Cibele Comini César

Non-adherence among patients initiating antiretroviral therapy: a challenge for health professionals in Brazil.

Objective:To assess the incidence, magnitude and factors associated with the first episode of non-adherence for 12 months after the first antiretroviral prescription. Design:A prospective study of HIV-infected patients receiving their first antiretroviral prescription in public referral centers, Belo Horizonte, Brazil. Baseline assessment occurred at the moment of the first prescription and follow-up visits at the first, fourth and seventh month, from May 2001 to May 2003. Methods:Non-adherence was self-reported and defined as the intake of less than 95% of the prescribed doses for 3 days before the follow-up interviews. Cumulative and person-time incidence were estimated and Coxs proportional model was used to assess the relative hazard (RH) of non-adherence with 95% confidence interval for both univariate and multivariate analysis. Results:Among 306 patients, the cumulative incidence of non-adherence was 36.9% (incidence rate 0.21/100 person-days). Multivariate analysis (P < 0.05) showed that unemployment (RH = 2.17), alcohol use (RH = 2.27), self-report of three or more adverse reactions (RH = 1.64), number of pills per day (RH = 2.04), switch in antiretroviral regimen (RH = 2.72), and a longer time between the HIV test result and the first antiretroviral prescription (RH = 2.27) were associated with an increased risk of non-adherence, whereas the use of more than one health service indicated a negative association (RH = 0.54). Conclusion:The current analysis has pointed out the importance of clinical and health service characteristics as potential indicators of non-adherence after initiating therapy. Early assessment and intervention strategies should be priorities in these AIDS public referral centres. Feasible and reliable indicators for the routine monitoring of adherence should be incorporated in clinical practice.

Factors associated with duration of breastfeeding

OBJECTIVES To determine rates of exclusive breastfeeding and of complementary feeding and to identify variables that interfere with breastfeeding in the municipality of Itaúna, MG, Brazil. METHODS A longitudinal study was undertaken enrolling 246 women who gave birth at the maternity unit of the Manoel Gonçalves Hospital, in Itaúna, MG. The mothers and their infants were seen monthly for the first 12 months after birth or until they stopped breastfeeding. Survival analysis procedures were used to study the duration of exclusive breastfeeding and of complementary feeding. The impact on breastfeeding duration of a series of co-variables was assessed by means of Cox regression modeling. RESULTS The prevalence of exclusive breastfeeding at 6 months was 5.3%, and for breastfeeding at 12 months it was 33.7%. The median duration of exclusive breastfeeding was 40 days, and median breastfeeding duration was 237 days. Multivariate analysis demonstrated a negative association (p<0.05) between duration of exclusive breastfeeding and the following variables: intended breastfeeding duration (<12 months), birth weight of child (<2,500 g) and use of a pacifier. Shorter breastfeeding duration was associated (p<0.05) with maternal age (< 20 years), number of prenatal consultations (<5 and >9 consultations), use of alcohol or tobacco, delay before first feed (>6 hours) and use of a pacifier. CONCLUSIONS Breastfeeding rates in Itaúna (MG) are well below those recommended by the World Health Organization. The principal variables with a negative relationship with duration of exclusive breastfeeding and of complementary feeding are related to mother and baby health care and, therefore, interventions are possible.

Self-rated Health Compared With Objectively Measured Health Status as a Tool for Mortality Risk Screening in Older Adults: 10-Year Follow-up of the Bambuí Cohort Study of Aging

Interest in self-rated health (SRH) as a tool for use in disease and mortality risk screening is increasing. The authors assessed the discriminatory ability of baseline SRH to predict 10-year mortality rates compared with objectively measured health status. Principal component analysis was used to create a health score that included systolic blood pressure, presence of diabetes mellitus, body mass index, electrocardiographic parameters, B-type natriuretic peptide, and other biochemical and hematologic measures. From 1997 to 2007, a total of 474 of the 1,388 baseline participants died and 81 were lost to follow-up, yielding 11,833 person-years of observation. The adjusted hazard ratio for death was 1.74 (95% confidence interval (CI): 1.32, 2.29) for persons reporting poor health versus those reporting good health. When combined with age and sex, SRH had a C statistic to predict death equal to 0.69 (95% CI: 0.67, 0.71), which was comparable to that of the inclusive health score (C = 0.69, 95% CI: 0.67, 0.72). The addition of other parameters, such as lifestyle, physical functioning, mental symptoms, and physical symptoms, had little effect on these 2 predictive models (C = 0.71 (95% CI: 0.69, 0.73) and C = 0.71 (95% CI: 0.69, 0.74), respectively). The abilities of the SRH and the health score models to predict death decreased in parallel fashion over time. These results suggest that older adults who report poor health warrant particular attention as persons who have accumulated biologic markers of disease.

Fatores associados com a duração do aleitamento materno

OBJECTIVES: To determine rates of exclusive breastfeeding and of complementary feeding and to identify variables that interfere with breastfeeding in the municipality of Itauna, MG, Brazil. METHODS: A longitudinal study was undertaken enrolling 246 women who gave birth at the maternity unit of the Manoel Goncalves Hospital, in Itauna, MG. The mothers and their infants were seen monthly for the first 12 months after birth or until they stopped breastfeeding. Survival analysis procedures were used to study the duration of exclusive breastfeeding and of complementary feeding. The impact on breastfeeding duration of a series of co-variables was assessed by means of Cox regression modeling. RESULTS: The prevalence of exclusive breastfeeding at 6 months was 5.3%, and for breastfeeding at 12 months it was 33.7%. The median duration of exclusive breastfeeding was 40 days, and median breastfeeding duration was 237 days. Multivariate analysis demonstrated a negative association (p 9 consultations), use of alcohol or tobacco, delay before first feed (> 6 hours) and use of a pacifier. CONCLUSIONS: Breastfeeding rates in Itauna (MG) are well below those recommended by the World Health Organization. The principal variables with a negative relationship with duration of exclusive breastfeeding and of complementary feeding are related to mother and baby health care and, therefore, interventions are possible.

Perinatal deaths and childbirth healthcare evaluation in maternity hospitals of the Brazilian Unified Health System in Belo Horizonte, Minas Gerais, Brazil, 1999

This paper analyzes the association between perinatal mortality and factors related to hospital care during labor, considering that healthcare assessment is needed in order to reduce perinatal mortality. A population-based case-control study was conducted with 118 perinatal deaths (cases) and 492 births (controls) that took place in maternity hospitals of the Brazilian Unified Health System (SUS) in Belo Horizonte, Minas Gerais, Brazil. Male sex, prematurity, diseases during pregnancy, low birth weight, newborn diseases, lack of prenatal care, lack of partograph use during labor, and less than one fetus assessment per hour during labor were significantly associated with perinatal deaths. In the multiple regression analysis, lack of partograph use during labor and type of hospital were associated with perinatal deaths. These results indicate inadequate quality of care in maternity hospitals and show that health services structure and health care process are related to perinatal mortality due to preventable causes.

Inquérito sobre uso de medicamentos por idosos aposentados, Belo Horizonte,MG

OBJETIVO: Caracterizar o uso de medicamentos por aposentados e pensionistas idosos, com enfase nas diferencas entre generos. METODOS: Inquerito domiciliar conduzido com amostra aleatoria simples de 667 individuos com 60 anos ou mais, residentes em Belo Horizonte, MG, em 2003. Os idosos foram entrevistados por farmaceuticos, utilizando questionario padronizado. Foram estimadas a prevalencia de uso e a media de medicamentos usados nos ultimos 15 dias anteriores a entrevista, as quais foram estratificadas de acordo com o genero segundo variaveis sociodemograficas e de saude. RESULTADOS: A prevalencia de uso de medicamentos foi de 90,1%, significativamente maior entre as mulheres (93,4%) do que entre os homens (84,3%). Mulheres utilizaram em media 4,6±3,2 produtos e homens 3,3±2,6 (p<0,001). Os principios ativos mais usados pelos idosos pertenciam aos sistemas cardiovascular, nervoso, e do trato alimentar e metabolismo. O consumo foi superior entre as mulheres nesses tres grupos, assim como as medias de uso de medicamentos segundo variaveis sociodemograficas e de saude selecionadas. CONCLUSOES: O estudo identificou uso mais intenso de medicamentos pelas mulheres, fato que as torna mais vulneraveis aos prejuizos de polifarmacia, como risco de interacoes e uso inadequado.

Missed opportunities for congenital syphilis and HIV perinatal transmission prevention

OBJECTIVE To estimate the prevalence of missed opportunities for congenital syphilis and HIV prevention in pregnant women who had access to prenatal care and to assess factors associated to non-testing of these infections. METHODS Cross-sectional study comprising a randomly selected sample of 2,145 puerperal women who were admitted in maternity hospitals for delivery or curettage and had attended at least one prenatal care visit, in Brazil between 1999 and 2000. No syphilis and/or anti-HIV testing during pregnancy was a marker for missed prevention opportunity. Women who were not tested for either or both were compared to those who had at least one syphilis and one anti-HIV testing performed during pregnancy (reference category). The prevalence of missed prevention opportunity was estimated for each category with 95% confidence intervals. Factors independently associated with missed prevention opportunity were assessed through multinomial logistic regression. RESULTS The prevalence of missed prevention opportunity for syphilis or anti-HIV was 41.2% and 56.0%, respectively. The multivariate analysis showed that race/skin color (non-white), schooling (<8 years), marital status (single), income (<3 monthly minimum wages), having sex during pregnancy, history of syphilis prior to the current pregnancy, number of prenatal care visits (<6), and last prenatal visit before the third trimester of gestation were associated with an increased risk of missed prevention opportunity. A negative association with missed prevention opportunity was found between marital status (single), prenatal care site (hospital) and first prenatal visit in the third trimester of gestation. CONCLUSIONS High rates of non-tested women indicate failures in preventive and control actions for HIV infection and congenital syphilis. Pregnant women have been discontinuing prenatal care at an early stage and are failing to undergo prenatal screening for HIV and syphilis.OBJETIVO: Estimar a prevalencia de oportunidade perdida de prevencao a sifilis e HIV entre gestantes que tiveram acesso ao pre-natal e fatores associados a nao-testagem para esses agravos. METODOS: Estudo transversal com amostra aleatoria de 2.145 puerperas do Brasil, 1999 e 2000 admitidas em maternidades para parto ou curetagem e que haviam realizado pelo menos uma consulta de pre-natal. A nao-realizacao de exame de teste para sifilis e/ou anti-HIV durante a gravidez foi usada como marcador para oportunidade perdida de prevencao. Mulheres que realizaram apenas exame de sifilis ou apenas o anti-HIV, ou nao realizaram nenhum, foram comparadas aquelas que realizaram os dois (categoria de referencia). A prevalencia de oportunidade perdida de prevencao foi estimada para cada categoria, com intervalo de confianca de 95%. Os fatores associados com oportunidade perdida de prevencao foram analisados por meio de regressao logistica multinomial. RESULTADOS: A prevalencia de oportunidade perdida de prevencao para a realizacao do teste de sifilis ou anti-HIV foi de 41,2% e 56,0%, respectivamente. A analise multivariada indicou que raca/cor (nao branca), escolaridade (< 8 anos de estudo), estado civil (solteira), renda <3 salarios minimos, relacao sexual durante a gravidez, relato de nao ter tido sifilis anterior a gravidez atual, realizacao de seis ou mais consultas de pre-natal e a realizacao da ultima visita antes do terceiro trimestre de gravidez estavam associados a maior risco de ter oportunidade perdida de prevencao. Observou-se uma associacao negativa entre estado civil (solteira), local de realizacao do pre-natal (hospital) e a realizacao da primeira consulta de pre-natal no terceiro trimestre com oportunidade perdida de prevencao. CONCLUSOES: Altas percentagens de gestantes nao testadas apontam falhas na prevencao e controle da infeccao pelo HIV e da sifilis congenita pelos servicos de saude. As gestantes continuam interrompendo o cuidado pre-natal precocemente e nao conseguindo realizar os procedimentos de triagem para HIV e sifilis.

Medication errors and drug-dispensing systems in a hospital pharmacy

Pharmacies permeate and interconnect various actions developed in different sectors within the complex process of the use of drugs in a hospital. Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents. Present concepts on drug-related incidents may be classified as side effects, adverse effects, and medication errors. Among these are dispensing errors, usually associated with poor safety and inefficient dispensing systems. Factors associated with dispensing errors may be communication failures, problems related to package labels, work overload, the physical structure of the working environment, distraction and interruption, the use of incorrect and outdated information sources and the lack of patient knowledge and education about the drugs they use. So called banal dispensing errors reach significant epidemiological levels. The purpose of this paper, which is part of a study on the occurrence of dispensing errors in the pharmacy of a large hospital, is to review the main concepts that guide studies on adverse effects and to provide an update on dispensing errors.

Baixo peso ao nascer em coorte de recém-nascidos em Goiânia-Brasil no ano de 2000

OBJETIVO: analisar o peso ao nascer da coorte de recem-nascidos do ano 2000, em Goiânia, pela determinacao do coeficiente de mortalidade e probabilidade de sobrevivencia neonatal, estratificados por categorias de peso ao nascer e, ainda, pela identificacao dos fatores associados ao baixo peso ao nascer (BPN). METODOS: estudo de coorte retrospectivo, constituido por linkage dos arquivos do SIM (Sistema de Informacoes de Mortalidade) e do SINASC (Sistema de Informacoes de Nascimentos). Foram calculados coeficientes de mortalidade neonatal para as categorias de peso ao nascer e construido um grafico de probabilidades de sobrevivencia neonatal por meio de analise de regressao linear. Foram identificados fatores de risco para o BPN mediante analise univariada (RR) e regressao logistica, considerando-se nivel de significância de 5%. RESULTADOS: a incidencia de BPN foi de 6,9%, sendo que 140 (66,8%) obitos neonatais ocorreram nesse grupo. Trinta por cento dos obitos se deram na categoria de peso entre 1.500-2.500 g. Os fatores identificados como de risco para o BPN foram: prematuridade, presenca de malformacoes congenitas, maes com idade em extremos reprodutivos, residencia na regiao noroeste do municipio, baixo numero de consultas no pre-natal, parto em hospital publico e sexo feminino. CONCLUSAO: a incidencia de BPN foi semelhante aos paises desenvolvidos e os coeficientes de mortalidade neonatal, por categoria de peso, aquem dos encontrados naqueles paises. Os resultados encontrados orientam atencao para: prematuridade, hospitais publicos e regiao noroeste de Goiânia.

Consumo alimentar da população adulta segundo perfil sócio-econômico e demográfico: Projeto Bambuí

A nutritional survey was performed in a random sample of 546 individuals (ages 18 and over) in a city named Bambuí (15,000 inhabitants) in Minas Gerais State, Brazil, using the Semi-Quantitative Food Frequency Questionnaire (SFFQ). Median calorie intakes for women and men were 2,807 and 3,775kcal, respectively. Men consumed four times more alcohol than women, and women consumed more carbohydrates, fiber, and polyunsaturated fatty acids (PUFA). The relative consumption of proteins (15%), carbohydrates (57%), and lipids (28%) were adequate in both genders. The average proportions, for all participants, of an inadequate share of lipids, saturated fatty acids (SFA), PUFA, and cholesterol in the total calorie intake were, respectively, 36%, 90%, and 50%, and were more pronounced in men than in women. The lipid, SFA, and PUFA intake for women and the lipid and SFA intake for men increased with income. The PUFA/SFA ratio and the PUFA and dietary fiber intake were below the recommended levels in both genders. Dietary habits presented a differential inadequacy, suggesting possible population risk clusters for cardiovascular diseases.Foi realizado inquerito nutricional em amostra probabilistica de 546 individuos (idade > 18 anos), residentes na cidade de Bambui (15 mil habitantes), Minas Gerais, Brasil, utilizando-se o Questionario Semiquantitativo de Frequencia Alimentar (QSFA). A mediana de ingestao calorica entre mulheres e homens foi de 2.807 e 3.775kcal, respectivamente. Homens ingeriram quatro vezes mais alcool que mulheres e estas, mais carboidratos, fibras e acidos graxos polinsaturados (AGP). A distribuicao de proteinas (15%), carboidratos (57%) e lipidios (28%) foi adequada. As proporcoes medias de inadequacao da participacao de lipidios, acidos graxos saturados (AGS), AGP e colesterol na energia total foram, respectivamente, 36%, 50% e 90%, sendo mais pronunciadas entre os homens. A ingestao de lipidios, AGS e AGP, entre mulheres, e de lipidios e AGS entre homens, aumentou de acordo com a renda. A ingestao de AGP e fibras e a relacao AGP/AGS estavam abaixo do recomendado nos dois generos. A dieta apresentou proporcoes de inadequacao diferenciais, sugerindo possiveis agregados de risco a saude da populacao para doencas cardiovasculares.