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1.
Pediatr Infect Dis J ; 38(9): 934-938, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31232892

RESUMO

BACKGROUND: A recent systematic review concluded that critically ill pediatric patients have higher odds of vancomycin-related nephrotoxicity [odds ratio (OR): 3.61, 95% CI: 1.21-10.74]. We aimed to assess the incidence and risk factors for vancomycin-associated nephrotoxicity in critically ill children without preexisting renal injury. METHODS: A cohort of children admitted to a pediatric intensive care unit, from 2011 to 2016 treated with vancomycin without preexisting renal injury. The main diagnosis, therapeutic interventions and medications administered in this period were evaluated. Generalized estimating equation models were used to assess the association between clinical covariates and the dependent variable pediatric risk, injury, failure, loss, end-stage renal disease (pRIFLE). RESULTS: Hundred ten patients, representing 1177 vancomycin days, were analyzed. Vancomycin-associated nephrotoxicity was seen in 11.8%. In a multivariate model, higher vancomycin doses were not associated with poorer renal function (P = 0.08). Higher serum vancomycin levels were weakly associated with pRIFLE classification (OR: 1.05, 95% CI: 1.02-1.07). Furosemide or amphotericin B in addition to the vancomycin treatment was associated with impaired renal function (OR: 2.56, 95% CI: 1.38-4.8 and OR: 7.7 95% CI: 2.55-23, respectively). CONCLUSIONS: Vancomycin-associated nephrotoxicity in acute ill children without preexisting renal injury, measured with pRIFLE, is close to 11.8%. Furosemide and amphotericin B in addition to the vancomycin treatment are strong predictors of worse pRIFLE scores. The influence of acute kidney injury status at pediatric intensive care unit admission and the method used for renal function assessment might influence the incidence of vancomycin-associated nephrotoxicity and its associated risk factors.

2.
J. bras. econ. saúde (Impr.) ; 10(1): 75-79, Abr. 2018.
Artigo em Português | LILACS, ECOS | ID: biblio-884397

RESUMO

Avaliações econômicas em saúde são essenciais para a tomada de decisão de gestores, visto que as inovações no setor nem sempre podem ser incorporadas conforme as expectativas dos usuários e da indústria. Logo, a análise de impacto orçamentário (AIO), uma das principais ferramentas da avaliação de tecnologias em saúde (ATS), permite aos gestores estimar o potencial número de indivíduos elegíveis para determinada tecnologia ao longo dos anos, prever quanto será necessário gastar para incorporar a tecnologia ou, eventualmente, se haverá economia nos cofres do pagador com a inclusão dela. Com a crescente publicação de artigos científicos sobre AIO no Brasil, surge a preocupação a respeito da qualidade metodológica desses estudos. O objetivo desta revisão é apresentar recomendações-chave para a elaboração de uma AIO adequada e expor a utilidade prática da AIO para a tomada de decisão de gestores de saúde por meio da análise de quatro estudos publicados. O formato de apresentação de uma AIO possibilita rápido entendimento e possui atributos que permitem evidenciar o maior valor de produtos e serviços de saúde junto aos tomadores de decisão em saúde, contribuindo para as melhores escolhas do ponto de vista clínico e econômico, nos sistemas público e privado. Porém, cabe ressaltar que alguns estudos ainda carecem de evidências de mundo real ou dados epidemiológicos para as estimativas e trabalham de maneira insuficiente as ferramentas para a redução de incertezas paramétricas.


Health economics evaluations are essential for decision makers, since innovations can not always be incorporated according to expectations of users and industry. Therefore, the Budget Impact Analysis (BIA), one of the main tools in Health Technology Assessment (HTA), allows managers to estimate the potential number of individuals eligible for a given technology over the years, to predict how much it will be necessary to spend for incorporate the technology or, eventually, whether there will be savings in the payer's coffers with the inclusion of the same. With the growing publication of scientific articles on BIA in Brazil, there is concern about the methodological quality of these studies. The objective of this review is to present key recommendations to elaborate an adequate BIA, commenting on four published studies, aiming to expose the practical utility of BIA for health managers. The presentation format of the BIA provides a quick understanding and has attributes that allows evidence of the highest value of health products and services among health decision makers, contributing to the best clinical and economic choices in public and private health systems. However, it should be noted in some studies there is still a lack of real-world evidence or epidemiological data for the estimates and insufficient using of tools to reduce parametric uncertainties.


Assuntos
Humanos , Gestão em Saúde , Avaliação da Tecnologia Biomédica
6.
Rev. paul. pediatr ; 35(4): 472-475, out.-dez. 2017. graf
Artigo em Português | LILACS-Express | ID: biblio-902871

RESUMO

RESUMO Objetivo: Descreve se uma criança do sexo feminino, com quatro meses de idade, que necessitou de varfarina 0.7 mg/kg/dia (5 mg). Discutem se os fatores de risco clinicamente relevantes para prescrição de altas doses do anticoagulante em crianças. Descrição do caso: Em novembro de 2015, uma criança de 5 kg (36 semanas, pré termo) foi admitida no pronto atendimento por status epilepticus e febre. Diazepam, fenitoína e ceftriaxona foram prescritos inicialmente. A pesquisa no líquor revelou presença de sete leucócitos, 150 mg/dL de proteínas, 1 mg/dL de glucose e cocos Gram positivos. Em tomografia de crânio, foram observados sinais hipodensos em cerebelo, lobo temporal e núcleos de base à esquerda, sugerindo vasculite infecciosa por meningite pneumocócica. Após o quadro agudo da encefalite, a criança desenvolveu uma trombose e necessitou de anticoagulação com enoxaparina e, posteriormente, com varfarina. Dez dias de tratamento com o segundo fármaco foram necessários para atingir relação normalizada internacional (RNI) terapêutica, tendo sido realizados cinco ajustes de dose desde a primeira prescrição de varfarina. Comentários: Os fatores de risco determinantes para necessidade de doses maiores de varfarina foram idade e uso de nutrição enteral. Fenobarbital e prednisona também podem ter contribuído para o uso de uma das maiores doses de varfarina já relatadas na literatura. A despeito da importância dos testes de polimorfismo genético, os pediatras devem estar atentos para identificar os fatores que contribuem para a prescrição de maiores doses de varfarina, de forma a minimizar os riscos de trombose, reduzindo os custos com internação e exames laboratoriais.


ABSTRACT Objective: To report a case of a 4-month old girl that required 0.7 mg/kg/day (5 mg) of warfarin and discuss relevant risk factors for requiring higher doses. Case Description: In November 2015, a 5 kg female infant (36-week preterm) was admitted to the hospital due to status epilepticus and fever. Diazepam, phenytoin and ceftriaxone were prescribed. Cerebrospinal fluid contained 7 leukocytes, 150 mg/dL proteins, 1 mg/dL glucose and gram positive cocci were observed. Cranial tomography suggested hypodense signs in the cerebellum, right temporal lobe and left basal nuclei, which was consistent with pneumococcal meningitis-induced infectious vasculitis. She required low molecular weight heparin and warfarin for post-encephalitis thrombosis. About 10 days were required to achieve therapeutic INR, and warfarin was adjusted five times since the initial prescription. Comments: The risk factors for higher warfarin doses were age and enteral tube feeding. Phenobarbital and prednisone might also have contributed with one of the highest warfarin dose ever reported. Despite current importance given to genetics testing, clinicians should attempt to identify common contributing factors for prolonged non-therapeutic INR, to minimize the risk of coagulation, and to reduce costs of hospital stay and laboratory exams.

7.
Rev Paul Pediatr ; 35(4): 472-475, 2017 Oct-Dec.
Artigo em Português, Inglês | MEDLINE | ID: mdl-29185625

RESUMO

OBJECTIVE: To report a case of a 4-month old girl that required 0.7 mg/kg/day (5 mg) of warfarin and discuss relevant risk factors for requiring higher doses. CASE DESCRIPTION: In November 2015, a 5 kg female infant (36-week preterm) was admitted to the hospital due to status epilepticus and fever. Diazepam, phenytoin and ceftriaxone were prescribed. Cerebrospinal fluid contained 7 leukocytes, 150 mg/dL proteins, 1 mg/dL glucose and gram positive cocci were observed. Cranial tomography suggested hypodense signs in the cerebellum, right temporal lobe and left basal nuclei, which was consistent with pneumococcal meningitis-induced infectious vasculitis. She required low molecular weight heparin and warfarin for post-encephalitis thrombosis. About 10 days were required to achieve therapeutic INR, and warfarin was adjusted five times since the initial prescription. COMMENTS: The risk factors for higher warfarin doses were age and enteral tube feeding. Phenobarbital and prednisone might also have contributed with one of the highest warfarin dose ever reported. Despite current importance given to genetics testing, clinicians should attempt to identify common contributing factors for prolonged non-therapeutic INR, to minimize the risk of coagulation, and to reduce costs of hospital stay and laboratory exams.


Assuntos
Anticoagulantes/administração & dosagem , Coeficiente Internacional Normatizado , Trombose/tratamento farmacológico , Varfarina/administração & dosagem , Feminino , Humanos , Lactente , Fatores de Risco
12.
Br J Clin Pharmacol ; 83(5): 1108-1117, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27868231

RESUMO

AIMS: To review the efficacy and safety of aprepitant in combination with ondansetron and dexamethasone (triple therapy) in children and adolescents on moderate to highly emetogenic chemotherapy. METHODS: Medline, Embase, Scielo, Lilacs, Cochrane and congress abstracts published until September 2016 were used as data sources. Two reviewers independently selected manuscripts and extracted data. A third reviewer solved discrepancies in study selection and data extraction. The primary outcome was overall complete response (no vomiting from 0 to 120 h). Secondary outcomes were: response in acute phase, delayed phase and reported toxicities. Each study was considered a unit of analysis. Summarized relative risks were recalculated based on reported data. All meta-analyses used a random-effects model and heterogeneity was reported using the I2 method. RESULTS: From 1004 studies, we screened 288 titles and abstracts and included three trials for data extraction. The population comprised 451 patients. Most patients were males, ranging from 6 months to 19 years of age, and weighing from 6 to 134 kg. Bone cancer was the most incident (≥50%) neoplasm, followed by rhabdomyosarcoma and Hodgkin's lymphoma. Triple therapy was associated with a reduced risk of developing chemotherapy-induced vomiting (CIV) (RR = 0.48; 95% CI 0.34-0.67). There were no differences in incidence of febrile neutropenia between groups (RR = 1.02; 95% CI 0.66-1.58). CONCLUSIONS: Triple therapy decreased CIV risk, without increasing the occurrence of febrile neutropenia. However, this review could not address which subpopulations would most benefit from using this strategy. Future studies should focus on assessing risk factors for nausea and vomiting, as many patients did not achieve a complete antiemetic response.


Assuntos
Antieméticos/administração & dosagem , Morfolinas/administração & dosagem , Vômito/prevenção & controle , Adolescente , Antieméticos/efeitos adversos , Antineoplásicos/administração & dosagem , Antineoplásicos/efeitos adversos , Aprepitanto , Criança , Pré-Escolar , Dexametasona/administração & dosagem , Dexametasona/efeitos adversos , Quimioterapia Combinada , Humanos , Lactente , Morfolinas/efeitos adversos , Náusea/induzido quimicamente , Náusea/prevenção & controle , Neoplasias/tratamento farmacológico , Neoplasias/patologia , Ondansetron/administração & dosagem , Ondansetron/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Revisão Sistemática como Assunto , Vômito/induzido quimicamente , Adulto Jovem
13.
Rev. paul. pediatr ; 34(4): 397-402, Oct.-Dec. 2016. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-830750

RESUMO

Abstract Objective: Clinical Pharmacy Services (CPS) are considered standard of care and is endorsed by the Joint Commission International, the American Academy of Pediatrics, and the American College of Clinical Pharmacy. In Brazil, single experiences have been discreetly arising and the importance of these services to children and adolescents care has led to interesting results, but certainly are under reported. This short report aims to discuss the effect of implementing a bedside CPS at a Brazilian Pediatric Intensive Care Unit (PICU). Methods: This is a cross-sectional study conducted in a 12 bed PICU community hospital, from Campo Largo/Brazil. Subjects with<18 years old admitted to PICU were included for descriptive analysis if received a CPS intervention. Results: Of 53 patients accompanied, we detected 141 preventable drug-related problems (DRPs) which were solved within clinicians (89% acceptance of all interventions). The most common interventions performed to improve drug therapy included: preventing incompatible intravenous solutions (21%) and a composite of inadequate doses (17% due to low, high and non-optimized doses). Among the top ten medications associated with DRPs, five were antimicrobials. By analyzing the correlation between DRPs and PICU length of stay, we found that 74% of all variations on length of stay were associated with the number of DRPs. Conclusions: Adverse drug reactions due to avoidable DRPs can be prevented by CPS in a multifaceted collaboration with other health care professionals, who should attempt to use active and evidence-based strategies to reduce morbidity related to medications.


Resumo Objetivo: Serviços de Farmácia Clínica (SFC) são considerados um padrão de atendimento à saúde e são endossados pela Joint Commission International, pela American Academy of Pediatrics e pelo American College of Clinical Pharmacy. No Brasil, experiências isoladas vêm surgindo discretamente e a importância desses serviços para o cuidado de crianças e adolescentes tem levado a resultados interessantes, mas que certamente são sub-relatados. Este artigo tem como objetivo discutir o efeito da implantação de um SFC à beira do leito em uma Unidade de Cuidados Intensivos Pediátricos (UCIP) brasileira. Métodos: Este é um estudo transversal, feito em uma UCIP de hospital da comunidade com 12 leitos, em Campo Largo, Brasil. Foram incluídos indivíduos com<18 anos internados em UCIP para análise descritiva, quando receberam uma intervenção do SFC. Resultados: De 53 pacientes acompanhados, foram detectados 141 Problemas Relacionados a Medicamentos (PRM) evitáveis que foram resolvidos em conjunto com os médicos (89% de aceitação de todas as intervenções). As intervenções mais comuns para melhorar a terapia medicamentosa foram: prevenção de soluções intravenosas incompatíveis (21%) e doses inadequadas (17% devido a doses baixas e altas). Entre os dez principais medicamentos associados à PRM, cinco eram antimicrobianos. Ao analisar a correlação entre o PRM e tempo de permanência na UCIP, verificamos que 74% de todas as variações no tempo de permanência eram associadas com o número de PRM. Conclusões: Reações adversas a medicamentos devido a PRM evitáveis podem ser prevenidas por SFC em uma colaboração multifacetada com outros profissionais de saúde. Tais problemas podem ser evitados por meio de estratégias ativas e baseadas em evidências para reduzir a morbidade relacionada a medicamentos.

14.
Int J Clin Pharm ; 38(6): 1362-1366, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27817171

RESUMO

Background Adherence to prescribed drug therapy is associated with lower rates of cardiovascular causes of death. In view of the relevance for public health, it is important to understand the relation between medication adherence tools' scores, especially in low literacy patients discharged from a cardiology ward. Objectives We aimed to assess: (a) the association between number of controlled clinical conditions and adherence tools scores, and (b) the correlation between the scores of three instruments to assess adherence. Methods We conducted a prospective study and included patients discharged from a specialized cardiovascular ward in Brazil. The results of the Beliefs about Medicines questionnaire (BMQ), the Adherence to Refills and Medication Scale (ARMS) and the MedTake test were compared. Results Of 53 included patients, most of them were elderly, and did not complete primary school. On average, there were six health conditions per patient, where two of them were not controlled. ARMS was the only tool that was associated with number of controlled health conditions (r = -0.312, p < 0.05). Moreover, ARMS (average score 15.6 ± 3.4) had significant correlation with MEDTAKE (r = 0.535, p < 0.01) and BMQ (r = 0.38, p < 0.01). BMQ and MEDTAKE were also positively correlated (r = 0.311, p < 0.05). Conclusions Clinically, higher ARMS scores (>12) suggest assumed non-adherence. It is also negatively correlated with the number of controlled clinical conditions in low literacy elderlies with cardiovascular diseases.


Assuntos
Serviço Hospitalar de Cardiologia , Doenças Cardiovasculares/tratamento farmacológico , Alfabetização em Saúde , Adesão à Medicação , Alta do Paciente , Idoso , Brasil/epidemiologia , Serviço Hospitalar de Cardiologia/tendências , Doenças Cardiovasculares/epidemiologia , Feminino , Alfabetização em Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/tendências , Estudos Prospectivos
16.
Rev Paul Pediatr ; 34(4): 397-402, 2016 Dec.
Artigo em Inglês, Português | MEDLINE | ID: mdl-27578187

RESUMO

OBJECTIVE: Clinical Pharmacy Services (CPS) are considered standard of care and they are endorsed by the Joint Commission International, the American Academy of Pediatrics, and the American College of Clinical Pharmacy. In Brazil, single experiences have been discreetly arising and the importance of these services to children and adolescents care has led to interesting results, but certainly are under reported. This short report aims to discuss the effect of implementing a bedside CPS at a Brazilian Pediatric Intensive Care Unit (PICU). METHODS: This is a cross-sectional study conducted in a 12 bed PICU community hospital, from Campo Largo/Brazil. Subjects with<18 years old admitted to PICU were included for descriptive analysis if received a CPS intervention. RESULTS: Of 53 patients accompanied, we detected 141 preventable drug-related problems (DRPs) which were solved within clinicians (89% acceptance of all interventions). The most common interventions performed to improve drug therapy included: preventing incompatible intravenous solutions (21%) and a composite of inadequate doses (17% due to low, high and non-optimized doses). Among the top ten medications associated with DRPs, five were antimicrobials. By analyzing the correlation between DRPs and PICU length of stay, we found that 74% of all variations on length of stay were associated with the number of DRPs. CONCLUSIONS: Adverse drug reactions due to avoidable DRPs can be prevented by CPS in a multifaceted collaboration with other health care professionals, who should attempt to use active and evidence-based strategies to reduce morbidity related to medications.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Unidades de Terapia Intensiva Pediátrica , Serviço de Farmácia Hospitalar , Brasil , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos
17.
Pharm. pract. (Granada, Internet) ; 14(3): 0-0, jul.-sept. 2016. graf
Artigo em Inglês | IBECS | ID: ibc-156622

RESUMO

Background: Computerized Provider Order Entry (CPOE) and Clinical Decision Support System (CDSS) help practitioners to choose evidence-based decisions, regarding patients’ needs. Despite its use in developed countries, in Brazil, the impact of a CPOE/CDSS to improve cefazolin use in surgical prophylaxis was not assessed yet. Objective: We aimed to evaluate the impact of a CDSS to improve the use of prophylactic cefazolin and to assess the cost savings associated to inappropriate prescribing. Methods: This is a cross-sectional study that compared two different scenarios: one prior CPOE/CDSS versus after software implementation. We conducted twelve years of data analysis (3 years prior and 9 years after CDSS implementation), where main outcomes from this study included: cefazolin Defined Daily Doses/100 bed-days (DDD), crude costs and product of costs-DDD (cost-DDD/100 bed-days). We applied a Spearman rho non-parametric test to assess the reduction of cefazolin consumption through the years. Results: In twelve years, 84,383 vials of cefazolin were dispensed and represented 38.89 DDD/100 bed-days or USD 44,722.99. Surgical wards were the largest drug prescribers and comprised >95% of our studied sample. While in 2002, there were 6.31 DDD/100 bed-days, 9 years later there was a reduction to 2.15 (p<0.05). In a scenario without CDSS, the hospital would have consumed 75.72 DDD/100 bed-days, which is equivalent to USD 116 998.07. It is estimated that CDSS provided USD 50,433.39 of cost savings. Conclusion: The implementation of a CPOE/CDSS helped to improve prophylactic cefazolin use by reducing its consumption and estimated direct costs (AU)


No disponible


Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Cefazolina/economia , Cefazolina/uso terapêutico , Antibioticoprofilaxia , Profilaxia Pré-Exposição/organização & administração , Sistemas de Informação/economia , Tomada de Decisões Assistida por Computador , Sistemas de Apoio a Decisões Administrativas/economia , Antibacterianos/economia , Antibacterianos/farmacologia , Cefazolina/farmacologia , Antibioticoprofilaxia/economia , Profilaxia Pré-Exposição/economia , Farmacêuticos/economia , Estudos Transversais , Estatísticas não Paramétricas
19.
Braz. j. infect. dis ; 20(3): 255-261, May.-June 2016. tab, graf
Artigo em Inglês | LILACS-Express | ID: lil-789477

RESUMO

Abstract There is a lack of formal economic analysis to assess the efficiency of antimicrobial stewardship programs. Herein, we conducted a cost-effectiveness study to assess two different strategies of Antimicrobial Stewardship Programs. A 30-day Markov model was developed to analyze how cost-effective was a Bundled Antimicrobial Stewardship implemented in a university hospital in Brazil. Clinical data derived from a historical cohort that compared two different strategies of antimicrobial stewardship programs and had 30-day mortality as main outcome. Selected costs included: workload, cost of defined daily doses, length of stay, laboratory and imaging resources used to diagnose infections. Data were analyzed by deterministic and probabilistic sensitivity analysis to assess model's robustness, tornado diagram and Cost-Effectiveness Acceptability Curve. Bundled Strategy was more expensive (Cost difference US$ 2119.70), however, it was more efficient (US$ 27,549.15 vs 29,011.46). Deterministic and probabilistic sensitivity analysis suggested that critical variables did not alter final Incremental Cost-Effectiveness Ratio. Bundled Strategy had higher probabilities of being cost-effective, which was endorsed by cost-effectiveness acceptability curve. As health systems claim for efficient technologies, this study conclude that Bundled Antimicrobial Stewardship Program was more cost-effective, which means that stewardship strategies with such characteristics would be of special interest in a societal and clinical perspective.

20.
Braz J Infect Dis ; 20(3): 255-61, 2016 May-Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27094234

RESUMO

There is a lack of formal economic analysis to assess the efficiency of antimicrobial stewardship programs. Herein, we conducted a cost-effectiveness study to assess two different strategies of Antimicrobial Stewardship Programs. A 30-day Markov model was developed to analyze how cost-effective was a Bundled Antimicrobial Stewardship implemented in a university hospital in Brazil. Clinical data derived from a historical cohort that compared two different strategies of antimicrobial stewardship programs and had 30-day mortality as main outcome. Selected costs included: workload, cost of defined daily doses, length of stay, laboratory and imaging resources used to diagnose infections. Data were analyzed by deterministic and probabilistic sensitivity analysis to assess model's robustness, tornado diagram and Cost-Effectiveness Acceptability Curve. Bundled Strategy was more expensive (Cost difference US$ 2119.70), however, it was more efficient (US$ 27,549.15 vs 29,011.46). Deterministic and probabilistic sensitivity analysis suggested that critical variables did not alter final Incremental Cost-Effectiveness Ratio. Bundled Strategy had higher probabilities of being cost-effective, which was endorsed by cost-effectiveness acceptability curve. As health systems claim for efficient technologies, this study conclude that Bundled Antimicrobial Stewardship Program was more cost-effective, which means that stewardship strategies with such characteristics would be of special interest in a societal and clinical perspective.


Assuntos
Antibacterianos/administração & dosagem , Antibacterianos/economia , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/economia , Análise Custo-Benefício , Infecções Bacterianas/mortalidade , Brasil , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Cadeias de Markov , Avaliação de Resultados (Cuidados de Saúde) , Serviço de Farmácia Hospitalar
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