Primary care professional validation of visual model of prescription – Illustrated prescription

Issue

Chronic diseases such as hypertension and diabetes have great global impact on morbidity, mortality and costs. Incorrect use of medicines is especially worrisome for vulnerable populations with low health literacy, and visual models of prescription can bring benefit. The objective of this study was to validate the visual model of prescription Illustrated Prescription to obtain an adapted prescription with greater clarity, correction and cost-efficiency especially for risk users in a vulnerable peripheral region of the capital of Brazil served free of charge by the Unified Health System.

Description of the Problem

We conducted a content validation by primary health care nurses, pharmacists and physicians (PHC) by Delphi technique, applied in two phases from November to December 2018, through a questionnaire that evaluated clarity, relevance and feasibility of performing Illustrated Prescription, with field for comments. We used a 4-point Likert scale, Cronbach Alpha for reliability and Content Validation Index (CVI) with agreement above 0.8 indicating validation. Project approved by the Ethics Committee - FEPECS.

Results

Round-1: 29 out of 32 items were validated, with Cronbach's alpha .9812. Round-2: Included 4 new items, guidelines for indicating whole tablet, adjustment of the font size and color column size of elastic alloys, all items being validated and Cronbach's alpha of 0.9876.

Lessons

Validation ensures clarity and correction of the Illustrated Prescription, being extremely important for dissemination of the visual model for prescribing. It allows future evaluation of increased drug adherence and risk reduction related to incorrect use of medications especially for illiterate or visually impaired users.

Key messages

Illustrated Prescription is a validated tool that opens up the possibility of greater safety and efficient use of chronic medications, especially for vulnerable users with chronic diseases. Validation ensures clarity and correction of the Illustrated Prescription, being extremely important for dissemination of the visual model for prescribing.

Allergy to beta-lactam antibiotics in children: Risk factors for a positive diagnostic work-up

BACKGROUND

Allergy to beta-lactam (βL) antibiotics is highly reported in children, but rarely confirmed. Risk factors for a positive diagnostic work-up are scarce. The primary aim was to characterize the cases of children with confirmed βL allergy, investigating potential risk factors. Secondary aims were to assess the prevalence of allergy to βL in this population and to confirm the safety of less extensive diagnostic protocols for milder reactions.

METHODS

We reviewed the clinical data from all children evaluated in our Department for suspected βL allergy, over a six-year period.

RESULTS

Two hundred and twenty children (53% females) with a mean age of 6.5±4.2 years were evaluated. Cutaneous manifestations were the most frequently reported (96.9%), mainly maculopapular exanthema (MPE). The reactions were non-immediate in 59.5% of the cases. Only 23 children (10.5%) were diagnosed with allergy to βL. The likelihood of βL allergy was significantly higher in children with a family history of drug allergy (p<0.001) and in those with a smaller time period between the reaction and the study (p=0.046). The probability of not confirming βL allergy is greater in children reporting less severe reactions (p<0.001) and MPE (p<0.001). We found the less extensive diagnostic protocol in milder reactions safe, since only 4.2% of the children presented a positive provocation test (similar reaction as the index reaction).

CONCLUSION

This study highlights family history of drug allergy as a risk factor for a positive diagnostic work-up. Larger series are required, particularly genetic studies to accurately determine future risk for βL allergy in children.

Lisbon Burn Centre experience with intentional burn injuries

Burn injury as a form of hetero or auto-aggression accounts for a significant amount of admissions to a Burn Care Unit, with epidemiologic and clinical specificities. To investigate the differences in risk factors, psychiatric comorbidities, injury severity and mortality among adult patients with accidental or intentional burns, we analyzed routinely collected data from a Central Hospital Burn Unit over a period of 6 years (January 1st, 2010 to December 31st, 2015). We identified 22 intentional burn patients (5%) among all the admissions to our Burn Unit. When compared to the accidental burns, the intentional burn patients are significantly younger (45.7±14.7 vs. 54.9±19.9), have a bigger percentage of body surface area burned (35% vs. 14%), have a higher incidence of inhalation burn (50% vs. 22.8%) and higher mortality (18.2% vs. 6.1%). Fifty-five percent of cases of intentional burns were self-inflicted. Self-inflicted burns have a worse prognosis than hetero-aggressions (inhospital mortality 25% vs. 10%). Psychiatric comorbidities were largely more prevalent in the intentional burn patients (59% vs. 6.6%), namely mood disorders. Compared to patients with accidental burns, intentional burn patients have worse clinical condition and prognosis. A multidisciplinary preventive approach, looking at the specificities of the violent nature of the lesions and identifying risk groups may reduce the incidence and severity of this type of burns.

Predicting incomplete basal cell carcinoma excisions - a large multidisciplinary retrospective analysis in a tertiary center

Introduction: Surgical treatment of basal cell carcinomas is often performed by physicians with different surgical backgrounds. Collecting data from different surgical departments would better reflect their real-life surgical management.Objectives: To identify the rate, recurrence risk, and predictive factors accordingly to their relative contribution for an incomplete basal cell carcinoma excision in a large multidisciplinary real-life settingMethods: Retrospective cohort study of 2305 surgically treated lesions in different departments of a tertiary center.Results: There was a rate of incomplete excisions (15%) and a recurrence rate (35.5% vs. 6.8% in incomplete vs. complete excisions (p < .001)). A third of incompletely excised basal cell carcinoma (BCC) will recur over time. Stratified by relevancy, high-risk histological subtypes (micronodular (OR 5.10 - p < .001) and morpheaform (OR 5.42 - p < .001), smaller specimen sizes ( <0.5 cm or 0.5-1 cm, OR 3.99 and 2.49, respectively, p < .001) high-risk locations (OR 3.06 on the nose, OR 2.77 on the eyelids, p < .001), and recurrent BCCs (OR 1.72, p < .001). are the best predictors of an incomplete excision.Conclusions: Acknowledging the rate, recurrence risk and predictive factors for incomplete excisions may be beneficial for optimal preoperative planning and to prevent unwarranted re-interventions, morbidity, and healthcare costs.

HIV screening of tuberculosis patients in Portugal: what are we missing?

BACKGROUND

Knowledge of human immunodeficiency virus (HIV) status is essential to effectively manage both tuberculosis (TB) and HIV infection. This is why the World Health Organization (WHO) recommends routine HIV testing in all TB patients.

OBJECTIVE

To determine the number of TB patients with unknown HIV status in Portugal and to identify the factors associated with unknown HIV status.

METHODS

A retrospective study of all TB notifications from 2008 to 2014 in Portugal was conducted. A multiple logistic regression model was used to evaluate the association of sociodemographic and clinical factors with unknown HIV status.

RESULTS

We examined the records of 18 445 patients with TB notification, 2402 of whom (13%) had unknown HIV status. Unknown HIV status was positively associated with age 65 years (adjusted odds ratio [aOR] 1.208, 95%CI 1.037-1.408) and extra-pulmonary TB (aOR 1.381, 95%CI 1.252-1.523), but negatively associated with unemployment (aOR 0.755, 95%CI 0.637-0.895), alcohol dependence (aOR 0.809, 95%CI 0.682-0.959) and drug dependence (aOR 0.566, 95%CI 0.449-0.713).

CONCLUSION

Risk perception is the most important barrier to complete knowledge of HIV status in TB patients in Portugal. Given the importance of HIV screening in TB patients, every effort should be made to ensure that all TB patients undergo HIV screening.

Choroid thickness profile in patients with lupus nephritis

BACKGROUND

Choroidopathy is a rare manifestation of systemic lupus erythematosus (SLE). This entity is associated with active phases of severe SLE and it is frequently accompanied by acute kidney failure, central nervous system involvement and coagulopathy.

PURPOSE

To evaluate the choroid thickness of patients with lupus nephritis (LN) without choroidopathy, and to compare this with that of age-matched SLE patients without LN and healthy control subjects.

STUDY DESIGN

Cross-sectional case control study.

MATERIAL AND METHODS

Fifteen women with LN in remission phase (study group), 15 women with SLE in remission without LN (SLE control group), and 15 healthy women (healthy control group), without ocular diseases or significant refractive error, were recruited. Full ophthalmological examination and a macular optical coherence tomography in enhanced depth imaging mode were performed. The choroid thickness was measured at nine macular points and six lines of mean choroidal thickness were determined. A comparative analysis between the three groups was performed using the one-way ANOVA test and the paired t-test. The choroid thickness of patients under corticotherapy was also compared to that of patients without corticotherapy. Additionally, the correlation between choroid thickness and disease duration was evaluated using the Pearson analysis.

RESULTS

The mean macular choroidal thickness was 295.73 ± 67.62 μm in the study group, 233.34 ± 41.01 µm in the SLE control group, and 240.98 ± 37.93 μm in the control group ( p = 0.00006 and p = 0.0003, respectively). Additionally, the choroid thickness was significantly thicker than in the SLE and healthy control groups at the foveal ( p = 0.004 and p < 0.000), nasal ( p < 0.000 and p = 0.001), superior ( p = 0.002 and p < 0.000) and inferior ( p < 0.000 and p = 0.001) mean lines. The choroidal thickness in this group was not associated with the duration of the disease. The subgroup of patients with LN under corticotherapy did not reveal a significantly different choroidal thickness.

CONCLUSION

This study suggests a relationship between LN and choroidal changes, which may represent an increased risk for choroidopathy in these patients. Choroid thickening was not related with the duration of the disease. This thickening may be correlated with histopathological changes similar to those occurring in kidney glomeruli.

Occipital blood-brain barrier permeability is an independent predictor of visual outcome in type 2 diabetes, irrespective of the retinal barrier: A longitudinal study

Blood-brain barrier (BBB) permeability in type 2 diabetic patients has been previously shown to be altered in certain brain regions such as the basal ganglia and the hippocampus. Because of the histological and functional similarities between the BBB) and the blood-retinal barrier (BRB), we aimed to investigate how the permeability of both barriers predicts visual outcome. We included 2 control groups (acute unilateral stroke patients, n = 9; type 2 diabetics without BRB leakage n = 10) and a case study group of type 2 diabetics with established BRB leakage (n = 17). We evaluated sex, age, disease duration, metabolic impairment, retinopathy grade and BBB permeability as predictors of visual acuity at baseline, 12  and 24 months in the type 2 diabetics without BRB leakage group and the case study group. We have also explored differences in BBB permeability in the occipital lobe and frontal lobe in the 3 different groups. K^trans (volume transfer coefficient) and V_p (fractional plasma volume) were estimated. The BBB permeability parameter V_p was higher in the case study group compared to the unaffected hemisphere of the stroke patient control group, suggesting vascular dynamics were changed in the occipital lobe of type 2 diabetics with established BRB leakage. These patients showed a significant correlation between glycated hemoglobin (HbA1C) levels and occipital and frontal K^trans . We report for the first time that occipital BBB permeability is an independent predictor of visual acuity at baseline, as well as at 12 and 24 months, in type 2 diabetics with established BRB leakage. Our results suggest that occipital BBB permeability might be an independent biomarker for visual impairment in patients with established BRB leakage.

Dietary fatty acids modulation of human colon cancer cells: mechanisms and future perspectives

Colorectal cancer (CRC) is one of the most common malignancies worldwide and its pathogenesis is proven to be related with dietary patterns, namely dietary fatty acid (FA) intake. We reviewed the evidences regarding the effect of different dietary FAs on human CRC cell lines proliferation and apoptosis. Altogether, the results obtained from in vitro studies show that monounsaturated FAs lack evidence regarding both proliferation and apoptosis, whereas there is a consensus about the anti-proliferative and pro-apoptotic effects, involving different intracellular targets, of n-3 polyunsaturated FAs, while n-6 series show a similar effect or no effects. The response to these dietary components depends on the cell type as well as the amount and duration of exposure. These results highlight the importance of identifying molecular targets for dietary components aiming to interfere with one of the main risk factors related with CRC incidence and prevalence.

The effect of live feeds bathed with the red seaweed Asparagopsis armata on the survival, growth and physiology status of Sparus aurata larvae

Larval rearing is affected by a wide range of microorganisms that thrive in larviculture systems. Some seaweed species have metabolites capable of reducing the bacterial load. However, no studies have yet tested whether including seaweed metabolites on larval rearing systems has any effects on the larvae development. This work assessed the development of Sparus aurata larvae fed preys treated with an Asparagopsis armata product. Live prey, Brachionus spp. and Artemia sp., were immersed in a solution containing 0.5% of a commercial extract of A. armata (Ysaline 100, YSA) for 30 min, before being fed to seabream larvae (n = 4 each). In the control, the live feed was immersed in clear water. Larval parameters such as growth, survival, digestive capacity (structural-histology and functional-enzymatic activity), stress level (cortisol content), non-specific immune response (lysozyme activity), anti-bacterial activity (disc-diffusion assay) and microbiota quantification (fish larvae gut and rearing water) were monitored. Fish larvae digestive capacity, stress level and non-specific immune response were not affected by the use of YSA. The number of Vibrionaceae was significantly reduced both in water and larval gut when using YSA. Growth was enhanced for YSA treatment, but higher mortality was also observed, especially until 10 days after hatching (DAH). The mortality peak observed at 8 DAH for both treatments, but higher for YSA, indicates larval higher susceptibility at this development stage, suggesting that lower concentrations of YSA should be used until 10 DAH. The application of YSA after 10 DAH onwards promotes a safer rearing environment.

Hoarding disorders: Two different clinical presentations

Introduction

Hoarding disorders (HD) have increasingly become a public health hazard. It usually emerges during two broad life periods: in early age-of-onset is usually associated with obsessive-compulsive disorder (OCD); in the elderly, it can be due to psychiatric and organic disorders, unrelated to OCD.

Objectives

Our objective is to increase medical awareness and to highlight that both young and elderly people may suffer from this condition.

Aims

The aim of this presentation is to address HD and its different presentations.

Methods

Presentation of two clinical cases of HD and pathology revision.

Results

A 30-year-old woman was hoarding litter, food and several items in a systematic way, become aggressive when her family tried to clean the house and was admitted several times in a psychiatric facility for cleanliness of her house. She had a history of depressive symptoms and severe OCD, with obsessive thoughts and several verification behaviors. A 78-year-old woman, with history of cerebral vascular disease, was self-neglected, living in a filthy home, with hoarding of litter and many worthless objects in a disorganized way, become aggressive after her relatives try to enter her house and refused to get help of any kind. Later on, she was admitted in a psychiatric facility and diagnosed with vascular dementia.

Conclusions

Timely diagnosis and proper management of these two variations of HD will allow more advanced studies in this matter and more effective pharmacological and psychotherapeutic treatments. These clinical cases reinforce the importance of practical guidelines for appropriate approach of these patients with complex and multidimensional needs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

REUTILIZAÇÃO DA SOBRA DE ÁGUA PERMEADA E DE REJEITO DE UMA CENTRAL DE TRATAMENTO DE ÁGUA POR OSMOSE REVERSA DE UMA UNIDADE DE HEMODIÁLISE HOSPITALAR

Esse trabalho trata da possibilidade de reutilizar a água do rejeito e a sobra da água permeada proveniente de um sistemade Osmose Reversa, OR, da unidade de hemodiálise do Hospital das Clínicas de Ribeirão Preto (HCRP-USP). O estudo foi feito por meio de levantamento estrutural com plantas físicas e ‘layout’do local, fazendo visitas a esse local para analisar a qualidade e verificar a quantidade de água utilizada no mesmo e, principalmente, do estudo das características bacteriológicas e físico-químicas da água a ser reaproveitada. O resultado obtido das análises da sobra de água permeada e do rejeito mostrou que é possível reutilizar a sobra de água permeada diretamente na caixa central do HCRP-USP, pois esse procedimento não altera a qualidade da água de abastecimento do hospital, sendo somente de 0,73 % dediluição. Com a instalação do sistema de reaproveitamento da sobra de água permeada o HCRP-USP passou a ter uma economia em volume de água de 575 m3/mês. O custo total de implantação do sistema não passou de 5.809,43 reais, ou seja, com pouquíssimo recurso financeiro o hospital obteve uma grande economia no insumo água.