Maria Auxiliadora Parreiras Martins

Atrial fibrillation in women: treatment

Sex-specific differences in the epidemiology, pathophysiology, presentation, prognosis, and treatment of atrial fibrillation (AF) are increasingly recognized. Women with AF generally experience worse symptoms, poorer quality of life, and have higher risk of stroke and death than men with AF. Effective treatment of the arrhythmia in women is critical to reduce the rate of adverse events. We review the current evidence on sex-specific differences in the utilization and outcomes of treatments for AF, including rate-control and rhythm-control strategies, and stroke-prevention therapy. In addition, we provide a critical evaluation of potential disparities and biases in health-care use that might be associated with differences in the outcomes between women and men. We underscore current knowledge gaps that need to be addressed in future studies to improve the management of AF in women. In particular, we suggest several strategies to produce high-quality evidence from randomized clinical trials for women with AF.

Review on mechanisms and interactions in concomitant use of herbs and warfarin therapy.

The effectiveness of warfarin, an oral anticoagulant originally derived from a plant, is strongly affected by patients characteristics such as the age, presence of comorbidities, and concomitant use of another drug. Warfarin has the potential to interact with many drugs, medicinal plants, and food, which increases the risk of adverse events. A critical analysis of scientific literature was conducted to assess the interferences of medicinal plants with blood haemostasis and then with warfarin anticoagulation. We found 58 different plants that may alter the blood haemostasis and anticoagulation with warfarin. The herbs that showed the greatest potential to interact with warfarin include garlic, ginger, ginkgo, St. Johns wort, and ginseng, i.e. plants normally consumed as food and also used for therapeutic purposes. The interactions between drugs and herbs are varied because of the complex chemical matrix of plants. Mainly coumarins, quinones, xanthones, terpenes, lignans, and vitamin K showed significant influence on warfarin treatment. In general, these plants can potentiate the effect of warfarin by stimulating anticoagulation in multiple ways, and the clinical outcome associated with this interaction is the increase of bleeding risk. Moreover, potential interactions between herbal products and drugs are a safety concern, especially for drugs with a narrow therapeutic index or for patients receiving drug treatment for chronic diseases, and both of these apply to warfarin pharmacotherapy. Therefore, this review article summarises the data on the influence of medicinal plants on warfarin treatment and analyses this information in view of the interaction targets. The relevant plants were categorised according to their target, and their effects are discussed in order to organise the isolated information and to highlight the need of further discussion and new studies on the safety of herbal medicines and warfarin.

Drug-Induced Nephrotoxicity and Dose Adjustment Recommendations: Agreement Among Four Drug Information Sources.

Hospitalized patients require the use of a variety of drugs, many of which individually or in combination have the potential to cause kidney damage. The use of potentially nephrotoxic drugs is often unavoidable, and the need for dose adjustment should be evaluated. This study is aimed at assessing concordance in information on drug-induced nephrotoxicity and dose adjustment recommendations by comparing four drug information sources (DRUGDEX®, UpToDate®, Medscape® and the Brazilian Therapeutic Formulary) using the formulary of a Brazilian public hospital. A total of 218 drugs were investigated. The global Fleiss’ kappa coefficient was 0.265 for nephrotoxicity (p < 0.001; CI 95%, 0.211–0.319) and 0.346 for recommendations (p < 0.001; CI 95%, 0.292–0.401), indicating fair concordance among the sources. Anti-infectives and anti-hypertensives were the main drugs cited as nephrotoxic by the different sources. There were no clear definitions for qualitative data or quantitative values for dose adjustments among the four information sources. There was no advice for dosing for a large number of the drugs in the international databases. The National Therapeutic Formulary offered imprecise dose adjustment recommendations for many nephrotoxic drugs. Discrepancies among information sources may have a clinical impact on patient care and contribute to drug-related morbidity and mortality.

Health Literacy and Atrial Fibrillation: Relevance and Future Directions for Patient-centred Care

Atrial fibrillation (AF) is a common cardiac arrhythmia with significant clinical outcomes, and is associated with high medical and social costs. AF is complicated for patients because of its specialised terminology, long-term adherence, symptom monitoring, referral to specialty care, array of potential interventions and potential for adversity. Health literacy is a frequently under-recognised, yet fundamental, component towards successful care in AF. Health literacy is defined as the capacity to obtain, process and understand health information, and has had markedly limited study in AF. However, health literacy could contribute to how patients interpret symptoms, navigate care, and participate in treatment evaluation and decision-making. This review aims to summarise the clinical importance and essential relevance of health literacy in AF. We focus here on central aspects of AF care that are most related to self-care, including understanding the symptoms of AF, shared decision-making, adherence and anticoagulation for stroke prevention. We discuss opportunities to enhance AF care based on findings from the literature on health literacy, and identify important gaps. Our overall objective is to articulate the importance and relevance of integrating health literacy in the care of individuals with AF.

Fatores Associados à Automedicação em um Serviço Brasileiro de Emergência Odontológica

Resumen pt: Objetivo: investigar os fatores associados a automedicacao por pacientes atendidos em um servico de emergencias odontologicas em Belo Horizonte, MG, Bras...

Análise de medicamentos novos registrados no Brasil na perspectiva do Sistema Único de Saúde e da carga de doença

The most important aspect of a new drug in terms of public health is its therapeutic value and benefit it provides for the patient and for the society. The aim of this study was to analyze new drugs registered in Brazil between 2003 and 2013 with respect to Pharmaceutical Assistance programs within the Brazilian health system and to the disease burden in the country. In our retrospective cohort study, new drugs registered in Brazil were identified through document analysis of databases and publicly available documents from National Health Surveillance Agency. The data on disease burden in Brazil was obtained from the Global Burden of Disease Study 2012, published by the World Health Organization. The level of therapeutic innovation was determined using the Motola algorithm. Although a total of 159 new medicines were used in the cohort, only 28 (17.6%) were classified as important therapeutic innovations. There is a disproportionate relationship between the percentage of new drugs and the burden of disease, with an under-representation of drugs for infectious respiratory diseases, heart disease, and digestive diseases. Incentive strategies for research and development of medicines should be prioritized to reduce the disparity regarding the burden of disease and to help develop innovative medicines necessary to improve health throughout the country.

Health literacy and warfarin therapy at two anticoagulation clinics in Brazil

Objective Health literacy has been related to health-related conditions and health outcomes. Studies examining the association of health literacy and anticoagulation have had variable results. We sought to investigate the relations of health literacy and percentage of time in therapeutic range (TTR) in a vulnerable Brazilian cohort at two hospital-based anticoagulation clinics. Methods We measured health literacy with the Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA-18) in 2015–2016. We identified the demographic and clinical characteristics associated with health literacy and related health literacy to TTR. Results We enrolled 422 adults prescribed chronic warfarin therapy in our observational study (median age 62.1 years; 58.8% women; monthly income

Adaptação Transcultural do Oral Anticoagulation Knowledge Test para o Português do Brasil

200.00). The prevalence of inadequate health literacy (score 0–14 points) was 72.3% with a median score of 12 (quartiles, Q1=10; Q3=15) on the SAHLPA-18. The median TTR was 66.1%. In the multivariable logistic analysis, cognitive impairment and assistance with taking warfarin were associated with inadequate health literacy. Prosthetic heart valves and more school years were associated with adequate health literacy. Our analyses showed no significant relation between health literacy and TTR, analysing health literacy as a categorical (adjusted OR 1.05; 95% CI 0.65 to 1.70) or continuous variable (Spearman’s coefficient 0.02; p=0.70). Conclusions Inadequate health literacy was highly prevalent in this impoverished Brazilian cohort receiving anticoagulation with warfarin. However, we did not identify an association between health literacy and TTR. Future investigations may consider the systemic factors that contribute towards successful anticoagulation outcomes for vulnerable patient cohorts with inadequate health literacy.

Anxiolytics, Sedatives, and Hypnotics Prescribed by Dentists in Brazil in 2010

Resumo O conhecimento dos pacientes sobre o tratamento com anticoagulantes orais pode favorecer o alcance dos resultados terapeuticos e a prevencao de eventos adversos relacionados a farmacoterapia. No Brasil, observa-se a ausencia de instrumentos validados para avaliacao do conhecimento do paciente sobre o tratamento com a varfarina. O objetivo deste estudo foi realizar a adaptacao transcultural do instrumento Oral Anticoagulation Knowledge (OAK) Test do ingles para o portugues do Brasil. Trata-se de estudo metodologico desenvolvido em uma clinica de anticoagulacao de um hospital publico universitario. O estudo compreendeu as etapas de traducao inicial, sintese das traducoes, retrotraducao, revisao pelo comite de especialistas e pre-teste com 30 individuos. A equivalencia semântica foi obtida atraves da analise do significado referencial e geral de cada item. A equivalencia conceitual dos itens buscou demonstrar a relevância e a aceitabilidade do instrumento. Com o processo de adaptacao transcultural foi obtida a versao final do OAK Test em lingua portuguesa do Brasil, intitulada “Teste de Conhecimento sobre Anticoagulacao Oral”. Constatou-se uma equivalencia semântica e conceitual adequada entre a versao adaptada e a original, bem como uma excelente aceitabilidade desse instrumento.

Paciente com cardiopatia chagásica crônica, esquistossomose hepatoesplênica e síndrome da imunodeficiência adquirida: possível resolução espontânea de trombo no ventrículo direito

Objective To describe dental prescriptions for anxiolytics, sedatives, and hypnotics for Brazilian outpatients in 2010. Methods A cross-sectional study was conducted using data on the use of anxiolytics, sedatives, and hypnotics from the Brazilian Health Surveillance Agency, Brazil, 2010. For each prescription, prescribed drugs and the prescribed amount were identified. Prescribed medications were classified according to Anatomical Therapeutic Chemical code. We calculated the number of Defined Daily Doses (DDD) for anxiolytics, sedatives, and hypnotics by code, their mean DDD, and DDD per inhabitant per year. Results There were 16,436 prescriptions dispensed, including anxiolytics, sedatives, and hypnotics. These prescriptions corresponded to 3,555,780.50 mg, distributed as 2,286,200.50 mg (64.30%) of anxiolytics and 1,269,580.00 mg (35.70%) of sedatives and hypnotics. This amount allowed treating approximately 474,106 individuals (number of DDD). The anxiolytics most frequently dispensed were bromazepam (25.30%), alprazolam (19.19%), and diazepam (15.60%). Sedatives and hypnotics mostly prescribed were zolpidem (9.55%), midazolam (6.99%), and flunitrazepam (2.14%). The per capita rates (100,000 inhabitants) of anxiolytics and sedatives/hypnotics were 6.83 and 1.78, respectively. Conclusions Benzodiazepines and derivatives were the most frequently prescribed drugs. There was a low rate of dental prescriptions for anxiolytics, sedatives, and hypnotics, although excessive doses were concentrated in the same prescription.