COVID, así como protocolos de desinfección de los sistemas de transporte de medicación y protocolos de gestión de las devoluciones de medicación. Todo esto sin olvidar los cambios en los protocolos de tratamiento de la COVID que se vieron afectados por la disponibilidad de los fármacos. El incremento del número de camas en dispositivos extrahospitalarios, como hospitales de campaña, hoteles, centros sociosanitarios y residencias geriátricas, ha sido un reto para los servicios de farmacia, ya que se han tenido que crear nuevos circuitos de dispensación y de conciliación de la medicación, obligando a reforzar la plantilla del servicio de farmacia y modificar los turnos de trabajo, estableciendo guardias presenciales para poder llevar a cabo todas las nuevas tareas con éxito. La elaboración de planes de contingencia de las diferentes actividades del servicio de farmacia y el establecimiento de canales de comunicación fluidos son elementos clave para situaciones de crisis o emergencias sanitarias como la actual


In response to the SARS-CoV-2 pandemic, the Hospital Pharmacy Services have quickly adapted to respond to a critical situation characterized by the constant and continuous admission of patients with severe pneumonia who needed treatment, requiring a transformation of the hospital in order to increase the number of hospital and critical beds. Moreover, other out-of-hospital spaces have been transformed into hospitalization units to absorb the large number of patients that had to be treated and isolated. To guarantee the distribution of medicines and the quality of the pharmaceutical care, drug distribution systems, such as unit dose and automated dispensing systems, have undergone transformations. Standard stocks were assigned for COVID units, and different dispensing circuits to avoid the risk of cross-contamination between COVID and non-COVID units were created, as well as disinfection protocols for medication transport systems and medication return protocols. All this without forgetting COVID treatment protocol’s changes that were affected by the availability of the drugs. The increase in the number of beds in out-of-hospital spaces, such as field hospitals, hotels, socio-medical centers and nursing homes, has challenged Pharmacy Services, since new medication dispensing and conciliation circuits have been created forcing the increase of pharmacy staff’s presence and modifying work shifts, to afford all the new tasks successfully. Development of contingency plans for the different Pharmacy Service activities and providing fluent communication channels are key elements for crisis situations or health emergencies such as the current pandemic


Assuntos
Humanos , Betacoronavirus , Infecções por Coronavirus , Serviço de Farmácia Hospitalar/organização & administração , Pandemias , Farmacêuticos , Pneumonia Viral , Armazenamento de Medicamentos , Prescrições de Medicamentos , Equipamentos e Provisões/provisão & distribução , Previsões , Necessidades e Demandas de Serviços de Saúde , Alta do Paciente , Sistemas de Medicação no Hospital , Admissão e Escalonamento de Pessoal
7.
Pharm. pract. (Granada, Internet) ; 17(4): 0-0, oct.-dic. 2019. tab, graf
Artigo em Inglês | IBECS | ID: ibc-191958

RESUMO

BACKGROUND: Urinary tract infections are considered as one of the most frequent bacterial infections in the community and hospital settings. In this era of increasing antimicrobial resistance, antimicrobial stewardship has become highly important in the struggle to preserve the effectiveness of available drugs. One the main causes of antibiotic resistance is the inappropriate prescribing of antibiotics; which evidence show that community pharmacists contribute to. OBJECTIVE: This study aims to evaluate antibiotic prescribing rate and responses of the contact persons in community pharmacies and to assess the conformity of the prescribed antibiotics with international guidelines. It also aims to evaluate the responses with sociodemographic characteristics. METHODS: A cross-sectional, nationwide study conducted between February and May 2017 using a simulated patient case of acute uncomplicated cystitis. Two hundred fifty pharmacies were included. Descriptive data was reported for the medications prescribed, conformity, questions asked and counseling. Bivariate analysis using the Pearson chi-squared, Fisher's exact and Student's t-tests were used to identify possible factors affecting the prescribing rates and responses in community pharmacies. RESULTS: The prescribing rate of antibiotics was 83.6% (n=209) with ciprofloxacin being the most prescribed (50.2%, n=105). The global conformity to international guidelines was 3.8% (n=8) with the highest conformity rate for the antibiotic choice (91.4%, n=191). Counseling about what to do in case symptoms persist was 12.8% (n=32) and that of non-pharmacological management was 53.6% (n=134). Male participants (88.1%) had a higher prescribing rate than female participants (77.6%) (p < 0.05). The number of questions asked was higher in pharmacists and in female participants (p < 0.05). Other results showed non-significant differences in diagnosis, antibiotic prescribing, conformity rates, referral rates and counseling points between the pharmacists and assistants. CONCLUSIONS: The high antibiotic prescribing rate in Lebanese community pharmacies is alarming and calls for action. This should be tackled by legislative bodies, which should enforce laws that restrict such practices


Assuntos
Humanos , Masculino , Feminino , Cistite/tratamento farmacológico , Anti-Infecciosos/uso terapêutico , Serviços Comunitários de Farmácia/organização & administração , Uso Excessivo de Medicamentos Prescritos/estatística & dados numéricos , Infecções Urinárias/tratamento farmacológico , Líbano/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Antibacterianos/uso terapêutico , Simulação de Paciente , Estudos Transversais , Prescrição Inadequada/estatística & dados numéricos , Doença Aguda/terapia
8.
Pharm. pract. (Granada, Internet) ; 17(4): 0-0, oct.-dic. 2019. tab, graf
Artigo em Inglês | IBECS | ID: ibc-191961

RESUMO

BACKGROUND: Previous attempts to develop an instrument to measure factors that influence prescribing decisions among physicians were relatively insufficient and lacked validation scale. OBJECTIVE: We present a new tool that attempts to address this shortcoming. Hence, this study aims to develop and validate a self-administrated instrument to explain factors that influence the prescribing decisions of physicians. METHODS: The questionnaire was developed based on literature and then subjected to an exhaustive assessment by a board of professionals and a pilot examination before being administered to 705 physicians. Three pre-tests were carried out to evaluate the quality of the survey items. In pre-test 1, after items are generated and the validity of their content is assessed by academics and physicians. In pre-test 2, the scale is carried out with a small sample of 20 respondents of physicians. In pre-test 3, fifty drop-off questionnaires were piloted amongst physicians to test the reliability. RESULTS: On the basis of partial least squares structural equation modelling (PLS-SEM) analyses using SmartPLS 3, the content and convergent validity of the instrument were confirmed with 44 items grouped into four categories, namely, marketing efforts, patient characteristics, pharmacist variables, and contextual factors with 13 reflective constructs. CONCLUSIONS: The study outcomes prove that the scale is more valid and reliable for measuring factors that influence the decision of the physician to prescribe the drug. The development and presentation of a scale of thirteen factors related to physicians prescribing decisions help to ensure valid findings and facilitates comparisons of studies and research settings


No disponible


Assuntos
Humanos , Masculino , Feminino , Probabilidade , Prescrições de Medicamentos/classificação , Tomada de Decisões , Padrões de Prática Médica/classificação , Psicometria/instrumentação , Pontuação de Propensão , Prática Profissional/tendências , Reprodutibilidade dos Testes , Análise dos Mínimos Quadrados
9.
Pharm. pract. (Granada, Internet) ; 17(4): 0-0, oct.-dic. 2019. tab
Artigo em Inglês | IBECS | ID: ibc-191964

RESUMO

OBJECTIVES: To develop a semi-quantitative instrument to assess pharmacists' confidence in medication counseling for patients with depression, The Pharmacists' Confidence scale about Medication Consultation for Depressive patients (PCMCD), and investigated its validity. METHODS: Following discussions with practicing pharmacists, we developed a 12-item questionnaire to assess pharmacists' confidence in medication counseling for patients with depression. We launched web-based cross-sectional survey during November and December 2018 to 77 pharmacists employed at drug chain stores in Kansai area. Factor analysis was performed to evaluate the configuration concept validity. The least-squares method was used for factor extraction, and the resulting factors were subjected to direct oblimin rotation, with a factor loading cut-off of 0.4. To assess internal consistency, Cronbach's alpha values were calculated for each of the extracted factors (subscales). A multiple regression analysis was performed using simultaneous forced entry, with the scores obtained for each subscale as dependent variables and responder attributes as independent variables in order to investigate the factors associated with each subscale. RESULTS: During the factor analysis procedure, four questions were excluded by the cut-off rule. Eventually, a model with three subscales was identified, with a cumulative sum of squared loadings being 61.9%. The subscales were termed "relationship building," "comprehension of condition," and "information provision" based on the nature of the questions relevant for each of them. The Cronbach's alpha values for these subscales were 0.92, 0.73, and 0.72, respectively. The average inter-item correlation was 0.378. In addition, multiple regression analysis revealed that there were significant correlations between pharmacist career and both relationship building and information provision. CONCLUSIONS: The PCMCD model demonstrated a satisfactory construct validity and internal consistency. This model will provide an excellent tool for assessing pharmacists' confidence in depression care


No disponible


Assuntos
Humanos , Depressão/epidemiologia , Transtorno Depressivo/tratamento farmacológico , Assistência Farmacêutica/organização & administração , Confidencialidade/psicologia , Psicometria/instrumentação , Transtorno Depressivo/diagnóstico , Prescrições de Medicamentos/estatística & dados numéricos , Autoimagem , Inquéritos e Questionários/estatística & dados numéricos , Boas Práticas de Dispensação
10.
Rev. esp. quimioter ; 32(6): 497-515, dic. 2019. ilus, tab, graf
Artigo em Espanhol | IBECS | ID: ibc-190609

RESUMO

La exacerbación de la enfermedad pulmonar obstructiva crónica y la neumonía adquirida en la comunidad son las infecciones del tracto respiratorio inferior más frecuentes en la práctica clínica diaria. La selección del antibiótico es un componente crucial en su tratamiento y, en la mayoría de las ocasiones, se realiza de forma empírica. Las sociedades científicas elaboran recomendaciones terapéuticas basadas en la evidencia científica y/o recomendaciones de expertos que son de gran ayuda para los clínicos. Los betalactámicos, las fluoroquinolonas y los macrólidos son los fármacos más utilizados por vía oral. Desde un punto de vista práctico, existen tres claves para la adecuada elección del tratamiento antibiótico oral, que son la efectividad, la seguridad y el impacto ecológico en la microbiota del paciente, incluyendo el desarrollo de resistencias, que van a ser valoradas en profundidad en esta revisión


Exacerbation of chronic obstructive pulmonary disease and community-acquired pneumonia are the most frequent infections of the lower respiratory tract in daily clinical practice. Antibiotic selection is a crucial component in its treatment and, in most cases, it is performed empirically. Scientific societies make therapeutic recommendations based on scientific evidence and / or expert recommendations that are of great help to clinicians. Beta-lactams, fluoroquinolones and macrolides are the most commonly used drugs for oral administration. From a practical point of view, there are three keys to the appropriate choice of oral antibiotic treatment, which are the effectiveness, safety and the ecological impact on the patient's microbiota, including the development of resistance, which will be assessed in depth in this review


Assuntos
Humanos , Antibacterianos/administração & dosagem , Infecções Respiratórias/tratamento farmacológico , Administração Oral , Antibacterianos/efeitos adversos , Prescrições de Medicamentos/normas , Farmacorresistência Bacteriana , Infecções Respiratórias/microbiologia
12.
Med. oral patol. oral cir. bucal (Internet) ; 24(6): e752-e758, nov. 2019. tab
Artigo em Inglês | IBECS | ID: ibc-192235

RESUMO

BACKGROUND: The implantologists frequently prescribe antibiotics, analgesics and anti-inflammatories in dental implant surgery. The aims of this study were to evaluate the attitudes of implantologists in Murcia (Spain) to prescribing antibiotics, analgesics and anti-inflammatories in healthy patients during different implant dentistry procedures, and to see how these are influenced by individual dentist's academic level, professional experience, and ongoing training (attending courses or reading scientific literature on medication use). MATERIALS AND METHODS: This cross-sectional study included a total of 200 implantologists from the Murcia area (Spain), who each completed a two-page questionnaire consisting of 26 questions. RESULTS: The implant procedure in which most dentists (n = 97) prescribed antibiotics was multiple implant surgery with flap raising, in which 55.6% of these 97 respondents used a prophylactic antibiotic regime for 7 days after implant placement. All subjects (n = 200) prescribed analgesics for eight out of the eleven procedures included in the survey and anti-inflammatories in six. Dentists with higher academic levels or longer professional experience prescribed more antibiotics, but those who underwent continuous training (attending courses or reading scientific literature) reduced antibiotic prescription. CONCLUSIONS: Dentists often prescribed antibiotics, analgesics and anti-inflammatories in almost all implant procedures in healthy patients, but ongoing training reduced the frequency of antibiotic prescription in some procedures


No disponible


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Antibacterianos/administração & dosagem , Padrões de Prática Odontológica , Analgésicos/administração & dosagem , Anti-Inflamatórios/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Inquéritos e Questionários , Estudos Transversais , Atitude , Espanha
13.
Rev. esp. enferm. dig ; 111(10): 738-743, oct. 2019. tab, graf
Artigo em Inglês | IBECS | ID: ibc-190445

RESUMO

Background: proton pump inhibitors (PPI) have been widely used in the clinic but inappropriate prescribing has also increased dramatically. Objective: to describe the prescribing patterns and assess the appropriateness of the prescribed PPI use in 45 hospitals in China. Materials and methods: PPI prescriptions for non-hospitalized patients were collected from hospitals in Beijing, Chengdu, Guangzhou and Hangzhou of China over a 40-day period in 2016. These data were analyzed using the prescription number, proportion and economic indicators (defined daily dose system [DDD], defined daily cost [DDC] and drug utilization index [DUI]). The evaluation criteria of PPI use was based on Martindale: The Complete Drug Reference, New Materia Medica and drug instructions. Results: in total, 357,687 prescriptions using oral PPI and 38,216 prescriptions using injectable PPI were assessed. The average age of PPI users was 53 years. The most commonly used oral PPI was rabeprazole, while the most common injectable PPI was pantoprazole. The DDD of oral rabeprazole and DDC of injectable rabeprazole were the highest. Meanwhile, only the DUI values of oral rabeprazole, lansoprazole and ilaprazole were less than 1.0. The clinical diagnosis of some users included well identified risky comorbidities such as kidney disease (2.9%). Furthermore, between 32.6% and 56.8% of the PPI prescriptions were used for inappropriate indications. Conclusion: this survey demonstrated that PPI use was accompanied by unapproved indications and excessive dosages. Comprehensive measures are urgently needed to improve PPI use and reduce unnecessary drug costs


No disponible


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Inibidores da Bomba de Prótons/uso terapêutico , Prescrição Inadequada/estatística & dados numéricos , Rabeprazol/uso terapêutico , Refluxo Gastroesofágico/tratamento farmacológico , China/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos
14.
Rev. clín. esp. (Ed. impr.) ; 219(7): 367-374, oct. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-186641

RESUMO

Antecedentes y objetivo: El consumo de opioides es un indicador adecuado de cómo se trata el dolor. En España apenas existen estudios de la evolución del consumo y de su utilización pormenorizada en los distintos ámbitos. Materiales y métodos: Estudio analítico, observacional, retrospectivo de las prescripciones realizadas en la Comunidad de Madrid (CM) en toda la atención primaria (AP) y la atención especializada (AE) entre 2004 y 2014 y de tres grandes hospitales, para determinar la influencia de los distintos servicios en su prescripción. Resultados: El consumo de opioides en la CM entre 2004 y 2014 aumentó más de tres veces (DHD 2004: 2,67; 2014: 8,10). El tramadol fue el opioide globalmente más prescrito (DHD 2014: 4,12). Entre los de tercer escalón, el más utilizado fue el fentanilo (DHD 2014: 1,23). En AP los opioides más prescritos de tercer escalón fueron el fentanilo (DHD 2014: 0,92), seguido de la buprenorfina (DHD 2014: 0,31), la oxicodona (DHD 2014: 0,20) y el tapentadol (DHD 2014: 0,14). En AE los opioides más prescritos fueron el fentanilo (DHD 2014: 0,05), la oxicodona (DHD 2014: 0,03) y el tapentadol (DHD 2014: 0,02). En ambos casos la morfina representaba un porcentaje muy reducido (DHD 2014: AP 0,12 y AE 0,02). Por último, el opioide más utilizado en los hospitales fue la morfina (DHD 2014: 0,38), seguido del fentanilo (DHD 2014: 0,27) y la oxicodona (DHD 2014: 0,04). Los equipos de cuidados paliativos, tanto domiciliarios como hospitalarios, mostraron un consumo mayoritario de morfina (40-50% del total) y de metadona (35% del total). Conclusiones: El consumo global de opioides en la CM se triplicó entre 2004 y 2014. El tramadol y el fentanilo fueron los más prescritos del segundo y tercer escalón analgésico, respectivamente. La morfina está teniendo un papel residual en la prescripción de opioides


Background and objectives: Opioid consumption is an appropriate indicator of pain treatment. In Spain, there are scarcely any studies on the evolution of the consumption of opioids and their detailed use in the various settings. Material and methods: We conducted an analytical, observational, retrospective study of prescriptions performed in the Community of Madrid in all primary care and specialized care centres and the three major hospitals between 2004 and 2014 to determine the influence of the various departments on the prescription of opioids. Results: Opioid consumption in Madrid between 2004 and 2014 increased more than 3-fold (2.67 vs. 8.10 defined daily doses/1000 inhabitants/day [DIDs] for 2004 and 2014, respectively).Tramadol was the most widely prescribed opioid (4.12 DIDs in 2014).Among the stepIII opioids, the most widely employed was fentanyl (1.23 DIDs in 2014). In primary care, the most prescribed stepIII opioids were fentanyl (0.92 DIDs in 2014), buprenorphine (0.31 DIDs in 2014), oxycodone (0.20 DIDs in 2014) and tapentadol (0.14 DIDs in 2014). In specialized care, the most prescribed opioids were fentanyl (0.05 DIDs in 2014), oxycodone (0.03 DIDs in 2014) and tapentadol (0.02 DIDs in 2014). In both cases, morphine represented a tiny percentage (0.12 primary care and 0.02 specialized care DIDs in 2014). Lastly, the most widely used opioid in the hospitals was morphine (0.38 DIDs in 2014), fentanyl (0.27 DIDs in 2014) and oxycodone (0.04 DIDs in 2014). For the palliative care teams (both home and hospital), the most consumed opioids were morphine (40-50% of the total) and methadone (35% of the total). Conclusions: The overall consumption of opioids in Madrid tripled between 2004 and 2014. Tramadol and fentanyl were the most prescribed of the stepII andIII analgesics, respectively. The role of morphine is diminishing in the prescription of opioids


Assuntos
Humanos , Analgésicos Opioides/uso terapêutico , Manejo da Dor/métodos , Dor/tratamento farmacológico , Cuidados Paliativos/métodos , Prescrições de Medicamentos/estatística & dados numéricos , Espanha/epidemiologia , Farmacoepidemiologia/tendências , Estudos Retrospectivos , Analgesia/métodos
17.
Pharm. pract. (Granada, Internet) ; 17(3): 0-0, jul.-sept. 2019. graf
Artigo em Inglês | IBECS | ID: ibc-188114

RESUMO

Background: Drug utilisation studies from paediatric hospitals that do not have access to patient level data on medication use are limited by a lack of standardised units of measures that reflect the varying daily dosage requirements among patients. The World Health Organization's defined daily dose is frequently used in adult hospitals for benchmarking and longitudinal analysis but is not endorsed for use in paediatric populations. Objective: Explore agreement between standard adult-based defined daily doses (DDD) and paediatric estimates of daily injectable antibiotic use in a Paediatric Intensive Care Unit that does not have access to individual patient-level data. Methods: Hospital pharmacy antibiotic use reports and age-specific occupied bed-day data from 1 January 2010 to 31 May 2016 were extracted. Paediatric reference dosages and frequencies for antibiotics were defined and applied to three paediatric units of measure. Measures were applied to extracted data, measured in the adult DDD and each of the paediatric measures was assessed visually via Bland-Altman plots and linear regression for each antibiotic. Results: Thirty one different antibiotics were used throughout the study period. Despite varying daily dosages in grams, the daily use of vials was unchanged from birth to 18 years for thirteen antibiotics. Agreement between DDD and vial-based measures was closer than the total recommended daily dose that did not account for wastage during preparation and administration. Vial-based measures were unaffected by vial size changes due to drug shortage. Conclusions: Agreement between the DDD and vial-based measures of use supports the use of DDD for select antibiotics that may be targeted by antimicrobial stewardship programs. Vial based measures should be further explored in hospitals with single vial policies; detailed understanding of hospital practice is needed before inter-hospital comparisons are made


No disponible


Assuntos
Humanos , Masculino , Feminino , Recém-Nascido , Lactente , Pré-Escolar , Criança , Adolescente , Prescrições de Medicamentos/estatística & dados numéricos , Antibacterianos/uso terapêutico , Controle de Doenças Transmissíveis/métodos , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Estudos Retrospectivos , Atenção Terciária à Saúde/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Padrões de Referência , Qualidade da Assistência à Saúde
18.
Pharm. pract. (Granada, Internet) ; 17(3): 0-0, jul.-sept. 2019. tab, graf
Artigo em Inglês | IBECS | ID: ibc-188117

RESUMO

Background: Patients requiring medications during discharge are at risk of discharge medication errors that potentially cause readmission due to medication-related events. Objective: The objective of this study was to develop interventions to reduce percentage of patients with one or more medication errors during discharge. Methods: A pharmacist-led quality improvement (QI) program over 6 months was conducted in medical wards at a tertiary public hospital. Percentage of patients discharge with one or more medication errors was reviewed in the pre-intervention and four main improvements were developed: increase the ratio of pharmacist to patient, prioritize discharge prescription order within office hours, complete discharge medication reconciliation by ward pharmacist, set up a Centralized Discharge Medication Pre-packing Unit. Percentage of patients with one or more medication errors in both pre- and post-intervention phase were monitored using process control chart. Results: With the implementation of the QI program, the percentage of patients with one or more medication errors during discharge that were corrected by pharmacists significantly increased from 77.6% to 95.9% (p<0.001). Percentage of patients with one or more clinically significant error was similar in both pre and post-QI with an average of 24.8%. Conclusions: Increasing ratio of pharmacist to patient to complete discharge medication reconciliation during discharge significantly recorded a reduction in the percentage of patients with one or more medication errors


No disponible


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Erros de Medicação/prevenção & controle , Sumários de Alta do Paciente Hospitalar/normas , Assistência Farmacêutica/organização & administração , Reconciliação de Medicamentos/métodos , Melhoria de Qualidade/tendências , Avaliação de Eficácia-Efetividade de Intervenções , Prescrições de Medicamentos/normas , Continuidade da Assistência ao Paciente/normas , Estudos Prospectivos
19.
Pharm. pract. (Granada, Internet) ; 17(3): 0-0, jul.-sept. 2019. tab
Artigo em Inglês | IBECS | ID: ibc-188119

RESUMO

Background: The introduction of universal healthcare coverage in 2014 has affected the practice of community pharmacies in Indonesia. Studies regarding the practice of pharmacist in the chain community pharmacy setting in Indonesia are very limited. The chain community pharmacies in Indonesia are operated and controlled by the same management. The chain community pharmacies usually show better services compared to independent community pharmacies in Indonesia. Objective: The study aimed to assess the knowledge, attitude and practice (KAP) of pharmacist working in chain community pharmacy towards their current function and performance in delivering pharmacy services. Methods: A cross-sectional study using questionnaires was conducted between January and March 2017 in KF, one of the largest chain community pharmacies in Indonesia. The total sampling method was used in the recruitment process. The data were analyzed using descriptive statistics, independent t-Test and one-way ANOVA. The KAP scores were assessed and categorized as "poor", "moderate" and "good" based on the standardized scoring system. Results: A total of 949 KF's pharmacists (100% response rate) were participated in the study. The majority of pharmacists showed a good score in terms of knowledge and attitude, which is in contrast to practice as majority only obtained a moderate score. Working experience, age and the availability of standard operating procedures (SOP) for both dispensing and self-medication services were found to be statistically significant (p<0.005) aspects to KAP of pharmacists in delivering pharmacy services. Conclusions: This study identified several important aspects that could affect the KAP of pharmacists working in chain community pharmacies in Indonesia. Specific policies should be conceived to improve the competencies of pharmacist and to ensure the compliance with the SOP and standardization system within pharmacy sector


No disponible


Assuntos
Humanos , Competência Profissional/estatística & dados numéricos , Serviços Comunitários de Farmácia/estatística & dados numéricos , Farmacêuticos/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Indonésia , Estudos Transversais , Automedicação/estatística & dados numéricos , Prescrições de Medicamentos/estatística & dados numéricos , Fatores Etários
20.
Pharm. pract. (Granada, Internet) ; 17(3): 0-0, jul.-sept. 2019.
Artigo em Inglês | IBECS | ID: ibc-188122

RESUMO

Background: Kosovo is a new state and has a high consumption of antibiotics in relation to other European countries. Existing quantitative studies have shown that practices exist that is not optimal when it comes to antibiotic use in Kosovo, this includes citizens' use of antibiotics, pharmacy practices of selling antibiotics without prescriptions and physicians' prescribing behaviours. To address these problems, there is a need for a deeper understanding of why antibiotics are handled in a suboptimal way. Objective: The objective was to explore antibiotic users', community pharmacists' and prescribers' attitudes towards, experiences of, and knowledge about antibiotics in Kosovo. Methods: Semi-structured interviews were conducted with patients who recently received an antibiotic prescription for an upper respiratory tract infection (URTI), patients who recently received antibiotics for a URTI without a prescription, community pharmacists, and physicians. Interviews were recorded, translated into English, and analysed using deductive content analysis. Results: In total, 16 interviews were conducted in the period from 2015-2016. Five themes were identified: Obtaining antibiotics, Choice of antibiotics, Patient information, Patients' knowledge and views on when to use antibiotics, and Professionals' knowledge and attitudes towards antimicrobial resistance. Antibiotics were sometimes obtained without a prescription, also by patients who currently had received one. The specific antibiotic could be chosen by a physician, a pharmacist or the patient him/herself. Former experience was one reason given by patients for their choice. Patients' knowledge on antibiotics was mixed, however health professionals were knowledgeable about e.g. antimicrobial resistance. Conclusions: There is currently a culture of antibiotic use in Kosovo, including attitudes and behaviours, and hence also experiences, which is possibly underlying the high consumption of antibiotics in the country. The culture is reproduced by patients, pharmacists and physicians. There is, however, an awareness of the current problematic situation among practitioners and policy makers; and as Kosovo is a new country, opportunities to effectively tackle antimicrobial resistance exist


No disponible


Assuntos
Humanos , Antibacterianos/uso terapêutico , Doenças Transmissíveis/tratamento farmacológico , Serviços Comunitários de Farmácia/estatística & dados numéricos , Prescrições de Medicamentos/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Kosovo/epidemiologia , Fatores Culturais , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Médicos/estatística & dados numéricos , Pacientes/estatística & dados numéricos , Farmacorresistência Bacteriana , Infecções Respiratórias/tratamento farmacológico , Atitude do Pessoal de Saúde
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