Cristina Rolim Neumann

Teste de Morisky-Green e Brief Medication Questionnaire para avaliar adesão a medicamentos

OBJECTIVE To analyze the reliability and performance of the Portuguese version of questionnaires used to evaluate adherence to hypertensive treatment. METHODS Hypertensive patients attending a primary healthcare unit in Porto Alegre, Southern Brazil, from January to September 2010, were randomly selected (n = 206). To evaluate adherence, Portuguese versions of the Morisky-Green test (MGT) and the Brief Medication Questionnaire (BMQ) were used. The analysis considered internal consistency, temporal stability and performance compared to three gold standards, which are: inadequate control of blood pressure (BP > 140/90 mmHg); insufficient rate of medication acquisition at the institutions pharmacy (<80%) and a combination of both factors. RESULTS Of the patients studied, 97 only used medications dispensed by the Basic Health Unit. The tests showed good internal consistency by Cronbachs α: BMQ 0.66 (95%CI 0.60 to 0.73) and the MGT 0.73 (95%CI 0.67 to 0.79). The BMQ Regimen Screen had a sensitivity of 77%, specificity of 58%, and an area under the ROC curve of 0.70 (95%CI 0.55 to 0.86); for MGT sensitivity was 61%, specificity 36% and area under the ROC curve 0.46 (95%CI 0.30 to 0.62). The correlation between the BMQ and the MGT was r=0.28, p> 0.001. Low adherence per the BMQ is associated with higher blood pressure levels when compared to adherent patients (148.4 [SD 20.1] vs 128.8 [SD 17.8]; p <0.001), but not for the MGT. CONCLUSIONS The BMQ showed better performance than the MGT, with greater sensitivity and specificity. Evaluation of adherence may help clinicians discriminate between inadequate use of medication and insufficient treatment regimen.OBJETIVO: Analizar la confiabilidad y el desempeno de la version en portugues de instrumentos de evaluacion de la adherencia al tratamiento antihipertensivo. METODOS: Pacientes hipertensos atendidos de enero a septiembre de 2010 en una unidad de atencion primaria en Porto Alegre, Sur de Brasil, fueron seleccionados aleatoriamente (n=206). En la evaluacion de la adherencia fueron utilizadas versiones en portugues de la Prueba de Morisky-Green (TMG) y del Brief Medication Questionnarie (BMQ). Se analizaron consistencia interna, estabilidad temporal y desempeno con relacion a tres patrones-oro: control inadecuado de la presion arterial (> 140/90 mmHg); tasa insuficiente de retirada de medicacion en la farmacia de la Unidad Basica de Salud ( 0,001. La baja adherencia al BMQ esta asociada a mayores niveles tensionales al compararlo con pacientes adherentes 148,4 [de 0,1] vs 128,8 [de 17,8], p<0,001), pero no para el TMG. CONCLUSIONES: El BMQ presento mejor desempeno que el TMG, con mayor sensibilidad y especificidad. La evaluacion de la adherencia puede auxiliar al clinico en la discriminacion entre el uso inadecuado de la medicacion y esquema terapeutico insuficiente.

Nocturnal oxygen desaturation in diabetic patients with severe autonomic neuropathy

The aim of the study was to assess whether diabetic patients with autonomic neuropathy suffer from arterial oxygen desaturation during sleep. Two groups of subjects were evaluated: group I consisted of 12 patients with cardiovascular autonomic neuropathy (five with insulin-dependent diabetes mellitus (IDDM) and seven with non-insulin-dependent diabetes mellitus (NIDDM)). Group II consisted of 8 healthy subjects. Age, percentage male and body mass index (BMI) were similar in both groups. Exclusion criteria were abnormalities in arterial gas measurements, chest X-ray, spirometry or the presence of cardiac arrhythmias, obesity, uremia, alcohol abuse and use of drugs other than insulin and oral hypoglicemic agents. The results of arterial oximetry when the subjects were awake showed no differences between the two groups. However, during sleep, diabetics with autonomic neuropathy had an increased number of desaturation episodes under 85% and those episodes were more prolonged. The results suggest that diabetics with autonomic neuropathy might have abnormal control of respiration that is apparent only during sleep.

The Brief Medication Questionnaire and Morisky-Green Test to evaluate medication adherence

OBJECTIVE To analyze the reliability and performance of the Portuguese version of questionnaires used to evaluate adherence to hypertensive treatment. METHODS Hypertensive patients attending a primary healthcare unit in Porto Alegre, Southern Brazil, from January to September 2010, were randomly selected (n = 206). To evaluate adherence, Portuguese versions of the Morisky-Green test (MGT) and the Brief Medication Questionnaire (BMQ) were used. The analysis considered internal consistency, temporal stability and performance compared to three gold standards, which are: inadequate control of blood pressure (BP > 140/90 mmHg); insufficient rate of medication acquisition at the institutions pharmacy (<80%) and a combination of both factors. RESULTS Of the patients studied, 97 only used medications dispensed by the Basic Health Unit. The tests showed good internal consistency by Cronbachs α: BMQ 0.66 (95%CI 0.60 to 0.73) and the MGT 0.73 (95%CI 0.67 to 0.79). The BMQ Regimen Screen had a sensitivity of 77%, specificity of 58%, and an area under the ROC curve of 0.70 (95%CI 0.55 to 0.86); for MGT sensitivity was 61%, specificity 36% and area under the ROC curve 0.46 (95%CI 0.30 to 0.62). The correlation between the BMQ and the MGT was r=0.28, p> 0.001. Low adherence per the BMQ is associated with higher blood pressure levels when compared to adherent patients (148.4 [SD 20.1] vs 128.8 [SD 17.8]; p <0.001), but not for the MGT. CONCLUSIONS The BMQ showed better performance than the MGT, with greater sensitivity and specificity. Evaluation of adherence may help clinicians discriminate between inadequate use of medication and insufficient treatment regimen.OBJETIVO: Analizar la confiabilidad y el desempeno de la version en portugues de instrumentos de evaluacion de la adherencia al tratamiento antihipertensivo. METODOS: Pacientes hipertensos atendidos de enero a septiembre de 2010 en una unidad de atencion primaria en Porto Alegre, Sur de Brasil, fueron seleccionados aleatoriamente (n=206). En la evaluacion de la adherencia fueron utilizadas versiones en portugues de la Prueba de Morisky-Green (TMG) y del Brief Medication Questionnarie (BMQ). Se analizaron consistencia interna, estabilidad temporal y desempeno con relacion a tres patrones-oro: control inadecuado de la presion arterial (> 140/90 mmHg); tasa insuficiente de retirada de medicacion en la farmacia de la Unidad Basica de Salud ( 0,001. La baja adherencia al BMQ esta asociada a mayores niveles tensionales al compararlo con pacientes adherentes 148,4 [de 0,1] vs 128,8 [de 17,8], p<0,001), pero no para el TMG. CONCLUSIONES: El BMQ presento mejor desempeno que el TMG, con mayor sensibilidad y especificidad. La evaluacion de la adherencia puede auxiliar al clinico en la discriminacion entre el uso inadecuado de la medicacion y esquema terapeutico insuficiente.

Impacto de um programa mínimo de exercícios físicos supervisionados no risco cardiometabólico de pacientes com obesidade mórbida

OBJECTIVE: The objective aims at evaluating the impact of a minimum program of supervised physical exercise on functional capacity and cardiometabolic risk (CMR) in patients with morbid obesity. MATERIAL AND METHODS: By studying cases with pre and post analyses, we have assessed the variations in weight, functional capacity and in CMR, due to the program of supervised aerobic exercise on a weekly intensity of 30 minutes during a period of 6 months. RESULTS: We have studied 61 subjects, where 34 have only adhered to the intervention. There were significant changes in weight (-5.3 ± 5.3 kg, p < 0.0001), distance in the 6-minute walking test (69.8 ± 48.6 m, p < 0.0001), systolic pressure (-23.8 ± 27.7 mmHg, p < 0.0001), diastolic pressure (-14.4 ± 8.9 mmHg, p < 0.0001) and Framingham Score Risk (-4.4 ± 5.1, p < 0.0001) in the adherent patients. CONCLUSION: The results show that a supervised exercise program of low intensity and frequency might interfere positively on CMR in individuals with morbid obesity.

Proliferative diabetic retinopathy is related to cardiovascular autonomic neuropathy in non-insulin-dependent diabetes mellitus

The aim of the study was to define the relationship between the presence of proliferative diabetic retinopathy and nephropathy with objectively defined autonomic neuropathy in non-insulin-dependent diabetes mellitus (NIDDM) patients. The research design used was a cross-sectional, case control study. A cohort of NIDDM patients was classified, according to five cardiovascular autonomic tests described by Ewing, as: (1) no involvement--no abnormal tests (n = 17); (2) cardiovascular autonomic neuropathy--two out of five abnormal tests (n = 18). Age, age at diagnosis, plasma creatinine, fasting plasma glucose, glycated haemoglobin and blood pressure measurements were not statistically different among the two groups. According to indirect ophthalmoscopy and the presence of macroproteinuria and microalbuminuria, respectively, patients were also classified as having proliferative, non-proliferative or no retinopathy and with or without nephropathy. The results showed a striking relationship between cardiovascular autonomic neuropathy and proliferative diabetic retinopathy. Relative odds for nephropathy, non-proliferative diabetic retinopathy and proliferative retinopathy were, respectively, 16.0, 10.1 and 34.7. When odds ratios were adjusted for the presence of nephropathy, hypertension, non-proliferative and proliferative retinopathy, only proliferative retinopathy was significantly associated (odds ratio, 7.1). It was concluded that in NIDDM the presence of cardiovascular autonomic neuropathy is strongly associated with proliferative retinopathy. Long-term prospective studies on large cohorts of patients must be done to evaluate if having autonomic dysfunction would be a risk factor or a risk indicator of an etiologic process underlying the development of proliferative retinopathy.

Severe Autonomic Neuropathy: How Many Symptoms?

Although references to symptomatic autonomic neuropathy (AN) are often found in the literature (1), the degrees of AN at which specific symptoms related to objective measures of autonomic dysfunction are found are not well defined. Most symptoms usually attributed to AN are not specific to this condition, and although cardiovascular tests that can objectively define the presence of autonomic dysfunction in patients with diabetes have been described in several studies, the relationship of the symptoms to the degree of cardiovascular autonomic neuropathy (CAN) is rarely presented. Further, the questions patients were asked were unrelated and probably not the same.

Intentional injuries and patient survival of burns: a 10-year retrospective cohort in southern Brazil

BACKGROUND Patients burned intentionally experience extensive injuries with high rates of morbidity and mortality. Nonetheless, there is no consensus if these patients have worse outcomes than unintentional burns considering injury severity and other preexistent comorbidities. METHODS We conducted a ten-year retrospective review on all patients treated at the Burn Unit of Hospital de Pronto Socorro, Porto Alegre, Brazil, between 2003 and 2012. The aim was to compare survival of self-inflicted burns and burns from assaults with unintentional injuries using a Multivariable Cox Regression Analysis. RESULTS 1734 patients were included in the study, 87.7% non-intentional, 6.6% self-inflicted and 5.8% from aggression. Intentional injuries resulted in more severe injuries and were associated with psychiatric disorders and drug abuse. After controlling for injury severity, previous clinical comorbidities and previous psychiatric disorders, only self-inflicted burns correlated significantly with a higher risk of death (HR=1.59, CI 95% 1.05-2.41, p=0.03). CONCLUSIONS Self-inflicted injuries were independently associated with a higher risk of death. Burns from aggression were not associated with higher mortality in this model. Prevention of these injuries must be priority and treating the main associated factors such as drug abuse and psychiatric disorders may lower its occurrence.

Diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care

Introduction We must study alternatives to structure an effective diabetic retinopathy screening program for Brazilian public health system. Objectives Evaluate the diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care, accuracy of the family physician in diabetic retinopathy identification compared to the ophthalmologist, and the need for dilation. Methodology In a primary care service were performed retinal photographs with non-mydriatic Retinal Camera in 219 type 2 diabetic patients with and without medication mydriasis. We evaluated the performance of the diagnostic of the photos graded by three family physicians with training compared to two ophthalmologists (gold standard), and explore related factors with the need for mydriasis pharmacologically. Results The prevalence of diabetic retinopathy and proliferative diabetic retinopathy was 19.2% and 1.5%, respectively. The sensitivity of family physicians to evaluate diabetic retinopathy averaged 82.9% (66.7-94.8%); specificity, 92% (90.2-93.3%); the accuracy, 90.3% (88.2-93%) and positive predictive value, 71.2% (68-75.5%). The agreement calculated using the kappa adjusted coefficient was from 0.74 to 0.8 for retinopathy and 0.88 to 0.92 for macular edema. Without drug mydriasis the photos were unreadable by 14.8%, when using mydriatic collyrium this number decreased to 8.7% (McNemar test, P < 0.005). Patients with more than 65 years old has more readability after drug mydriasis (McNemar test, P = 0.011). Conclusion Trained family physician reached a good performance for evaluation of retinography for diabetic retinopathy. There was improvement in readability with pupil dilation in older patients.

Diabetes education in primary care: a randomized clinical trial

O objetivo deste estudo foi avaliar o efeito de um programa de educacao estruturado em grupo, aplicado por enfermeira de cuidados primarios a pacientes com diabetes mellitus tipo 2. A amostra contou com 137 pacientes com diabetes mellitus tipo 2, randomizados em dois grupos: intervencao, (curso educativo de cinco semanas e reforcos a cada 4 meses, durante um ano) e grupo controle (sem educacao estruturada) com avaliacao do controle metabolico, peso, pressao arterial, escores de estresse e conhecimento relacionados ao diabetes. Nao houve diferencas entre os grupos na HbA1c em 4, 8 ou 12 meses, quando comparado aos valores basais. Foi observado um incremento na HbA1c no grupo controle apos ajustes para HbA1c no basal e dose de insulina (p = 0,044 entre grupos). Os escores de conhecimento e estresse relacionados ao diabetes melhoraram apos a intervencao. Um programa educacional estruturado ministrado a pacientes com diabetes mellitus tipo 2 atendidos em atencao primaria melhorou o conhecimento e estresse associados a doenca. Alem disso, nossos resultados sugerem uma prevencao de elevacao da HbA1c.The aim of the study was to evaluate the effect of a structured group education program administered by a primary care nurse in patients with type 2 diabetes mellitus. The sample included 137 patients with type 2 diabetes mellitus, randomized into two groups: intervention (5-week educational course and reinforcements every 4 months for one year) and control (with no structured diabetes mellitus education) with an evaluation of metabolic control, weight, blood pressure, distress scores, and knowledge on diabetes. There were no differences between the two groups in HbA1c at 4, 8, or 12 months when compared to baseline values. An increase in HbA1c was observed in the control group after adjusting for baseline HbA1c and insulin dose (p = 0.044 between groups). Knowledge scores and diabetes-related distress improved after the intervention. A structured educational program administered to type 2 diabetes mellitus patients seen at a primary care unit improved the knowledge and distress associated with the disease. The results also suggest the prevention of an increase in HbA1c.

Educação em diabetes na atenção primária: um ensaio clínico randomizado

O objetivo deste estudo foi avaliar o efeito de um programa de educacao estruturado em grupo, aplicado por enfermeira de cuidados primarios a pacientes com diabetes mellitus tipo 2. A amostra contou com 137 pacientes com diabetes mellitus tipo 2, randomizados em dois grupos: intervencao, (curso educativo de cinco semanas e reforcos a cada 4 meses, durante um ano) e grupo controle (sem educacao estruturada) com avaliacao do controle metabolico, peso, pressao arterial, escores de estresse e conhecimento relacionados ao diabetes. Nao houve diferencas entre os grupos na HbA1c em 4, 8 ou 12 meses, quando comparado aos valores basais. Foi observado um incremento na HbA1c no grupo controle apos ajustes para HbA1c no basal e dose de insulina (p = 0,044 entre grupos). Os escores de conhecimento e estresse relacionados ao diabetes melhoraram apos a intervencao. Um programa educacional estruturado ministrado a pacientes com diabetes mellitus tipo 2 atendidos em atencao primaria melhorou o conhecimento e estresse associados a doenca. Alem disso, nossos resultados sugerem uma prevencao de elevacao da HbA1c.The aim of the study was to evaluate the effect of a structured group education program administered by a primary care nurse in patients with type 2 diabetes mellitus. The sample included 137 patients with type 2 diabetes mellitus, randomized into two groups: intervention (5-week educational course and reinforcements every 4 months for one year) and control (with no structured diabetes mellitus education) with an evaluation of metabolic control, weight, blood pressure, distress scores, and knowledge on diabetes. There were no differences between the two groups in HbA1c at 4, 8, or 12 months when compared to baseline values. An increase in HbA1c was observed in the control group after adjusting for baseline HbA1c and insulin dose (p = 0.044 between groups). Knowledge scores and diabetes-related distress improved after the intervention. A structured educational program administered to type 2 diabetes mellitus patients seen at a primary care unit improved the knowledge and distress associated with the disease. The results also suggest the prevention of an increase in HbA1c.