Djenane Ramalho de Oliveira

Characterization of a new angiotensin antagonist selective for angiotensin-(1–7): Evidence that the actions of angiotensin-(1–7) are mediated by specific angiotensin receptors

In this study we describe a new angiotensin antagonist [Asp1-Arg2-Val3-Tyr4-Ile5-His6-D-Ala7, (A-779)] selective for the heptapeptide angiotensin-(1-7) [Ang-(1-7)]. A-779 blocked the antidiuretic effect of Ang-(1-7) in water-loaded rats and the changes in blood pressure produced by Ang-(1-7) microinjection into the dorsal-medial and ventrolateral medulla. In contrast, A-779 did not change the dipsogenic, pressor, or myotropic effects of angiotensin II (Ang II). Also, A-779 did not affect the antidiuretic effect of vasopressin or the contractile effects of angiotensin III, bradykinin, or substance P on the rat ileum. In the rostral ventrolateral medulla, the pressor effect produced by Ang-(1-7) microinjection was completely blocked by A-779 but not by AT1 or AT2 receptor antagonists (DUP 753 and CGP 42112A, respectively). Conversely, the pressor effect produced by Ang II was not changed by A-779 but was completely blocked by DUP 753. Binding studies substantiated these observations: A-779 did not compete significantly for 125I-Ang II binding to adrenocortical membranes at up to a 1 microM concentration. Low affinity binding was also observed in adrenomedullary membranes with an IC50 greater than 10 microM. Our results show that A-779 is a potent and selective antagonist for Ang-(1-7). More importantly, our data indicate that specific angiotensin receptors mediate the central and peripheral actions of Ang-(1-7).

Changes in the Baroreflex Control of Heart Rate Produced by Central Infusion of Selective Angiotensin Antagonists in Hypertensive Rats

We have recently shown that an angiotensin-(1-7) [Ang-(I-7)] analogue, D-Ala7-Ang-(1-7) (A-779), is a selective Ang-(1-7) antagonist with no significant action on angiotensin type 1 or type 2 receptors. The availability of selective angiotensin antagonists prompted us to evaluate the role of Ang-(1-7) and Ang II on central modulation of the baroreflex control of heart rate in normotensive Wistar rats and spontaneously hypertensive rats (SHR). Blood pressure recording and reflex changes in heart rate elicited by intravenous bolus injections of phenylephrine were made before and within 1 and 3 hours of intracerebroventricular (ICV, lateral ventricle) infusion of saline (8 microL/h), A-779 (4 microg/h), DuP 753 (100 microg/h), or CGP 42112A (50 mu g/h) in conscious rats. The slope of the relationship between changes in pulse interval versus changes in mean arterial pressure was used as an index of the baroreflex control of heart rate. ICV infusion of saline or any of the antagonists did not significantly change basal levels of mean arterial pressure and heart rate in SHR (170 +/- 6 mm Hg nd 360 +/- 9 beats per minute, respectively; n = 29) or Wistar rats (108 +/- 2 mm Hg and 377 +/- 6 beats per minute, respectively; n=29). Three hours of ICV infusion of A-779 markedly decreased baroreflex sensitivity in Wistar rats (from a basal slope of 1.09 +/- O.3). In contrast, A-779 did not significantly alter the depressed baroreflex sensitivity of SHR (0.61 +/- O.l). ICV infusion of DuP 753 produced a significant increase (60 percent) in baroreflex control of heart rate in both Wistar rats and SHR. Saline or CGP 42112A infusions did not significantly alter baroreflex control of heart rate. These results suggest that endogenous Ang II and Ang-(1-7) are differentially affecting central baroreflex modulation, acting probably through distinct receptor subtypes. Although the central Ang II inhibitory effect is mediated by the type 1 receptor subtype, the facilitatory effect of Ang-(1-7) might be mediated by a different, unidentified receptor.

Understanding the meaning of medications for patients: The medication experience

Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers. The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care. The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis. The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience. The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control. The medication experience is an individual’s subjective experience of taking a medication in his daily life. It begins as an encounter with a medication. It is an encounter that is given meaning before it occurs. The experience may include positive or negative bodily effects. The unremitting nature of a chronic medication often causes an individual to question the need for the medication. Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs.

Factors that lessen the burden of treatment in complex patients with chronic conditions: a qualitative study

Purpose Patients with multiple chronic conditions (multimorbidity) often require ongoing treatment and complex self-care. This workload and its impact on patient functioning and well-being are, together, known as treatment burden. This study reports on factors that patients with multimorbidity draw on to lessen perceptions of treatment burden. Patients and methods Interviews (n=50) and focus groups (n=4 groups, five to eight participants per group) were conducted with patients receiving care in a large academic medical center or an urban safety-net hospital. Interview data were analyzed using qualitative framework analysis methods, and themes and subthemes were used to identify factors that mitigate burden. Focus groups were held to confirm these findings and clarify any new issues. This study was part of a larger program to develop a patient-reported measure of treatment burden. Results Five major themes emerged from the interview data. These included: 1) problem-focused strategies, like routinizing self-care, enlisting support of others, planning for the future, and using technology; 2) emotion-focused coping strategies, like maintaining a positive attitude, focusing on other life priorities, and spirituality/faith; 3) questioning the notion of treatment burden as a function of adapting to self-care and comparing oneself to others; 4) social support (informational, tangible, and emotional assistance); and 5) positive aspects of health care, like coordination of care and beneficial relationships with providers. Additional subthemes arising from focus groups included preserving autonomy/independence and being proactive with providers. Conclusion Patients attempt to lessen the experience of treatment burden using a variety of personal, social, and health care resources. Assessing these factors in tandem with patient perceptions of treatment burden can provide a more complete picture of how patients fit complex self-care into their daily lives.

Finalizing a measurement framework for the burden of treatment in complex patients with chronic conditions

Purpose The workload of health care and its impact on patient functioning and well-being is known as treatment burden. The purpose of this study was to finalize a conceptual framework of treatment burden that will be used to inform a new patient-reported measure of this construct. Patients and methods Semi-structured interviews were conducted with 50 chronically ill patients from a large academic medical center (n=32) and an urban safety-net hospital (n=18). We coded themes identifying treatment burden, with the themes harmonized through discussion between multiple coders. Four focus groups, each with five to eight participants with chronic illness, were subsequently held to confirm the thematic structure that emerged from the interviews. Results Most interviewed patients (98%) were coping with multiple chronic conditions. A preliminary conceptual framework using data from the first 32 interviews was evaluated and was modified using narrative data from 18 additional interviews with a racially and socioeconomically diverse sample of patients. The final framework features three overarching themes with associated subthemes. These themes included: 1) work patients must do to care for their health (eg, taking medications, keeping medical appointments, monitoring health); 2) challenges/stressors that exacerbate perceived burden (eg, financial, interpersonal, provider obstacles); and 3) impacts of burden (eg, role limitations, mental exhaustion). All themes and subthemes were subsequently confirmed in focus groups. Conclusion The final conceptual framework can be used as a foundation for building a patient self-report measure to systematically study treatment burden for research and analytical purposes, as well as to promote meaningful clinic-based dialogue between patients and providers about the challenges inherent in maintaining complex self-management of health.

A qualitative glimpse at pharmaceutical care practice

This manuscript presents an argument for a broader use of qualitative methodologies to investigate the practice and the surroundings of pharmaceutical care. Albeit the use of qualitative research methods is growing in the health care field, it is still insufficient in the area of pharmaceutical care. Pharmaceutical care, as a patient-centered practice, calls for a more comprehensive and humanistic approach to research. It is our contention that the attempt to understand pharmaceutical care practice from the perspective of patients, pharmacists and other health care professionals, by means of using qualitative methods, would notably contribute to a better assessment of the value of pharmaceutical care programs in the health care system. Moreover, because a deeper understanding of the nuances of this practice can be achieved with the use of qualitative methods, this approach might also assist us in making the necessary changes to create more effective pharmaceutical care practices.This manuscript presents an argument for a broader use of qualitative methodologies to investigate the practice and the surroundings of pharmaceutical care. Albeit the use of qualitative research methods is growing in the health care field, it is still insufficient in the area of pharmaceutical care. Pharmaceutical care, as a patient-centered practice, calls for a more comprehensive and humanistic approach to research. It is our contention that the attempt to understand pharmaceutical care practice from the perspective of patients, pharmacists and other health care professionals, by means of using qualitative methods, would notably contribute to a better assessment of the value of pharmaceutical care programs in the health care system. Moreover, because a deeper understanding of the nuances of this practice can be achieved with the use of qualitative methods, this approach might also assist us in making the necessary changes to create more effective pharmaceutical care practices.

La investigación cualitativa en Farmacia: aplicación en la Atención Farmacéutica

Se presenta desde una perspectiva teorica, el estado del arte de la metodologia de investigacion cualitativa en el campo de las Ciencias Farmaceuticas, haciendo especial enfasis en el area de la Atencion Farmaceutica. Se exponen los presupuestos teoricos e investigaciones cualitativas mas importantes realizadas en el ambito de las ciencias de la salud y en el sector asistencial farmaceutico internacional. A partir de la informacion expuesta, se considera que a pesar de que, la utilizacion de los metodos de investigacion cualitativa se ha desarrollado considerablemente en el ambito sanitario, su aplicacion en el campo de la Farmacia Asistencial y de la Atencion Farmaceutica, aun es insuficiente, lo que trasciende a Latinoamerica, donde el ejercicio de esta nueva filosofia de practica profesional no constituye actualmente una actividad globalmente establecida. La evaluacion desde una perspectiva social del status de la profesion farmaceutica, a partir de la percepcion de pacientes, farmaceuticos y otros profesionales sanitarios, asi como la profundizacion desde el punto de vista cualitativo, de las principales barreras que limitan la generalizacion de la Atencion Farmaceutica, pudieran contribuir fuertemente al mejoramiento de la actual actividad farmaceutica clinica, por un uso mas racional de los medicamentos y calidad de vida superior en los pacientes.

Development and validation of a logic model for comprehensive medication management services

To develop and validate a theoretical logic model for comprehensive medication management (CMM) services.

Competencies for the provision of comprehensive medication management services in an experiential learning project

Objective To understand students’ and tutors’ perceptions of the development of clinical competencies for the delivery of comprehensive medication management services in an experiential learning project linked to a Brazilian school of pharmacy. Methods An autoethnographic qualitative study was carried out based on participant observation, focus groups and individual interviews with students and tutors involved in an experiential learning project. Results The study revealed the development of competencies related to the philosophy of practice, the pharmacotherapy workup of drug therapy and interprofessional relationships. Conclusions The experiential learning project contributed to the professional development of pharmacy students in pharmaceutical care practice, pointing to its potential benefits for incorporation into professional pharmacy curricula.