Fernando de Sá Del Fiol

A febre maculosa no Brasil

Embora no Brasil o numero de casos confirmados de febre maculosa esteja em declinio desde 2005, a taxa de mortalidade (20 a 30%) ainda e muito alta quando comparada a outros paises. Esse alto indice de mortalidade tem estreita relacao com a dificuldade em fazer o diagnostico e estabelecer a terapia apropriada. Apenas dois grupos de antibioticos tem comprovada eficacia clinica, o cloranfenicol e as tetraciclinas. Ate pouco tempo atras, as tetraciclinas eram reservadas aos pacientes adultos em virtude das alteracoes dentarias e osseas em criancas. Recentemente, entretanto, a Academia Americana de Pediatria e diversos autores tem recomendado a utilizacao da doxiciclina tambem em criancas. Em casos mais severos, a falta de experiencia com uma tetraciclina injetavel no Brasil faz com que se opte pelo cloranfenicol injetavel. Como o pronto diagnostico e a escolha adequada do farmaco sao fatores determinantes de um prognostico positivo, todos os profissionais da saude devem estar melhor preparados para reconhecer e tratar a febre maculosa.

Perfil de prescrições e uso de antibióticos em infecções comunitárias

INTRODUCTION: The aim of this study was to find out about the patterns of antibiotic use in the municipality of Sorocaba, through evaluating the reported diagnosis and the therapy used. METHODS: An evaluation tool was applied among antibiotic users over a 12-month period. Sociodemographic data and information relating to health, diagnosis and therapeutics were gathered in relation to 403 users. RESULTS: Great present use and the greatest previous use was found in the 0-10 year-old age group (p < 0.05). Infections with lung involvement were the ones most mentioned (p < 0.05) and penicillins were the drugs most used, present in 45.1% of the prescriptions. The mean duration of therapy for otitis (8.9 days) was below the recommendation. For sinusitis, 22% of the prescriptions did not give guidance regarding recommended use (10 days). CONCLUSIONS: The lack and/or nonuse of therapeutic protocols resulted in great differences in prescription patterns, thereby leading to therapeutic failure and recurrence of infections, which were situations frequently found in this study.

Risk Factors for Foot Amputation in Patients Hospitalized for Diabetic Foot Infection.

The aim of this study was to identify and quantify risk factors for amputation in diabetic patients hospitalized for foot infections. This cross-sectional study comprised 100 patients with diabetic infectious complications in the lower limbs. The variables investigated were related to diabetes, infection, and treatment compliance. Multiple Cox regression analysis was performed to identify the variables independently associated with the outcome of amputation. The most prevalent chronic complications were neuropathy and hypertension. Most patients presented with a neuroischemic foot (86%). The Morisky test showed that 72% were not compliant with diabetes treatment. Regarding patient outcome, 61% progressed to amputation, 14% to debridement, and 9% to revascularization. The results showed a 42% higher risk for progression to amputation in patients with previous use of antimicrobials. Also, the amputation risk was 26% higher for those less compliant with diabetes treatment. An increase of one point in the Wagner ulcer classification criteria corresponded to a 65% increase in the risk of amputation. Undergoing conservative, nonsurgical procedures prior to admission provided a 63% reduction in the risk of amputation. Knowledge of these factors is critical to enable multidisciplinary teams to develop treatment plans for these patients so as to prevent the need for amputation.

Vitamin D and respiratory infections

Vitamin D or 1,25-hydroxyvitamin D (1,25(OH)2 D) has a well-established role in calcium homeostasis. In recent years, the discovery of vitamin D-metabolizing enzymes and vitamin D receptor (VDR) in the lungs and various cells of the immune system has led to numerous studies conducted to evaluate its role in respiratory functions and, in particular, upper respiratory tract infections (URTIs). A PubMed literature search was done using vitamin D and respiratory infections as key words. Only clinical studies were considered. This study aimed to review recent clinical and epidemiological studies conducted in adults and children, and to evaluate the functional role of vitamin D in respiratory infections. The evaluated studies show an important immunomodulatory role of vitamin D, which reduces the incidence and risk of URTIs, both in children and in adults. Combating URTIs can be done prophylactically, associating the use of vaccines against Streptococcus pneumoniae with strengthening the immune system through supplementation with vitamin D. These actions can significantly contribute to reducing the number of URTIs, the use of antibiotics, and consequently, the rates of antimicrobial resistance.

Evaluation of the prescription and use of antibiotics in Brazilian children

INTRODUCTION Inappropriate use of antibiotics leads to increased levels of bacterial resistance making it difficult to treat upper respiratory tract infections. The appropriate use of these drugs has a fundamental role in controlling resistance and in success of treatment of childhood infections. Therefore, the aim of this study was to assess the prescription and use of antibiotics for Brazilian children. METHODS The use of antibiotics in 160 children was monitored in two Primary Health Centers by questionnaires administered to parents and caregivers that assessed the social, demographic and clinical conditions of the children. Furthermore, the antibiotic use pattern was ascertained in these children and compared to the recommendations of the Brazilian and international guidelines. RESULTS The use of these drugs had an inverse relationship with children breast-fed to six months of age, showing that breast-fed children had a tendency to use less of these drugs. There was great variability in the amoxicillin doses used for upper respiratory infections ranging from 8.2 to 91.9mg/kg/day. The doses used in most treatments were far below the doses recommended in the Brazilian and international guidelines (50% and 97%, respectively). CONCLUSION Although there are guidelines for the use of these medications, compliance is still very low, leading to under dosage and therapeutic failures. It is essential for pediatricians to be aware of and comply with the guidelines, avoid personal decisions and take measures based on strong clinical evidence. The proper use of these medications, in addition to greater therapeutic success, decreases the possibility of the appearance of resistant microorganisms.

Patient reports of the frequency and severity of adverse reactions associated with biological agents prescribed for psoriasis in Brazil

Background: The safety of biological agents used to treat psoriasis remains uncertain. Objective: The authors determined the frequency and severity of adverse effects associated with use of biologic agents for psoriasis through patient-registered lawsuits to the government of Sao Paulo, Brazil. Methods: Sources of information included legal records, dispensing pharmacy data and interviews with patients. Research staff conducted telephone interviews with patients who used biologic drugs during 2004 – 2011, inquiring about medication-related adverse drug reactions (ADRs) and serious adverse events (SAEs). Results: Of the 218 patients identified, 15 proved ineligible or refused participation. 203 patients were interviewed, with 111 (54.7%) taking infliximab, 43 (21.2%) efalizumab, 35 (17.2%) etanercept and 14 (6.9%) adalimumab. Of 84 (41.4%) patients who experienced one or more ADR related to biological agents, 57 (67.9%) experienced one or more SAE. The only risk factor associated with ADRs was comorbidity odds ratio = 6.54 (95% confident interval [CI] 3.20 – 13.32), p < 0.0001. Conclusion: Biologic agents were associated with high rates of ADRs and SAEs. The data suggests that for patients taking a biologic agent to treat psoriasis and who have one or more comorbidities, warnings of possible adverse events and enhanced surveillance are warranted.

Adherence to guidelines in the use of biological agents to treat psoriasis in Brazil

Objective In São Paolo, Brazil, patients can appeal to the courts, registering law suits against the government claiming the need for biological agents for treatment of psoriasis. If the lawsuits are successful, which is usually the case, the government then pays for the biologic agent. The extent to which the management of such patients, after gaining access to government payment for their biologic agents, adheres to authoritative guidelines, is uncertain. Methods We identified patients through records of the State Health Secretariat of São Paulo from 2004 to 2011. We consulted guidelines from five countries and chose as standards only those recommendations that the guidelines uniformly endorsed. Pharmacy records provided data regarding biological use. Guidelines not only recommended biological agents only in patients with severe psoriasis who had failed to respond to topical and systemic therapies (eg, ciclosporin and methotrexate) but also yearly monitoring of blood counts and liver function. Results Of 218 patients identified in the database, 3 did not meet eligibility criteria and 12 declined participation. Of the 203 patients interviewed, 91 were still using biological medicine; we established adherence to laboratory monitoring in these patients. In the total sample, management failed to meet standards of prior use of topical and systemic medication in 169 (83.2%) patients. Of the 91 patients using biological medicine at the time of the survey, 23 (25.2%) did not undergo appropriate laboratory tests. Conclusions Important discrepancies exist between clinical practice and the recommendations of guidelines in the management of plaintiffs using biological drugs to treat psoriasis.

Paracoccidioidomycosis: evaluation of treatment and patient profile

Paracoccidioidomycosis (PCM) is a fungal disease, chronic and endemic, especially in Latin America.1 Aiming to acquire more information about the effectiveness of the treatment employed, this study aimed to describe the profiles of patients with paracoccidioidomycosis and compare treatments used in patients with PCM cared for at the Clinic of Tropical Medicine of the “Conjunto Hospitalar de Sorocaba” (CHS) regarding efficacy, safety and adherence to treatment. The present study evaluated treatment used and the profile of 45 patients with PCM diagnosis. We conducted a retrospective, epidemiological, quantitative, cross-sectional and observational study through analysis of data from medical records of 45 patients diagnosed with PCM. We found a patient profile very similar to that described in the literature, i.e., adult men (77.7%), aging 51.5 years.2 Regarding occupational activity, as in other studies, patients were mostly farmers (57.7%) or civil construction workers (11.1%).2 Three treatments evaluated were: trimoxazole {1600 + 800 mg/day} (SXT), amphotericin B {1 mg/kg/day} followed by trimoxazole for maintenance {1600 + 800 mg/day} (SXT + ANPH), and itraconazole {200 mg/day} (ITZ). To compare the treatments efficacy, each drug regimen was associated with clinical improvement (in days) defined as the absence of signs and symptoms and overall treatment time (in months) defined as a negative serology. The mean time to clinical improvement showed no difference between the three tested treatments (p = 0.714). Table 1 shows the results. Regarding the overall treatment time, the group treated with SXT finished treatment with medical discharge in 15.2 months. For the ANPH + SXT group, mean time was 13.3

Biological drugs for the treatment of psoriasis in a public health system

OBJECTIVE To analyze the access and utilization profile of biological medications for psoriasis provided by the judicial system in Brazil. METHODS This is a cross-sectional study. We interviewed a total of 203 patients with psoriasis who were on biological medications obtained by the judicial system of the State of Sao Paulo, from 2004 to 2010. Sociodemographics, medical, and political-administrative characteristics were complemented with data obtained from dispensation orders that included biological medications to treat psoriasis and the legal actions involved. The data was analyzed using an electronic data base and shown as simple variable frequencies. The prescriptions contained in the lawsuits were analyzed according to legal provisions. RESULTS A total of 190 lawsuits requesting several biological drugs (adalimumab, efalizumab, etanercept, and infliximab) were analyzed. Patients obtained these medications as a result of injunctions (59.5%) or without having ever demanded biological medication from any health institution (86.2%), i.e., public or private health services. They used the prerogative of free legal aid (72.6%), even though they were represented by private lawyers (91.1%) and treated in private facilities (69.5%). Most of the patients used a biological medication for more than 13 months (66.0%), and some patients were undergoing treatment with this medication when interviewed (44.9%). Approximately one third of the patients discontinued treatment due to worsening of their illness (26.6%), adverse drug reactions (20.5%), lack of efficacy, or because the doctor discontinued this medication (13.8%). None of the analyzed medical prescriptions matched the legal prescribing requirements. Clinical monitoring results showed that 70.3% of the patients had not undergone laboratory examinations (blood work, liver and kidney function tests) for treatment control purposes. CONCLUSIONS The plaintiffs resorted to legal action to get access to biological medications because they were either unaware or had difficulty in accessing them through institutional public health system procedures. Access by means of legal action facilitated long-term use of this type of medication through irregular prescriptions and led to a high rate of adverse drug reactions as well as inappropriate clinical monitoring.

Prescrição de benzodiazepínicos para adultos e idosos de um ambulatório de saúde mental

The aim of this study was to compare benzodiazepine (bzd) prescriptions for adults and older adults regarding appropriate use indicator. It is a cross-sectional study for collecting data on patients treated at the Citys Mental Health Clinic in Sorocaba/SP, between March and December 2013. Appropriate use indicators were used: appropriate drug, with adequate posology and period of use; as well as the use of a single bzd, as anxiolytic for less than 3 months in depression treatment with antidepressants, use for less than 2 months if associated to an antidepressant and no use of long-acting bzd in older adults. From the 330 participants, most were women, with a family history of mental disorders and bzd use, without monitoring of a psychologist and using other psychotropic and polypharmacy (p>0.05).The minority of prescriptions had indication for the use of bzd (37.5% for older adults and 32.4% for adults) (p>0.05). Only 5.8% of the prescriptions for older adults and 1.9 for adults were rational (p>0.05). The chronic use was observed in all adults and older adults with depressive and anxiety disorders (p>0.05). A minority of prescriptions for adults and older adults was appropriate.The aim of this study was to compare benzodiazepine (bzd) prescriptions for adults and older adults regarding appropriate use indicator. It is a cross-sectional study for collecting data on patients treated at the City’s Mental Health Clinic in Sorocaba/SP, between March and December 2013. Appropriate use indicators were used: appropriate drug, with adequate posology and period of use; as well as the use of a single bzd, as anxiolytic for less than 3 months in depression treatment with antidepressants, use for less than 2 months if associated to an antidepressant and no use of long-acting bzd in older adults. From the 330 participants, most were women, with a family history of mental disorders and bzd use, without monitoring of a psychologist and using other psychotropic and polypharmacy (p>0.05).The minority of prescriptions had indication for the use of bzd (37.5% for older adults and 32.4% for adults) (p>0.05). Only 5.8% of the prescriptions for older adults and 1.9 for adults were rational (p>0.05). The chronic use was observed in all adults and older adults with depressive and anxiety disorders (p>0.05). A minority of prescriptions for adults and older adults was appropriate.