Gestational syphilis at different health care levels: a cross-sectional study / Sífilis gestacional en diferentes niveles de atención de salud: un estudio transversal / Sífilis gestacional em diferentes níveis de atenção à saúde: um estudo transversal

Background and objectives: Syphilis is a sexually transmitted disease that can cause miscarriage, premature birth, malformations, and neonatal death. When diagnosed and treated in the first months of pregnancy, the neonatal risks are considerably reduced. This work aims to discuss the key points regarding prevention and effective treatment of gestational syphilis at different health care levels. Methods: Retrospective cross-sectional study. A survey was carried out about syphilis notifications recorded at a hospital in Porto Alegre, RS, from January to June 2021, considering the variables date of diagnosis and notification and laboratory, treatment, and prenatal care data collected in hospital records and the e-SUS system. Results: In the study period, 17 cases of gestational syphilis and 102 cases in newborns were notified. We selected the case of a patient with a history of two pregnancies without prenatal care and use of psychoactive substances. This case illustrates the patient's itinerary in Primary Care, in specialized services such as the Center for Psychosocial Care and High-Risk Prenatal Care, and hospital care, showing the availability of care and, at the same time, the fragmentation of services. Conclusion: Multidisciplinary actions are needed at different health care levels to ensure access to testing for pregnant women and their partners, family planning, and adequate syphilis treatment, which interrupts the disease transmission chain and avoids possible complications of neonatal syphilis.(AU)

Justificativa e objetivos: A sífilis é uma infecção sexualmente transmissível que pode causar aborto, parto prematuro, malformações e morte neonatal. Quando diagnosticada e tratada nos primeiros meses da gestação, os riscos neonatais são consideravelmente diminuídos. Este trabalho tem como objetivo discutir os pontos-chave na prevenção e no tratamento efetivo da sífilis gestacional no contexto dos diferentes níveis de atenção à saúde. Métodos: Estudo transversal retrospectivo. Foi realizado um levantamento das notificações de sífilis em um hospital de Porto Alegre, RS, de janeiro a junho de 2021, considerando as variáveis data do diagnóstico e da notificação e dados de exames laboratoriais, de tratamento e de atendimento pré-natal, coletadas nos registros hospitalares e no sistema e-SUS. Resultados: No período do estudo, foram notificados dezessete casos de sífilis em gestantes e 102 em recém-nascidos. Selecionamos o caso de uma paciente com histórico de duas gestações sem pré-natal e uso de substâncias psicoativas. O caso ilustra o itinerário da paciente na atenção primária, em serviços especializados, como Centro de Atenção Psicossocial e Pré-Natal de Alto Risco, além do atendimento hospitalar, demonstrando a disponibilidade dos atendimentos e, ao mesmo tempo, a fragmentação dos serviços. Conclusão: São necessárias ações multidisciplinares nos diferentes níveis de atenção à saúde para garantir acesso à testagem da gestante e seus parceiros, ao planejamento familiar e ao tratamento adequado da sífilis, que interrompa a cadeia de transmissão da doença e evite possíveis complicações da sífilis neonatal.(AU)

Justificación y objetivos: La sífilis es una infección de transmisión sexual que puede causar aborto espontáneo, parto prematuro, malformaciones y muerte neonatal. Su diagnóstico y tratamiento en los primeros meses de embarazo lleva a una considerable reducción en los riegos neonatales. Este trabajo tiene como objetivo discutir los puntos clave en la prevención y tratamiento efectivo de la sífilis gestacional en el contexto de los diferentes niveles de atención a la salud. Métodos: Estudio transversal retrospectivo. Se realizó una encuesta de notificaciones de sífilis en un hospital de Porto Alegre (Brasil), de enero a junio de 2021, considerando las siguientes variables fecha de atención y notificación, y datos de exámenes de laboratorio, de tratamiento y control prenatal, recabadas de los registros hospitalarios y del sistema e-SUS. Resultados: Durante el período de estudio se reportaron diecisiete casos de sífilis en embarazadas y 102 en recién nacidos. Seleccionamos el caso de una paciente con antecedentes de dos embarazos sin control prenatal y consumo de sustancias psicoactivas. El caso ilustra el itinerario de la paciente por la atención primaria, por servicios especializados como el Centro de Atención Psicosocial y Atención Prenatal de Alto Riesgo, además de la atención hospitalaria, lo que demostró la disponibilidad de la atención y, al mismo tiempo, la fragmentación de los servicios. Conclusiones: Son necesarias acciones multidisciplinarias en los diferentes niveles de atención a la salud para garantizar el acceso a la prueba de la embarazada y de sus parejas, a la planificación familiar y al tratamiento adecuado de la sífilis, lo que interrumpa la cadena de transmisión de la enfermedad y evite posibles complicaciones de la sífilis neonatal.(AU)

Elaboração de instrumento de avaliação da assistência ao paciente com tuberculose na atenção primária em saúde / Elaboration of instrument for assessing assistance to patients with tuberculosis in primary health care / Elaboración de instrumento de evaluación de asistencia a pacientes con tuberculosis en atención primaria de salud

Objetivo: elaborar e validar um instrumento de avaliação da assistência ao paciente com tuberculose na Atenção Primária em Saúde. Método: as etapas de construção do instrumento avaliativo foram: construção do modelo lógico, revisão bibliográfica, identificação das dimensões e subdimensões avaliativas e elaboração de indicadores. A Técnica Delfos com especialistas foi utilizada a fim de obter consenso sobre a relevância das dimensões e subdimensões e atribuir pesos aos indicadores. O teste piloto foi realizado em duas unidades de saúde. Resultados: o instrumento de avaliação resulta em uma nota máxima de dez pontos distribuída em recursos físicos, recursos humanos e capacidade técnica, subdividida em sete subdimensões e 44 indicadores. A avaliação possibilitou o conhecimento da realidade individual das unidades avaliadas. Conclusão: o instrumento proposto pode ser utilizado como instrumento de gestão, podendo ser útil na identificação de estratégias para qualificação da assistência do paciente com tuberculose na Atenção Primária em Saúde

Objective: validate an instrument for assessing the care of patients with tuberculosis in Primary Health Care. Method: the construction stages of the evaluation instrument were: construction of logical model, bibliographic review, identification of the evaluative dimensions and subdimensions and indicators development. The Delphi Technique with specialists was used in order to obtain consensus on the relevance of dimensions and subdimensions and to assign weights to the indicators. The pilot test was carried out in two units. Results: the evaluation instrument results in a maximum score of ten points distributed in physical resources, human resources and technical capacity, subdivided into seven subdimensions and 44 indicators. The evaluation enabled the knowledge of the individual reality of the units evaluated. Conclusion: the proposed instrument can be used as a management tool and can be useful in identifying strategies for qualifying the care of patients with tuberculosis in Primary Health Care

Objetivo: validar un instrumento de evaluación de la atención de pacientes con tuberculosis en Atención Primaria de Salud. Método:las etapas de construcción del instrumento de evaluación fueron: construcción del modelo lógico, revisión bibliográfica, identificación de las dimensiones y subdimensiones evaluativas y desarrollo de indicadores. Se utilizó la Técnica Delphi con especialistas para lograr consenso sobre la relevancia de dimensiones y subdimensiones y asignar ponderaciones a los indicadores. La prueba piloto se realizó en dos unidades. Resultados: el instrumento de evaluación arroja un puntaje máximo de diez puntos distribuidos en recursos físicos, recursos humanos y capacidad técnica, subdivididos en siete subdimensiones y 44 indicadores. La evaluación permitió conocer la realidad individual de las unidades evaluadas. Conclusión: el instrumento propuesto puede ser utilizado como herramienta de manejo y puede ser útil en la identificación de estrategias para calificar la atención de pacientes con tuberculosis en Atención Primaria de Salud

LIVER TRANSPLANTATION: TACROLIMUS BLOOD LEVELS VARIATION AND SURVIVAL, REJECTION AND DEATH OUTCOMES.

BACKGROUND: Immunosuppressive drugs have important role in transplant of solid grafts, it aim avoid episodes of acute and chronic rejection and improving graft survival and patient survival. In Brazil, in 2016, liver transplantation was the third most frequent, with 1,880 transplants performed, of which 150 in Rio Grande do Sul. Several studies evaluated the association between variability in blood levels of immunosuppressive tacrolimus and late acute cellular graft rejection. OBJECTIVE: To investigate the association of tacrolimus blood levels with clinical outcomes late acute cellular rejection, death, patient survival and graft survival in patients undergoing liver transplantation. METHODS: This is a retrospective longitudinal study including patients submitted to adult liver transplantation by the Liver Transplantation Group in the Santa Casa de Misericórdia Hospital of Porto Alegre, from January 2006 to January 2013, and who used tacrolimus as immunosuppressive therapy. RESULTS: Of the 127 patients included in the study, the majority were male (70.1%), 52-60 years old (33.9%) at the transplant. The most frequent causes of liver transplantation in this series were hepatitis C virus and hepatocellular carcinoma (24.4%) and alcohol (15.7%). Thirteen patients had late acute cellular rejection (10.2%); of these, three had two episodes. Regarding severity classification, seven patients had mild late acute cellular rejection. The mean time of rejection after liver transplantation was 14 months (ranging from 8 to 33 months). Overall survival was 8.98 years. Regarding tacrolimus blood levels, 52 patients with a variation ≥2 standard deviations were identified. Of these patients, eight had rejection; however, the association was not significant (P=0.146). A significant association was found between variation ≥2 standard deviations in tacrolimus blood levels and death (P=0.023) and survival (P=0.019). Regarding 5-year follow-up of graft survival, being two standard deviations above increases by 2.26 times the risk of transplanted graft loss, and for each unit of increase of standard deviation of tacrolimus blood levels there is a two-fold increase in the risk of graft loss in 5 years. CONCLUSION: Increased risk of graft loss associated with increased standard deviations of tacrolimus blood levels may indicate the need for more rigorous and prospective monitoring of tacrolimus blood levels.

Drug-induced liver injury and COVID-19: A review for clinical practice.

Coronavirus disease 2019 (COVID-19) consists of a systemic disease that can present many complications. The infection presents broad clinical symptoms and a high rate of transmissibility. In addition to severe acute respiratory syndrome, the patients manifest complications beyond the respiratory system. The frequency of liver damage in COVID-19 patients ranges from 14.8% to 53% of patients. One should pay attention to drug-induced liver injury (DILI) in patients with COVID-19, especially considering the off-label use of drugs in prophylactic and therapeutic regimens applied on large scales. This review aims to present relevant information on the medication used so far in COVID-19 patients and its possible hepatotoxicity. We reviewed liver damage in patients with COVID-19 on PubMed and Virtual Health Library to investigate DILI cases. Four studies were selected, involving the medicines remdesivir, tocilizumab and a pharmacovigilance analysis study. The hepatotoxicity profile of drugs presented in the literature considers use in accordance to usual posology standards for treatment. However, drugs currently used in the management of COVID-19 follow different dosages and posology than those tested by the pharmaceutical industry. The deficiency of uniformity and standardization in the assessment of hepatotoxicity cases hinders the publication of information and the possibility of comparing information among healthcare professionals. It is suggested that severe liver injury in COVID-19 patients should be reported in pharmacovigilance institutions, and physicians should pay attention to any considerable abnormal liver test elevation as it can demonstrate unknown drug hepatotoxicity. Liver disorders in COVID-19 patients and the use of several concomitant off-label medications - with a potential risk of further damaging the liver - should at least be a warning sign for rapid identification and early intervention, thus preventing liver damage from contributing to severe impairment in patients.

Transplante hepático: variação dos níveis sanguíneos de tacrolimo e desfechos de sobrevida, rejeição e óbito / Liver transplantation: tacrolimus blood levels variation and survival, rejection and death outcomes

ABSTRACT BACKGROUND: Immunosuppressive drugs have important role in transplant of solid grafts, it aim avoid episodes of acute and chronic rejection and improving graft survival and patient survival. In Brazil, in 2016, liver transplantation was the third most frequent, with 1,880 transplants performed, of which 150 in Rio Grande do Sul. Several studies evaluated the association between variability in blood levels of immunosuppressive tacrolimus and late acute cellular graft rejection. OBJECTIVE: To investigate the association of tacrolimus blood levels with clinical outcomes late acute cellular rejection, death, patient survival and graft survival in patients undergoing liver transplantation. METHODS: This is a retrospective longitudinal study including patients submitted to adult liver transplantation by the Liver Transplantation Group in the Santa Casa de Misericórdia Hospital of Porto Alegre, from January 2006 to January 2013, and who used tacrolimus as immunosuppressive therapy. RESULTS: Of the 127 patients included in the study, the majority were male (70.1%), 52-60 years old (33.9%) at the transplant. The most frequent causes of liver transplantation in this series were hepatitis C virus and hepatocellular carcinoma (24.4%) and alcohol (15.7%). Thirteen patients had late acute cellular rejection (10.2%); of these, three had two episodes. Regarding severity classification, seven patients had mild late acute cellular rejection. The mean time of rejection after liver transplantation was 14 months (ranging from 8 to 33 months). Overall survival was 8.98 years. Regarding tacrolimus blood levels, 52 patients with a variation ≥2 standard deviations were identified. Of these patients, eight had rejection; however, the association was not significant (P=0.146). A significant association was found between variation ≥2 standard deviations in tacrolimus blood levels and death (P=0.023) and survival (P=0.019). Regarding 5-year follow-up of graft survival, being two standard deviations above increases by 2.26 times the risk of transplanted graft loss, and for each unit of increase of standard deviation of tacrolimus blood levels there is a two-fold increase in the risk of graft loss in 5 years. CONCLUSION: Increased risk of graft loss associated with increased standard deviations of tacrolimus blood levels may indicate the need for more rigorous and prospective monitoring of tacrolimus blood levels.

RESUMO CONTEXTO: Os imunossupressores desempenham importante papel no transplante de órgãos sólidos, com o objetivo de evitar a rejeição aguda e crônica, aumentando o tempo de sobrevida do órgão e do paciente. No Brasil, em 2016, o transplante de fígado foi o 3° mais frequente, com um número de 1.880 transplantes, sendo 150 realizados no Rio Grande do Sul. OBJETIVO: Investigar a associação da variação dos níveis sanguíneos de tacrolimo com os desfechos clínicos, rejeição celular aguda tardia, óbito, sobrevida de paciente e enxerto em pacientes submetidos ao transplante hepático. MÉTODOS: Trata-se de um estudo longitudinal retrospectivo, no qual foram incluídos os pacientes submetidos ao transplante hepático adulto pelo grupo de transplante hepático na Irmandade Santa Casa de Misericórdia de Porto Alegre, no período de janeiro de 2006 a janeiro de 2013, e que fizeram o uso de tacrolimo como terapia imunossupressora. RESULTADOS: Dos 127 pacientes incluídos no estudo, a maioria era do gênero masculino (70,1%), caucasiana (86,4%), com idade entre 52 e 60 anos (33,9%). As associações de causas mais frequentes para transplante hepático foram vírus da hepatite C, carcinoma hepatocelular (24,4%) e álcool (15,7%). Um total de treze pacientes apresentaram rejeição celular aguda tardia (10,2%); destes, três tiveram dois episódios. O tempo médio de rejeição após o transplante hepático foi de 14 meses, variando de 8 a 33 meses. A sobrevida global foi de 8,98 anos. Em relação aos níveis sanguíneos de tacrolimo, foram identificados 52 pacientes com uma variação maior ou igual a dois desvios-padrão. Destes pacientes, oito tiveram rejeição, contudo, a associação não foi significativa (P=0,146). Foi encontrada uma associação significativa entre a variação maior ou igual a dois desvios-padrão nos níveis sanguíneos de tacrolimo com óbito (P=0,023) e sobrevida (P=0,019). Em relação ao acompanhamento de sobrevida do enxerto em cinco anos, estar dois desvios-padrão acima aumenta em 2,26 vezes o risco de perda do enxerto transplantado, e a cada unidade de aumento de desvio-padrão dos níveis sanguíneos de tacrolimo há um aumento de duas vezes no risco de perda do enxerto transplantado em 5 anos. CONCLUSÃO: O aumento do risco da perda do enxerto associado ao aumento da variação dos níveis sanguíneos de tacrolimo pode indicar a necessidade do acompanhamento mais rigoroso e prospectivo dos níveis sanguíneos de tacrolimo.

Polymorphism of the CYP2C9 and VKORC1 genes in patients on the public health system of a municipality in Southern Brazil.

BACKGROUND: Genetic factors can be responsible for part of the populational and interindividual differences observed in warfarin users. OBJECTIVES: To identify occurrence of polymorphisms of the CYP2C9 and VKORC1 genes in patients taking warfarin and relate these profiles to their medication dosages and the Time in Therapeutic Range (TTR). METHODS: Monthly interviews were conducted for data collection. Data were collected on demographic characteristics and medications in use, especially warfarin, including reason for prescription and weekly dose. TTR was calculated as the percentage of days with international normalized ratio (INR) between 2 and 3. The CYP2C9 and VKORC1 genes were analyzed at a Human Genetics Laboratory. RESULTS: 49 patients (74.2%) had polymorphisms of the CYP2C9 and/or VKORC1 genes; the remaining 17 (25.8%) did not have these polymorphisms. The average weekly dose of warfarin was lower among those who had a polymorphism for any of the genes compared to those who did not, with a significant difference (p = 0.035). The mean TTR was also lower among patients with polymorphism. However, the difference between the two groups was not significant for this variable (p = 0.438). CONCLUSIONS: An association was observed between the polymorphisms and the warfarin doses taken by the patients. However, there was no association with adverse events or the time spent within the therapeutic range in this sample.

CONTEXTO: Fatores genéticos podem ser responsáveis por parte das diferenças populacionais e interindividuais observadas em usuários de varfarina. OBJETIVOS: Identificar a ocorrência de polimorfismo dos genes CYP2C9 e VKORC1 em pacientes em uso de varfarina e relacionar esses perfis com a dose do medicamento e o tempo no intervalo terapêutico. MÉTODOS: Foram realizadas entrevistas mensais para a coleta de dados. Foram reunidos dados sobre características demográficas e medicamentos em uso, principalmente sobre varfarina, como motivo da prescrição e dose semanal. O tempo no intervalo terapêutico foi calculado como a porcentagem de dias com razão normalizada internacional entre os valores 2 e 3. Os genes CYP2C9 e VKORC1 foram analisados em laboratório de Genética Humana. RESULTADOS: Entre os participantes, 49 pacientes (74,2%) apresentaram polimorfismo dos genes CYP2C9 e/ou VKORC1; os 17 restantes (25,8%) não apresentaram esses polimorfismos. A dose média semanal de varfarina foi menor entre os que apresentaram polimorfismo para algum dos genes em comparação aos que não apresentaram, com diferença significativa (p = 0,035). O tempo no intervalo terapêutico médio também foi menor entre os pacientes com polimorfismo. Porém, não houve diferença significativa entre os dois grupos para essa variável (p = 0,438). CONCLUSÕES: Foi observada associação entre os polimorfismos e a dose de varfarina utilizada pelos pacientes; no entanto, não houve associação com eventos adversos e o tempo de permanência na faixa terapêutica nessa amostra.

Overview of drug induced liver injury in Brazil: What is the role of public health policy on the evidence?

BACKGROUND: Adverse drug reactions are responsible for increased costs and morbidity in the health system. Hepatotoxicity can be induced both by non-prescription drugs and by those used for chronic diseases. It is the main cause of safety-related drug marketing withdrawals and could be responsible for irreversible and fatal injuries. AIM: To identify and to summarize Brazilian studies reporting the drug-induced liver injury. METHODS: A systematic review of Brazilian studies was carried out until June 2020. It was found 32 studies, being 10 retrospective cohorts, 12 prospective cohorts, 5 cross-sectional, 3 case-control, one case series and one randomized clinical trial. In most studies were investigated tuberculosis patients followed by other infectious conditions like human immunodeficiency virus (HIV) and hepatitis C virus. The hepatotoxicity ranged from one to 57%, led by isoniazid, rifampicin, and pyrazinamide. Few studies reported algorithm to assess causality. In most studies, there were moderate outcomes and it was necessary drug interruption. However, few severe outcomes, such as chronic liver damage and liver transplantation were reported. RESULTS: Twenty-two different criteria for hepatotoxicity were found. The great heterogeneity did not allow a meta-analysis. Standardization of parameter of drug-induced liver injury and greater effort in pharmacovigilance could contribute to learn more about drug-induced liver injury (DILI)'s epidemiology in Brazil. CONCLUSION: The development of strategic public health policies seems to have an influence on the DILI scientific evidence in Brazil due to main studies are in HIV and tuberculosis line care, two strategic health policies in Brazil.

Polymorphism of the CYP2C9 and VKORC1 genes in patients on the public health system of a municipality in Southern Brazil / Polimorfismo dos genes CYO2C9 e VKORC1 em pacientes do Sistema Público de Saúde em um município do Sul do Brasil

Abstract Background Genetic factors can be responsible for part of the populational and interindividual differences observed in warfarin users. Objectives To identify occurrence of polymorphisms of the CYP2C9 and VKORC1 genes in patients taking warfarin and relate these profiles to their medication dosages and the Time in Therapeutic Range (TTR). Methods Monthly interviews were conducted for data collection. Data were collected on demographic characteristics and medications in use, especially warfarin, including reason for prescription and weekly dose. TTR was calculated as the percentage of days with international normalized ratio (INR) between 2 and 3. The CYP2C9 and VKORC1 genes were analyzed at a Human Genetics Laboratory. Results 49 patients (74.2%) had polymorphisms of the CYP2C9 and/or VKORC1 genes; the remaining 17 (25.8%) did not have these polymorphisms. The average weekly dose of warfarin was lower among those who had a polymorphism for any of the genes compared to those who did not, with a significant difference (p = 0.035). The mean TTR was also lower among patients with polymorphism. However, the difference between the two groups was not significant for this variable (p = 0.438). Conclusions An association was observed between the polymorphisms and the warfarin doses taken by the patients. However, there was no association with adverse events or the time spent within the therapeutic range in this sample.

Resumo Contexto Fatores genéticos podem ser responsáveis por parte das diferenças populacionais e interindividuais observadas em usuários de varfarina. Objetivos Identificar a ocorrência de polimorfismo dos genes CYP2C9 e VKORC1 em pacientes em uso de varfarina e relacionar esses perfis com a dose do medicamento e o tempo no intervalo terapêutico. Métodos Foram realizadas entrevistas mensais para a coleta de dados. Foram reunidos dados sobre características demográficas e medicamentos em uso, principalmente sobre varfarina, como motivo da prescrição e dose semanal. O tempo no intervalo terapêutico foi calculado como a porcentagem de dias com razão normalizada internacional entre os valores 2 e 3. Os genes CYP2C9 e VKORC1 foram analisados em laboratório de Genética Humana. Resultados Entre os participantes, 49 pacientes (74,2%) apresentaram polimorfismo dos genes CYP2C9 e/ou VKORC1; os 17 restantes (25,8%) não apresentaram esses polimorfismos. A dose média semanal de varfarina foi menor entre os que apresentaram polimorfismo para algum dos genes em comparação aos que não apresentaram, com diferença significativa (p = 0,035). O tempo no intervalo terapêutico médio também foi menor entre os pacientes com polimorfismo. Porém, não houve diferença significativa entre os dois grupos para essa variável (p = 0,438). Conclusões Foi observada associação entre os polimorfismos e a dose de varfarina utilizada pelos pacientes; no entanto, não houve associação com eventos adversos e o tempo de permanência na faixa terapêutica nessa amostra.

Polymorphism of the CYP2C9 and VKORC1 genes in patients on the public health system of a municipality in Southern Brazil / Polimorfismo dos genes CYO2C9 e VKORC1 em pacientes do Sistema Público de Saúde em um município do Sul do Brasil

Abstract Background Genetic factors can be responsible for part of the populational and interindividual differences observed in warfarin users. Objectives To identify occurrence of polymorphisms of the CYP2C9 and VKORC1 genes in patients taking warfarin and relate these profiles to their medication dosages and the Time in Therapeutic Range (TTR). Methods Monthly interviews were conducted for data collection. Data were collected on demographic characteristics and medications in use, especially warfarin, including reason for prescription and weekly dose. TTR was calculated as the percentage of days with international normalized ratio (INR) between 2 and 3. The CYP2C9 and VKORC1 genes were analyzed at a Human Genetics Laboratory. Results 49 patients (74.2%) had polymorphisms of the CYP2C9 and/or VKORC1 genes; the remaining 17 (25.8%) did not have these polymorphisms. The average weekly dose of warfarin was lower among those who had a polymorphism for any of the genes compared to those who did not, with a significant difference (p = 0.035). The mean TTR was also lower among patients with polymorphism. However, the difference between the two groups was not significant for this variable (p = 0.438). Conclusions An association was observed between the polymorphisms and the warfarin doses taken by the patients. However, there was no association with adverse events or the time spent within the therapeutic range in this sample.

Resumo Contexto Fatores genéticos podem ser responsáveis por parte das diferenças populacionais e interindividuais observadas em usuários de varfarina. Objetivos Identificar a ocorrência de polimorfismo dos genes CYP2C9 e VKORC1 em pacientes em uso de varfarina e relacionar esses perfis com a dose do medicamento e o tempo no intervalo terapêutico. Métodos Foram realizadas entrevistas mensais para a coleta de dados. Foram reunidos dados sobre características demográficas e medicamentos em uso, principalmente sobre varfarina, como motivo da prescrição e dose semanal. O tempo no intervalo terapêutico foi calculado como a porcentagem de dias com razão normalizada internacional entre os valores 2 e 3. Os genes CYP2C9 e VKORC1 foram analisados em laboratório de Genética Humana. Resultados Entre os participantes, 49 pacientes (74,2%) apresentaram polimorfismo dos genes CYP2C9 e/ou VKORC1; os 17 restantes (25,8%) não apresentaram esses polimorfismos. A dose média semanal de varfarina foi menor entre os que apresentaram polimorfismo para algum dos genes em comparação aos que não apresentaram, com diferença significativa (p = 0,035). O tempo no intervalo terapêutico médio também foi menor entre os pacientes com polimorfismo. Porém, não houve diferença significativa entre os dois grupos para essa variável (p = 0,438). Conclusões Foi observada associação entre os polimorfismos e a dose de varfarina utilizada pelos pacientes; no entanto, não houve associação com eventos adversos e o tempo de permanência na faixa terapêutica nessa amostra.

Hospital expenses and liver disease in Brazil / Gastos hospitalares e doença hepática no Brasil

Objective: This study aims at describing the values and morbimortality of hospital admissions for liver disease in the Brazilian public health system. Methods: The study was carried out in the DATASUS, for a period of five years. The number, causes, time, mortality rate and values of hospitalizations in the period were investigated. Results: In five years, there were 67,561,584 hospitalizations, of which 461,431 were due to liver diseases. The value of hospitalizations in the period was US$ 23 billion, and liver diseases accounted for US$ 384 million, which corresponds to 76 million per year. In liver diseases, the mean length of hospital stay was 8 days whereas for other hospitalizations the mean time was 5 days. The mortality rate from liver diseases was 14% while the general mortality rate was 4%. The average cost of hospitalizations was US$ 531 for liver diseases and US$ 84 for other causes of hospitalization. Conclusion: In the Brazilian public health system, liver diseases have a higher average value, a longer average hospital stay, and a higher mortality rate when compared to all causes of hospitalization.

Objetivo: Este estudo tem como objetivo descrever os valores e a morbimortalidade das internações por doenças hepáticas no sistema público de saúde brasileiro. Métodos: O estudo foi realizado no Sistema de Informações Hospitalares do Datasus, por um período de cinco anos. Foram investigados o número, as causas, o tempo, a taxa de mortalidade e os valores das internações no período. Resultados: Em cinco anos houve 67.561.584 internações, das quais 461.431 foram por hepatopatias. O valor das internações no período foi de US$ 23 bilhões, e as doenças do fígado representaram US$ 384 milhões, o que corresponde a 76 milhões por ano. Nas hepatopatias, o tempo médio de internação hospitalar foi de 8 dias, enquanto para outras internações o tempo médio foi de 5 dias. A taxa de mortalidade por doenças do fígado foi de 14%, enquanto a taxa geral de mortalidade foi de 4,0%. O custo médio das hospitalizações foi de US$ 531 para doenças do fígado, enquanto para outras causas de hospitalização foi de US$ 84. Conclusão: No sistema público de saúde brasileiro, as hepatopatias têm maior valor médio, maior tempo de internação e maior mortalidade quando comparadas a todas as causas de internação.

Cost and Effectiveness of the Treatment of Chronic Hepatitis C in Brazil: Real-World Data.

OBJECTIVES: To introduce and discuss the cost and effectiveness of using sofosbuvir, daclatasvir, and simeprevir antivirals, in combination or not with peginterferon alfa and ribavirin, for the treatment of hepatitis C, as based on real-world data. METHODS: We analyzed the treatment and outcomes of 253 patients from a retrospective cohort held in a specialized assistance service in the municipality of Porto Alegre, Brazil. Regarding costs, we considered only the direct costs of the antiviral medications per unit (pills), according to the financial receipts of the public procurements. We calculated the total cost of treatment per individual and the cost per cure expressed in sustained virologic response (SVR). RESULTS: Most patients (66.8%) were carriers of the genotype 1 of hepatitis, and 92.9% reached the SVR. The average cost of the treatment for genotype-1 patients was $5,862.31 USD per patient and $6,310.34 for the cure; for genotype-3 patients, on the other hand, the cost was $5,144.27 per patient and $5,974.76 for the cure. The drugs purchasing cost was around 40% less than was estimated for the process of incorporating them into the public health system. CONCLUSION: The results indicated that good rates of effectiveness were achieved with different combinations of the medicines. The costs of the medicines were still deemed too high for the Brazilian reality, however. Therefore the results contribute to support the formulation and review of public policies based on strong evidence and on real-world data for the treatment of hepatitis C.

Economic impact of the clinical pharmacist interventions in the pediatric intensive care unit

Clinical pharmacists in intensive care units are involved in patient safety, technical guidance and cost saving with rational use of medicines. This study aimed to estimate the cost saving of clinical pharmacist interventions in pediatric intensive care units (PICU). This was a retrospective, observational study. Savings were measured for three months based on (1) Clinical pharmacist interventions from prescription analysis, (2) Individualized doses of four antibiotics, (3) Comparison of drugs dispensing systems before and after the decentralization of pharmacy services. The main outcome is costs saving with strategic planning of medication use based on local reality. A number of 73 clinical pharmacist interventions were made, from which 13 allowed the calculation of economic impact, saving US$ 633.38/year. Cost saving from individualized doses of four antibiotics was US$ 8,754.46/year. The decentralization of pharmacy services saved US$ 28,770.52/year. The evaluated interventions were successful. Clinical pharmacist interventions, individualized antimicrobials doses and decentralization of pharmacy services reduce costs in the hospital.

Effectiveness and safety of protease inhibitors for the hepatitis C treatment in a hospital of South Brazil: real life data

The combination of Inhibitors of protease boceprevir (BOC) or telaprevir (TLV) concomitantly with peginterferon (PEG) and ribavirin (RBV) constitute the triple therapy (TT) for Hepatitis C treatment. Objective: To describe the experience of the TT treatment of chronic hepatitis C patients, besides discussing safety issues, in real life. Methods: Observational and retrospective study with 180 patients attended in a specialized center, between July 2014 and December 2015. Were evaluated variables as gender, age, access to drugs, pattern of alcohol consumption, pathway of contamination reported by the patient, previous treatment, degree of fibrosis, treatment regimen, treatment interruption and reason and Sustained Viral Response (SVR). Adverse Drug Reactions (ADRs) were collect through monthly self-report by the patient to the pharmacist. Results: 65 patients used BOC and 115 TLV, and the mean age was 54.20 (BOC) and 53.92 (TLV) years. End of treatment rate was 52.3% (BOC) and 53.3% (TLV). ADRs occurred in 18.5% of the patients (BOC) and 13.9% (TLV), being more frequent the severe anemia. Erythropoietin (EPO) used in 45.4% (BOC) and 58.2% (TLV). SVR rate calculated by intention to treat was 38.5% (BOC) e 50.4% (TLV). Conclusion: This study has shown that the effectiveness of TT is not significantly higher than double therapy and is lower than the reported in clinical trials. High dropout rates due to ADRs have been demonstrated, as well as a lower SVR found in clinical trials.(AU)

Conhecimento sobre plantas medicinais e fitoterápicos de agentes comunitários de saúde de Ijuí/RS / Conocimiento sobre plantas medicinales y remedios herbarios de agentescomunitarios de salud de Ijuí/RS / Knowledge on medicinal plants and herbal medicines by community health agents of Ijuí/RS

Objective: to assess the knowledge of medicinal plants and herbal medicines by Community Health Agents (ACS) in a ESF municipality Ijuí/RS. Method: Cross-sectional study, quantitative and qualitative, with 13ACS. Data collection occurred in April 2014, and the analysis of quantitative data was done using descriptive statistics. The qualitative data were presented through the Collective Subject Discourse. Results: The main understanding of ACS on herbal medicine is related to the use of medicinal plants. Everyone agrees on the availability of plants and herbal medicines in the NHS, and provide information as to the mode of preparation and storage plants. Also believe that the incorrect use of plants can cause health hazards. Conclusion: There is a lack of knowledge about herbal medicine for ACS. Herbal medicine can and should be considered as a field of interaction of knowledge and practice that values and considers cultural resources, practices and localknowledge, with the involvement of the professional health care team.

Objetivo: avaliar o conhecimento sobre plantas medicinais e fitoterápicos por Agentes Comunitários de Saúde (ACS) em uma ESF do Município de Ijuí/RS. Método: Estudo transversal, quanti-qualitativo, com 13 ACS. A coleta de dados ocorreu em abril de 2014, e a análise de dados quantitativos foi feita através de estatística descritiva. Já os dados qualitativos foram apresentados através do Discurso do Sujeito Coletivo. Resultados: O principal entendimento dos ACS sobre fitoterapia está relacionado ao uso de plantas medicinais. Todos concordam com a disponibilização de plantas e fitoterápicos no SUS, e prestam informações quanto ao modo de preparo e armazenamento das plantas. Também acreditam que o uso incorreto de plantas pode causar riscos à saúde. Conclusão: Existe uma lacuna de conhecimento a respeito da fitoterapia pelos ACS. A fitoterapia pode e deve ser considerada como um campo de interação de saberes e práticas que valoriza e considera os recursos culturais, práticas e saberes locais, com o envolvimento dos profissionais da equipe de saúde.

Objetivo: evaluar el conocimiento de las plantas medicinales y los medicamentos a base de hierbas por los Agentes Comunitarios de Salud(ACS) en una ESF Municipio Ijuí/RS. Método: Estudio transversal,cuantitativo y cualitativo, con 13 CHA. La recolección de datos tuvo lugar en abril de 2014, y el análisis de los datos cuantitativos se realizó mediante estadística descriptiva. Los datos cualitativos se presentaron a través del Discurso del Sujeto Colectivo. Resultados: La comprensión primaria de ACS en la medicina herbal se relaciona con el uso de plantas medicinales.Todo el mundo está de acuerdo sobre la disponibilidad de plantas y hierbas medicinales en el NHS, y proporcionar información en cuanto a la forma de las plantas de preparación y almacenamiento. También creen que el uso incorrecto de las plantas puede causar riesgos para la salud. Conclusión: Existe una brecha de conocimiento con respecto a la fitoterapia por ACS. La medicina herbaria puede y debe ser considerado como un campo de interacción de los conocimientos y la práctica que valora y considera los recursos culturales, las prácticas y el conocimiento local, con la participación del equipo profesional de la salud.

Uso de plantas medicinais por usuários do serviço público de saúde do município de Ijuí/RS / Medicinal plant use by patients using the public health service of the city of Ijuí, Rio Grande do Sul, Brazil / El uso de plantas medicinales por los usuarios del servicio público de salud del municipio de Ijuí/RS

Este estudo buscou descrever o uso de plantas medicinais por usuários do Serviço Público de Saúde do município de Ijuí/RS. Métodos: trata-se de estudo transversal, com questionário estruturado, aplicado aos usuários que buscam atendimento no Serviço Público de Saúde do município de Ijuí/RS, nas unidades da Secretaria Municipal de Saúde/Unidade de Saúde do Centro - UESF -, que atende os bairros Luis Fogliatto e Alvorada, e UESF do Meio-Rural. A coleta de dados ocorreu entre março a setembro de 2012 e foi aprovado pelo CEP/UNIJUÍ. Resultados: dos 446 entrevistados, 81,0% utilizam plantas e 71,5% afirmaram utilizá-las por indicação de familiares. As espécies mais citadas foram: Achyrocline satureioides D.C. (Lam.) (marcela) 22,8%, Matricaria chamomilla L. (camomila) 13,5%, Lippia alba (Mill.) N.E. Br. ex Britton & P. Wilson (cidreira) 9,7%. Quanto às indicações terapêuticas atribuídas às plantas, as mais citadas foram as doenças do trato gastrointestinal, sistema nervoso, distúrbios metabólicos, aparelho respiratório e hipertensão. Algumas destas indicações não encontraram embasamento científico na literatura pesquisada. Conclusão: entende-se necessária a capacitação dos profissionais da área da saúde para garantir a correta orientação ao usuário, bem como o fomento à pesquisa com plantas medicinais para embasar a implementação de políticas públicas de fitoterapia.

This study evaluated the use of medicinal plants by users of the Public Health Service of the city of Ijuí, Rio Grande do Sul, Brazil. Methods: this cross-sectional study used a structured questionnaire administered to users who sought care in the Public Health Service of the city of Ijuí in units of the Municipal Health Unit/Health Center - UESF serving the Luis Fogliatto, and Alvorada neighborhoods and UESF Meio-Rural. Data collection occurred between March and September 2012 and was approved by the Ethics Research Committee of UNIJUÍ. Results: of the 446 respondents, 81.0% used medicinal plants, and 71.5% said they did so following the advice of family members. The most cited species were Achyrocline satureioides D.C. (Lam.) (marcela), Matricaria chamomilla L. (chamomile), and Lippia alba (Mill.) N.E. Br. ex Britton & P. Wilson (bushy matgrass), which were used by 22.8%, 13.5%, and 9.7% of the respondents, respectively. The indications most attributed to the plants were diseases of the gastrointestinal tract and nervous system, metabolic disorders, respiratory problems, and hypertension. Some of these indications were not identified by a review of the scientific literature. Conclusion: it is necessary to train health professionals to ensure that correct advice is given to users and to foster research on medicinal plants to support the implementation of public policies on phytotherapy.

Este estudio describe el uso de plantas medicinales por los usuarios del Servicio de Salud Pública del municipio de Ijuí/RS. Métodos: estudio transversal mediante un cuestionario estructurado administrado a los usuarios que buscan atención en el Servicio de Salud Pública del municipio de Ijuí/RS, en unidades de la Unidad de Salud/Centro de Salud Municipal - UESF servir barrios Luis Fogliatto, y Dawn y UESF del Medio Rural. La recolección de datos tuvo lugar entre marzo y septiembre del 2012 y fue aprobado por el IRB/UNIJUI. Resultados: de los 446 encuestados, el 81,0% utilizan plantas y el 71,5% dijo que utilizan por indicación de la familia. Las especies más frecuentes fueron satureioides Achyrocline (marcela) 22,8%, Matricaria recutita (manzanilla) 13,5%, Lippia alba (limón) 9,7%. En cuanto a las indicaciones asignadas a las plantas más citadas fueron: tracto gastrointestinal, el sistema nervioso, trastornos metabólicos, respiratorios, hipertensión y otros. Algunas de estas indicaciones no se encontraron en la literatura científica. Conclusión: se entiende la formación necesaria de los profesionales de la salud para asegurar la orientación correcta para el usuario, así como el fomento de la investigación de plantas medicinales para apoyar a la implementación de políticas públicas en la medicina herbal.

Uso de medicamentos por hipertensos do Estado do Rio Grande do Sul, Brasil / Medications taken by hypertensive patients in Rio Grande do Sul State, Brazil

Fundamentos: A hipertensão arterial sistêmica (HAS) é um dos grandes problemas de saúde pública no Brasil e no mundo. Objetivos: Verificar a utilização de medicamentos por indivíduos hipertensos e avaliar a adesão ao tratamento. Métodos: Estudo transversal, descritivo e quantitativo, com usuários de uma farmácia comercial conveniada ao programa Farmácia Popular do Brasil de um município do Rio Grande do Sul, que utilizavam medicamentos anti-hipertensivos. Utilizou-se para a coleta de dados questionário estruturado com questões abordando características sociodemográficas e relacionadas ao uso de medicamentos. Resultados: Foram avaliados 155 usuários hipertensos, com predomínio do sexo feminino. Mais da metade dos usuários apresentou pressão arterial >140/90mmHg. Os medicamentos mais utilizados foram os diuréticos, seguidos pelos inibidores da enzima conversora da angiotensina (IECA). Houve correlação estatística entre o uso de medicamentos e os níveis pressóricos avaliados. Conclusões: Os resultados do estudo apontaram um bom nível de adesão ao tratamento, mas um controle da PA insatisfatório, mostrando um potencial viés na avaliação da adesão, que indicam a necessidade de ações mais efetivas no manejo da HAS, como adequação da terapia medicamentosa por parte dos médicos, com suporte de equipe multidisciplinar. O importante resultado encontrado neste trabalho.

Abstract Background: Hypertension is a major public health problem in Brazil and worldwide. Objectives: To investigate medications taken by hypertensive patients and assess compliance with treatment. Methods: A cross-sectional descriptive and quantitative study of customers taking antihy pertensive medications obtained at a commercial drugstore signed up with Brazil’s Farmácia Popular government- subsidized drugs program in a town in Rio Grande do Sul State. The data were collected through a structured questionnaire addressing issues related to sociodemographic characteristics and drug use. Results: 155 hypertensive patients were interviewed, mainly women. More than half of the users had blood pressure levels above 140/90mmHg. The most commonly used medications were diuretics, followed by angiotensin-converting enzyme inhibitors (ACEIs). A statistical correlation was noted between the medications taken and the blood pressure levels evaluated. Conclusions: The findings of this study show a good level of compliance with treatment, but poor blood pressure control, suggesting a potential bias in assessing compliance and indicating a need for more effective hypertension management actions, such as physicians adjusting medications, backed by multidisciplinary teams. The main result of this study shows that hypertensive patients are being under-treated.