Tatiane da Silva Dal Pizzol

Qualidade do processo da assistência pré-natal: unidades básicas de saúde e unidades de Estratégia Saúde da Família em município no Sul do Brasil

Prenatal care in traditional primary care units (UBS) and Family Health Strategy units (ESF) was evaluated by a cross-sectional study from July 2009 to February 2010 in Santa Maria, Rio Grande do Sul State, Brazil. Seven hundred and ninety-five postpartum women who had received prenatal care in either of the two types of units were interviewed. Four quality levels were used: level 1 (Kessner index modified by Takeda); level 2, which adds clinical obstetric procedures to level 1; level 3, which adds laboratory tests to level 1; and level 4, which includes all the above parameters. Prenatal care in the Family Health Strategy was superior to that of traditional primary care at all levels, with statistically significant differences in levels 1 and 2. Pregnant women received more guidance and prenatal care was superior in the Family Health Strategy. The study favored the Family Health Strategy, but improvement is still needed in the performance of procedures and laboratory tests in order to enhance prenatal care and strengthen primary care.

Uso alternado de antipiréticos para tratamento da febre em crianças: revisão sistemática de ensaios clínicos randomizados

OBJECTIVE To summarize the existing evidence on the efficacy of therapy with alternating antipyretics compared to monotherapy in the management of fever in children. SOURCES MEDLINE, EMBASE, Cochrane Library, LILACS, SciELO, IBECS, Web of Science, Clinical Trials, Google Scholar and references of the articles found. The review included randomized clinical trials published until December 2011, in which one of the arms was the alternating antipyretics therapy to treat fever in children younger than 12 years, treated on an outpatient basis. Data selection and extraction were performed independently by two reviewers. The quality of the studies was assessed according to CONSORT items. SUMMARY OF THE FINDINGS The selected studies showed great heterogeneity of participants, temperature for fever diagnosis, interventions (dose and dosing intervals) and assessed outcomes. The treatment groups ranged from 38 to 464 children. The studies compared paracetamol and ibuprofen alternated with paracetamol and/or ibuprofen. Only one study used different doses from the 15 mg/kg for paracetamol and 10 mg/kg for ibuprofen, but the dosing intervals varied considerably. The alternate use with dipyrone or acetylsalicylic acid was not assessed by any of the studies. Overall, the articles pointed to a tendency of lower mean temperatures in groups with alternating therapy. Few adverse effects were reported. CONCLUSION Although there was a tendency towards the reduction of mean temperatures with alternating antipyretics compared to the use of one antipyretic alone, there is not enough evidence to say that alternating antipyretic therapy is more effective than monotherapy.

Uso de medicamentos entre idosos residentes em áreas urbanas e rurais de município no Sul do Brasil: um estudo de base populacional

The study aimed to measure use of medication and polypharmacy among the elderly in Carlos Barbosa, Rio Grande do Sul State, Brazil, and to compare socio-demographic, economic, and health characteristics in relation to area of residence (urban versus rural) in a random sample of 811 persons 60 year of age or older. Interviews were used to collect data on socio-demographic characteristics, chronic illnesses, and self-reported use of medications. The association between area of residence and medication or polypharmacy was adjusted for confounders using Poisson regression with robust variance. Prevalence rates for use of medication and polypharmacy were higher among older persons living in the urban area. Living in the urban area was positively and independently associated with use of medication (PR = 1.10; 95%CI: 1.02-1.20) and polypharmacy (PR = 1.83; 95%CI: 1.27-2.65) in this group of elderly in southern Brazil.

Dipyrone use during pregnancy and adverse perinatal events.

ObjectiveTo evaluate the risk of adverse perinatal events among newborns exposed to dipyrone during gestation.Design and SettingThe present study is a secondary analysis of Brazilian study of gestational diabetes (EBDG), a cohort of women attended at healthcare units of the Brazilian national health system (SUS) located in six Brazilian state capitals, between February 1991 and June 1995.SampleA total number of 5,564 women aged 20 years and over who were between their 21st and 28th week of pregnancy were followed up.MethodsA structured questionnaire was used to obtain data on the pregnant women, their pregnancies, and their use of medications. Other data and the outcomes congenital abnormalities, intrauterine death, preterm birth, or low birth weight were obtained from the medical records. To estimate the odds ratios after adjustment for the potential confounding factors, logistic regression modeling was developed.Main outcome measuresCongenital abnormalities, intrauterine death, preterm birth, and low birth weight.ResultsDipyrone use was reported by 555 pregnant women (11.5%). Their exposure to this medication did not present any association with the outcomes of congenital abnormalities (OR 1.11; 95% CI, 0.58–2.10), intrauterine death (OR 0.69; 95% CI, 0.33–1.43), preterm birth (OR 0.94; 95% CI, 0.73–1.20), or low birth weight (OR 0.88; 95% CI, 0.64–1.22), in the crude analysis. This absence of associations was maintained after performing logistic regression analysis.ConclusionsThe data suggest that the exposure to dipyrone during pregnancy does not increase the risk of congenital abnormalities and other adverse events as outcomes from pregnancy.

Exposure to misoprostol and hormones during pregnancy and risk of congenital anomalies

This study evaluated the association between use of misoprostol and other drugs to induce menstruation, and congenital anomalies. A sample of 4,856 pregnant women 20 years and older were enrolled consecutively in prenatal services in the Unified National Health System, in six Brazilian State capitals. Data on socio-demographics and use of medicines were obtained using an interview from the 21st to 28th week of pregnancy. Other data, including information on delivery and diagnosis of congenital anomalies by the attending neonatal physician were obtained from patient charts. Potential confounders were adjusted by logistic regression. Use of drugs to induce menstruation was reported by 707 women (14.6%), of whom 120 (17%) reported use of misoprostol. After adjusting for the study center, a positive association was observed between misoprostol and congenital anomalies (OR = 2.64; 95% CI: 1.03-6.75); a positive association was also observed for sex hormones (OR = 2.24; 95% CI: 1.06-4.74). The results suggest that the use of misoprostol or sex hormones during pregnancy increases the risk of congenital anomalies.

Therapeutic procedures and use of alternating antipyretic drugs for fever management in children

OBJECTIVE The evidence on the effectiveness of alternating antipyretics in fever management is scarce and indicates clinically negligible differences. The present study aimed to describe therapeutic procedures and the use of alternating antipyretics in children, and to evaluate associated factors. METHODS This was a cross-sectional study with 692 children aged 0 to 6 years, living in Southern Brazil. Household interviews of the childrens caregivers were conducted through cluster sampling using a structured questionnaire. A descriptive analysis was carried out, and the association between the use of alternating antipyretics and sociodemographic factors was evaluated. A total of 630 cases were analyzed (91.0%), corresponding to children with a history of fever. RESULTS Approximately 73% of caregivers reported that the first measure adopted during the last fever episode was the administration of medication. The mean temperature considered as fever by caregivers was 37.4°C, and as high fever, 38.7°C. The use of alternating antipyretic therapy was reported by 26.7% of respondents, justified by the lack of response to monotherapy and medical indication, in most cases. The drugs most often used were dipyrone and paracetamol. Children whose primary caregiver was a parent with higher socioeconomic status and higher educational level received more alternating medications. Approximately 70% of the doses used were below the minimum recommended dose for the treatment of fever. CONCLUSIONS The use of medication to control fever is a common practice, including alternating antipyretic regimens. Most caregivers consider as fever temperatures lower than those established and they reported lack of response to monotherapy and medical indication as the main reasons for alternating medication.

Instrumento para avaliação do nível de conhecimento da prescrição na atenção primária

OBJETIVO: Desenvolver e testar um instrumento para avaliacao do nivel de conhecimento do paciente sobre a prescricao de medicamentos. METODOS: O estudo foi realizado com usuarios cadastrados nas Unidades de Estrategia de Saude da Familia de Santa Cruz do Sul, RS, recrutados por amostragem consecutiva. Foram considerados nome do medicamento, indicacao terapeutica, dose, horarios de administracao, forma de utilizacao, duracao do tratamento, atitude no caso de esquecimento de doses, possiveis efeitos adversos e interacoes. Cada item da escala foi ponderado segundo importância para a utilizacao segura do medicamento prescrito. O questionario foi testado por meio de entrevistas com os usuarios em 2006 e pela analise de 320 prescricoes. Foram calculadas estatisticas descritivas, razoes de prevalencias e qui-quadrado para variaveis categoricas e teste de Tukey para comparacao de medias. RESULTADOS: O nivel de conhecimento da terapia medicamentosa foi considerado bom para 11,3% dos entrevistados, regular para 42,5% e insuficiente para 46,3%. Os maiores niveis de conhecimento foram observados nos horarios de administracao, indicacao terapeutica e duracao do tratamento. Os menores niveis ocorreram em dose, efeitos adversos e o que fazer no caso de esquecimento de uma ou mais doses do medicamento. CONCLUSOES: O instrumento proposto permitiu examinar a magnitude da lacuna existente entre o que o paciente deve saber e o que ele realmente sabe sobre seus medicamentos. Assim, e possivel detectar focos de prevencao, educacao e acompanhamento para evitar problemas relacionados a utilizacao nao segura dos medicamentos.

Reproductive results associated with misoprostol and other substances utilized for interruption of pregnancy

Sir, In Brazil, the main use of misoprostol is to induce abortion, even though this practice is illegal. There are only two situations in which abortion is not a criminal act: when the pregnant woman’s life is at risk and when pregnancy has resulted from rape or incest. The use of misoprostol as an abortion-inducing substance may lead to a situation in which the pregnancy is not lost [1], thereby generating anxiety regarding the risk to the fetus and the pregnant woman. Case and case-control studies have suggested that the use of misoprostol in unsuccessful abortions may be associated with congenital malformations, for example in children with limb reduction defects and/or Mobius Sequence [2, 3] and anomalies of the central nervous system [4]. However, in one cohort study correlating the use of misoprostol with teratogenic effects, no difference was found in the rates of congenital malformations between 86 cases of exposure to misoprostol during pregnancy and 86 cases without exposure to this drug [5]. In this letter, we report an association observed between the use of misoprostol during the first trimester of pregnancy and congenital malformation of the child or fetal death, from the Brazilian Study of Gestational Diabetes, a cohort of women attending prenatal services at public hospitals in six Brazilian cities, between February 1991 and June 1995. Data relating to the use of misoprostol and other substances with the potential to induce abortion during the pregnancy (obtained during the first phase of the cohort) and data relating to the neonate’s state of health (obtained during the third phase of the cohort) were analyzed. Interviews were held with 5,564 women aged 20 years or over who were between their 21st week and 28th week of pregnancy (Table 1). Information on the use of substances with the potential to induce abortion was obtained from the interviews with the pregnant women. The diagnosis of congenital malformation was made by the attending doctor and entered in the pregnant woman’s records. The present analysis included the pregnant women who were followed through to the third phase of the cohort, thus resulting in a sample of 4,862 women (87.4% of the initial sample). Use of substances with the potential to induce abortion was reported by 707 pregnant women (14.6%); of these, 120 declared that they had used misoprostol during the first trimester of pregnancy. More cases of congenital malformation were found in the group exposed to misoprostol than in the unexposed group (RR=2.39), with threshold significance (95% CI 0.99–5.80) (Table 2). Using a logistic regression model that included the variables of skin color, marital situation and research center, the risk increased slightly (RR=2.61; 95% CI 1.01–6.75). The malformations that occurred in the sample of pregnant women who made use of misoprostol were: syndactyly, twisted foot, meningomyelocele, microcephaly and fingernail defects. A significant difference was also observed between the women with and without exposure to misoprostol, in relation to fetal death (RR=2.63; 95% CI 1.17–5.88 (Table 3). After adjustment using the regression model, the relative risk increased to 3.21 (95% CI 1.34–7.68). The data available in the literature on the effects on the fetus and child mostly come from case reports and case-control studies of limited sample size. Moreover, they do not include adverse events other than the congenital malformations that are important for the outcome of the pregnancy. The prospective populationbased study that included a cohort of 86 cases and 86 externally selected controls did not have sufficient T. da Silva Dal Pizzol (&) University of Passo Fundo, Rua Paissandu, 1973, apto 604, Passo Fundo, Rio Grande do Sul, 99010-102, Brasil E-mail: tatiane@saude.upf.tche.br

Utilização de medicamentos entre crianças de zero a seis anos: um estudo de base populacional no sul do Brasil

The scope of this article was to estimate the prevalence of medication use in children between zero and six years old, analyzing the associated socio-demographic characteristics, and evaluating the adequacy of the medication with respect to pediatric recommendations and restrictions per age group. A cross-sectional study was conducted by means of cluster sampling on a sample comprised of children aged six or under, residents of a city in the south of Brazil. A standardized questionnaire about medication use 15 days prior to the interview was applied. A descriptive analysis was carried out, and the association between medication use and socio-demographic factors was evaluated, as well as the analysis of the pediatric adequacy of the most prevalent medication. Of the 687 children evaluated, 52% used at least one drug in the period. Associations between medication use and socio-demographic characteristics were not found, with the exception of per capita monthly income. The most prevalent medication was paracetamol (17.1%), followed by amoxicillin (9.5%) and dipyrone (8.4%). Among the ten drugs most used in children, six had pediatric restrictions for the age group. The results indicate significant use of medication, including medication with age restrictions, particularly for children under two years of age.

Association between iron supplementation during pregnancy and prematurity, low birth weight, and very low birth weight

The objective was to evaluate the association between prophylactic iron supplementation and prematurity and low birth weight. Pregnant women 20 years and older with 21 to 28 weeks of gestational age were enrolled consecutively in prenatal services in the Unified National Health System in six Brazilian State capitals between 1991 and 1995. Socio-demographic data and information on iron supplementation up until the 28th gestational week were obtained by means of an interview. Outcomes and other variables were collected from medical records. Anemia was present in 31.3% of the 3,865 women. Among anemic women (hemoglobin < 11.0g/dL), 29.8% were taking iron supplements, as compared to 16.7% among non-anemic women (hemoglobin > or = 11.0g/dL). After adjusting for potential confounders, iron was not associated with prematurity (OR = 0.88; 95%CI: 0.73-1.07), low birth weight (OR = 0.99; 95%CI: 0.75-1.31), or very low birth weight (OR = 0.58; 95%CI: 0.29-1.13). The results suggest that iron supplementation up to the 28th gestational week does not reduce the risk of prematurity, low birth weight, or very low birth weight.