Introdução: Os Benzodiazepínicos estão entre as drogas mais prescritas no mundo. Possuem características ansiolíticas, hipnóticas, miorelaxantes e anticonvulsivantes. Estudos prévios evidenciam inadequações nas prescrições de benzodiazepínicos, como uso equivocado para quadros inespecíficos, tratamento prolongado e abuso por idosos. Benzodiazepínicos podem trazer sérios efeitos adversos, sobretudo em idosos, como sonolência diurna, deterioro da memória e funções cognitivas, desequilíbrio e quedas. Objetivos: Analisar a prevalência do uso de benzodiazepínicos nos pacientes do Centro de Atenção Psicossocial (CAPS) de Campo Bom-RS em um período de 24 meses (Junho de 2013 a Maio de 2015), faixa etária, frequência de dispensações, dosagens, CIDs e especialidades dos médicos prescritores; bem como possíveis relações com a função cognitiva, afetiva, e quedas em idosos. Métodos: Estudo transversal, com informações coletadas e tabuladas a partir dos prontuários e prescrições médicas do CAPS Campo Bom, bem como do seu sistema informatizado de gerenciamento (Software Multi 24 Horas). Foram obtidos dados como idade, gênero, identificação dos CIDs; bem como informações sobre prescrições de Benzodiazepínicos, como frequência, quantidade, tipo de medicamento, posologia, profissional prescritor e demais medicamentos utilizados. Critério de inclusão: utilização de qualquer benzodiazepínico disponível na rede SUS: Clonazepam 0,5mg, Clonazepam 2,5 mg/ml, Clonazepam 2mg e Diazepam 5mg. Foram aplicados os testes MEEM e GDS nos pacientes idosos, em entrevistas individuais, nas quais também se avaliou a escolaridade, ocorrência e frequência de quedas, além das comorbidades auto relatadas. Para construção do banco de dados foi utilizado o Software Microsoft® Office Excel® 2007, e para análise estatística o Software PASW V18 (SPSS®). Resultados: O número total de pacientes ativos identificados no CAPS foi de 855 indivíduos, sendo 543 (63,5%) mulheres e 84 idosos (9,8%). A prevalência de utilização de BZD nesta população representou 47,2% (n=404 indivíduos). Foram identificadas 12.680 prescrições médicas dispensadas e, deste total, a prevalência de prescrições de benzodiazepínicos foi de 21,7% (n=2.748). Dentre os pacientes que receberam BZD, 297 (73,5%) eram mulheres e 59 idosos (14,6%), dos quais 56 foram entrevistados. Dentre os idosos entrevistados, 42 (75,0%) possuíram significativa sintomatologia depressiva (GDS≥5) e 32 (57,1%) apresentaram duas ou mais quedas no período de 1 ano. Dezoito pacientes idosos demonstraram fazer uso de dois ou mais BZDs. Houve correlação linear negativa entre os escores do MEEM e do GDS (r = - ,416; p=,002). Houve também uma correlação linear negativa entre o escore do MEEM e número de quedas em idosos (r = -,327 p=,016). Conclusões: Os benzodiazepínicos corresponderam a 21,7 % do total de prescrições do CAPS e do total dos indivíduos 47,2% receberam benzodiazepínicos. Proporcionalmente aos homens, as mulheres tenderam a receber mais prescrições de benzodiazepínicos (p<.001). A prevalência de significativa sintomatologia depressiva nos idosos usuários do CAPS foi alta (75,0%), assim como a incidência de quedas, sendo que mais da metade dos idosos caiu 2 ou mais vezes no período. Identificou-se uma correlação linear negativa entre a função cognitiva como avaliada pelo MEEM e a sintomatologia depressiva avaliada pelo GDS; bem como houve uma correlação linear negativa entre o MEEM e o número de quedas em idosos. / Introduction: Benzodiazepines are among the most prescribed drugs in the world, they have characteristics such as anxiolytic, hypnotic, muscle relaxants and anticonvulsants. Studies have pointed out distortions in benzodiazepines’ prescriptions, such as misuse for unspecific cases, prolonged treatment and use by elderly. Such medications may cause serious damage, particularly in the elderly, and its continued use causes side effects such as daytime somnolence, imbalance, memory and cognitive function loss, increased incidence of falls. Objectives: To assess the prevalence of benzodiazepine use among patients of the Center for Psychosocial Care in Campo Bom-RS within the period of June 2013 to May 2015. The variables analyzed were: age, frequency of dispensations, dosages, ICDs and specialties of prescribing doctors; as well as possible correlations between cognitive function, emotional function and falls in the elderly. Methods: Cross-sectional study, with data collected and tabulated from medical records and prescriptions, as well as from the management system from CAPS (Software Multi 24 hours). Data obtained was age, gender, ICDs identification; as well as frequency of prescriptions, quantity and type of medication, dosage, prescribing professional, others used drugs. Inclusion criteria: Use of any benzodiazepine available in the Health Unic System: Clonazepam 0,5 mg, Clonazepam 2,5 mg/ml, Clonazepam 2 mg and Diazepam 5mg. MMSE and GDS tests have been applied in the elderly, through individual interviews, in which we found about educational level, occurrence and frequency of falls and other self-reported comorbidities. The software Microsoft® Excel® 2007 was used to build database, and for statistical analysis the software PASW V18 (SPSS) was used. Results: The total number of active patients identified at CAPS was 855 individuals, of these 543 were women (63.5%) and 84 elderly (9.8%). The prevalence of benzodiazepines’ use in this population was 47.2 % (n = 404). We have found 12.680 prescriptions dispensed and the prevalence of benzodiazepines’ prescriptions was 21.7 % (n = 2.748). Among patients who received benzodiazepines, 297 (73.5%) were women and 59 elderly (14.6%), of these 56 were interviewed. From the interviewed patients, 42 (75.0%) had significant depressive symptomatology (GDS≥5) and 32 (57.1%) have suffered two or more falls. Eighteen elderly patients demonstrated to use two or more benzodiazepines. There was a negative linear correlation between MMSE and GDS scores (r = -.416, p =.002). There was also a negative linear correlation between MMSE scores and number of falls in elderly (r = -.327 p =. 016). Conclusions: Benzodiazepines accounted for 21.7% of the total CAPS’ prescriptions, and 47.2% individuals treated at CAPS received benzodiazepines. Women tended to receive more prescriptions of benzodiazepines (p <.001) than men. The prevalence of significant depressive symptomatology in the elderly was very high (75.0%). As well as the incidence of falls, since more than half of the elderly patients presented two or more falls in the period. We identified a negative linear correlation between cognitive function as assessed by MMSE and depressive symptoms assessed by the GDS; and there was a negative linear correlation between MMSE and the number of falls in the elderly.

I NTRODUÇÃO: A refratariedade aos inibidores da bomba de prótons (IBP) tem sido o grande desafio dos gastroenterologistas. Este trabalho visa caracterizar os pacientes que persistem com sintomas típicos de doença do refluxo gastroesofágico (DRGE), em uso de inibidores de bomba de prótons em doses de, pelo menos 40mg/dia, quanto aos aspectos demográficos, clínicos e laboratoriais, determinando-se a freqüência da persistência de refluxo ácido pela pH-metria esofágica de 24h. Secundariamente procurouse determinar a freqüência da esofagite eosinofílica nessa população. MÉTODO: Foram entrevistados 110 pacientes que apresentavam persistência de sintomas de pirose e/ou regurgitação em uso de pelo menos 40 mg de IBP por pelo menos 6 semanas. Os mesmos foram submetidos à endoscopia digestiva alta (EDA) com biópsia esofágica, manometria, pHmetria esofágica de duplo canal e exames laboratoriais. RESULTADOS: Dos pacientes avaliados, 77,3% eram do sexo feminino, com média de 46 anos e predomínio de baixa escolaridade. Apenas 10,9% eram tabagistas, 55% apresentavam índice de massa corpórea (IMC) acima de 25Kg/m2, sendo o IMC médio de 27Kg/m2. Entre as comorbidades, as mais freqüentes foram: alergias (72,7%); hipertensão arterial (34,5%), asma (18,2%), depressão (29,1%) e fibromialgia (8,2%), sendo estas duas últimas maiores que a encontrada na população geral. Observou-se freqüência elevada de sintomas dispépticos (70% dos pacientes relataram epigastralgia e 70% plenitude pós-prandial), disfagia (60,9%); globus (37,3%), tosse (37,3%) e dor torácia não cardíaca (30,9%). Apenas 16,4% evidenciavam à endoscopia, lesão em corpo esofágico e 23,6% hérnia de hiato. A maioria dos pacientes (61,8%) apresentava alguma alteração à manometria esofágica. Encontrou-se, entre os pacientes estudados, 24,6% com pHmetria positiva (8,1% no canal distal e 16,45% no proximal) e 75,4% com pH-metria normal. Comparando-se os resultados desses dois grupos de pacientes (pH-metria positiva e normal), segundo as variáveis estudadas, apenas a presença de lesão no corpo esofágico à endoscopia e a elevada escolaridade evidenciaram associação com persistência de pH-metria positiva (p: 0,0061 OR: 4,11 IC: 1,43:11,84 e p: 0,0237 OR: 2,74 IC: 1,13: 6,67 respectivamente). Ao se comparar presença de sintomas atípicos com a presença de refluxo ácido (no esôfago proximal versus distal), apenas globus apresentou associação com pH-metria positiva no canal proximal. Foi diagnosticado um único caso de esofagite eosinofílica entre os pacientes com sintomas típicos de DRGE refratários ao IBP. CONCLUSÃO: DRGE refratária predomina em mulheres de meia idade, associada à alta freqüência de história de alergia, depressão, fibromialgia e sintomas dispépticos. Segundo os resultados da pH-metria, a presença de esofagite erosiva em uso do IBP ou elevada escolaridade foram os únicos fatores de risco para a persistência de refluxo ácido nos dois canais, e globus no canal proximal. Não se observou diferença entre os pacientes com pH-metria positiva ou normal quanto às demais variáveis, até mesmo sintomas dispépticos. É baixa a freqüência de esofagite eosinofílica entre pacientes com pirose e/ou regurgitação refratários ao inibidor da bomba de próton / BACKGROUND: Proton pump inhibitor (PPI) refractory patients have been a big challenge to gastroenterologists. The aim of this study was to characterize the patients that had gastroesophageal reflux disease (GERD) persistent typical symptoms, undergoing PPI medication, administered at a dose of at least 40 mg/day, according to demographic, clinical and laboratory aspects. The primary outcome was to determine the frequency of acid reflux persistence based on the 24-hour esophageal pH-metry result. The secondary outcome was to determine, the frequency of eosinophilic esophagitis in the same population. METHODS: We interviewed 110 patients that presented persistence of heartburn and/or regurgitation symptoms and were undergoing treatment with PPI at a minimum dose of 40 mg/day for at least six weeks. They underwent upper gastrointestinal endoscopy with esophageal mucosa biopsy, esophageal manometry and double probe 24- hour esophageal pH-metry, as well as laboratory tests. RESULTS: 77.3% of the evaluated patients were female, with mean age of 46 years old, and most of them with low educational level. Only 10.9% were tobacco smokers and 55% had body mass index (BMI) greater than 25Kg/m2, showing mean BMI of 27Kg/m2. The most frequent comorbidities were allergy (72.7%), arterial systemic hypertension (34.5%), asthma (18.2%), depression (29.1%) and fibromyalgia (8.2%). Comparing the general population and the group of patients, a higher frequency of depression and fibromyalgia was observed. Some symptoms were found in high frequency: dyspeptic symptoms (70% associated with epigastric pain and 70% with postprandial fullness), dysphagia (60.9%), globus and cough (37.3% each) and no-cardiac chest pain (30.9%). By endoscopy, only 16.4% showed esophageal body lesion and 23.6% hiatal hernia. Most patients (61.8%) presented some alteration in esophageal manometry. Among studied patients, 24.6% had abnormal pHmetry (8.1% in distal probe and 16.45% in the upper probe) and 75.4%, a normal result. When comparing normal to abnormal pH-metry patients according to studied variables only the presence of esophageal body lesion, observed by endoscopy, and high educational level were associated to the persistence of abnormal pH-metry (p: 0.0061; OR: 4.11; IC: 1.43:11.84; and p: 0.0237; OR: 2.74; IC: 1.13: 6.67; respectively). When comparing atypical symptoms with the presence of acid reflux (proximal versus distal esophagus) only globus was associated with abnormal upper probe pHmetry. Only one patient was diagnosed with eosinophilic esophagitis among the total sample with typical gastroesophageal reflux symptoms refractory to PPI treatment. CONCLUSION: Refractory GERD was predominant in middleaged females, associated with high frequency of previous allergy, depression, fibromyalgia and dyspeptics symptoms. The risk factors to the persistence of acid reflux in the two pH-metry probes and to the symptom of globus in the upper pH-metry probe were the persistence of erosive esophagitis in patients undergoing treatment with PPI an a higher educational level. No differences between abnormal or normal pH-metry results patients were found regarding the other variables, such as dyspeptic symptoms. The frequency of eosinophilic esophagitis was low in heartburn and/or regurgitation in PPI refractory patients

Alors que l’accès aux traitements antirétroviraux se généralise dans les pays en développement, l’émergence de résistances virales, liées aux échecs thérapeutiques, constitue une menace sur un plan individuel et collectif. Au Cameroun, la prévention, la détection et la prise en charge des échecs thérapeutiques se heurtent à différentes contraintes. A travers une approche anthropologique, cette thèse explore le contexte et les déterminants des échecs thérapeutiques. Le défaut d’observance est la principale cause de leur survenue. Les équipes médicales et psychosociales font face à l’absence de guides et de procédures adaptées. Aussi l’annonce de l’échec est-elle souvent associée à une culpabilisation des patients, auxquels les soignants attribuent la seule responsabilité de l’échec. L’adaptation des structures est limitée. La prise en charge médicale et psychosociale est focalisée sur le démarrage du traitement et le changement de traitement, mais le suivi à long terme est inexistant. La perception, par les patients, des médicaments antirétroviraux, est perturbée par la survenue de l’échec. L’échec redéfinit les relations de pouvoir et de confiance entre les soignants et les patients. L’attitude des soignants oscille entre compassion et réprobation, alors que l’échec renforce la dépendance des patients. Cette thèse vise à contribuer aux réflexions anthropologiques sur les médicaments, le système de santé et les relations soignants-soignés mais aussi à contribuer à l’amélioration de la prise en charge des patients en échec, pour préserver l’efficacité des thérapies antirétrovirales, sur laquelle repose l’espoir, d’éradiquer un jour l’épidémie. / When antiretroviral treatment becomes widespread in countries in the Global South, the emergence of viral resistance related to treatment failures is a threat for individuals and the general public. In Cameroon, various constraints hinder the prevention, detection and case management of treatment failures. Through an anthropological approach, this dissertation explores the context and determinants of treatment failures. Nonadherence is the main cause of their onset. Medical and psychosocial teams must face a lack of suitable guidelines and procedures. Also, notification of the failure is often associated with placing blame on patients, on whom caregivers assign sole responsibility for the failure. Adaptation in facilities is limited. Medical and psychosocial care is focused on starting treatment and making changes in treatment, but long-term follow-up does not exist. Patients’ perceptions of antiretrovirals are hampered by failures. The failure redefines power relationships and trust between caregivers and patients. Caregivers’ attitudes vacillate between compassion and condemnation, while the failure reinforces the patients’ dependence. This dissertation aims to contribute to the anthropological discussion on medicines, the health system and the caregiver-patient relationship as well as to improve care for patients with treatment failure to ensure the continued effectiveness of antiretroviral therapies that underlie any hopes of one day eradicating the epidemic.

The Chlamydiaceae are widespread pathogens of both humans and animals. Chlamydia trachomatis infection causes blinding trachoma and reproductive complications in humans. Chlamydia pneumoniae causes human respiratory tract infections and atypical pneumonia. Chlamydia suis infection is associated with conjunctivitis, diarrhea, and failure to gain weight in domestic swine. Chlamydial infections in humans and domesticated animals are generally controlled by antibiotic treatment—particularly macrolides (usually azithromycin) and tetracyclines (tetracycline and doxycycline). Tetracycline-containing feed has also been used to limit infections and promote growth in livestock populations, although its use has decreased because of growing concerns about antimicrobial resistance development. Because Sandoz and Rockey published an elegant review of chlamydial anti-microbial resistance in 2010, we will review the following: (i) antibiotic resistance in C. suis, (ii) recent evidence for acquired resistance in human chlamydial infections, and (iii) recent non-genetic mechanisms of antibiotic resistance that may contribute to treatment failure.

Treatment of Pseudomonas aeruginosa remains challenging, despite the availability ceftolozane-tazobactam. We report a treatment failure with ceftolozane-tazobactam salvage therapy for pneumonia complicated by lung abscess. Drug resistance, dose selection, and source control are possible contributing factors. Ceftolozane-tazobactam susceptibility testing should precede therapy and consideration should be given to dosing selection.

What is known and objective: Treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia is a long-standing challenge to health care, often complicated by metastatic infections, treatment failure and mortality. When MRSA bacteraemia persists despite adequate initial treatment, current Infectious Diseases Society of America guidelines recommend evaluation and removal of possible sources of infection. In addition, a change in therapy may be considered. The objective of this review was to explore the therapeutic options for the treatment of persistent MRSA bacteraemia. Methods: A literature search of PubMed, MEDLINE and Google Scholar was performed using the following search terms: [methicillin-resistant Staphylococcus aureus OR MRSA] AND [bacteraemia OR bloodstream infection] AND [persistent OR persistence OR refractory OR treatment failure OR salvage] AND treatment. We evaluated relevant, adult, English-language, peer-reviewed studies published between 1985 and May 2018. In vitro and animal studies were considered as supportive of in vivo data. Results and discussion: Randomized, controlled trials are lacking. However, case series and case reports support multiple treatment options including high-dose daptomycin in combination with an antistaphylococcal β-lactam, ceftaroline, trimethoprim-sulfamethoxazole (TMP-SMX) or fosfomycin; ceftaroline alone or in combination with vancomycin or TMP-SMX; linezolid alone or in combination with a carbapenem, or telavancin. What is new and conclusion: Given the heterogeneity of the data, a preferred regimen has not emerged. Prescribers must take into consideration recent exposure, source control, and available synergy and clinical data. Further comparative trials are needed to establish a preferred regimen and the creation of a universal treatment algorithm.

To date, outcome research suggests that providing clinicians with patient progress feedback and problem-solving tools is effective in improving therapeutic outcome for clients who are predicted to have a negative treatment outcome. To expand upon this body of research, the current study examined the efficacy of using these problem-solving tools (Clinical Support Tools; CST) to reduce the risk of treatment failure and enhance positive outcome with 118 clients who were not identified as at -risk for a negative outcome. Results of this study indicated that the intervention failed to lower the rate of becoming an at-risk case or to enhance treatment outcome. A possible explanation for the null results observed is poor treatment compliance. Based on the findings of this study, the CST cannot be recommended as an intervention across the broad range of clients who enter treatment. However, qualitative analysis results reflect positive indicators for continued research with at-risk cases.

Outcome research has documented worsening among a minority of the patient population (5 to 10%). In this study a psychotherapy quality assurance system intended to enhance outcomes in patients at risk of treatment failure was reviewed through the use of meta-analytic, mega-analytic, and multilevel analytic techniques. A pooled dataset from six major studies conducted at a large university counseling center and a hospital outpatient setting (N = 6151, mean age = 23.3 years, female = 63.2%, Caucasian = 85%) were re-analyzed to examine the effects of progress feedback on patient outcome. In this quality assurance system, the Outcome Questionnaire-45 was routinely administered to patients to monitor their therapeutic progress and was utilized as part of an early alert system to identify patients at risk of treatment failure. Patient progress feedback based on this alert system was provided to clinicians to help them intervene before treatment failure occurred. Intent-to-treat and efficacy analyses of the effects of feedback interventions were conducted to obtain the estimates of effects expected from implementation of this quality assurance system as a policy as well as in clinical trials. Three forms of feedback interventions—integral elements of this quality assurance system—were effective in enhancing treatment outcome, especially for signal alarm patients. Two of the three feedback interventions were also effective in preventing treatment failure (Clinical Support Tools and the provision of patient progress feedback to therapists). The Clinical Support Tool intervention was effective not only in terms of the amount of outcome enhancing effect, but also in the rate of patient recovery. The current state of evidence appears to support the efficacy and effectiveness of feedback interventions in enhancing treatment outcome.

During the last decade, substantial advances have been made in the understanding of the complex molecular, immunological and cellular disturbances involved in the initiation as well as evolution of myelodysplastic syndromes (MDS). In 85% of the mainly frail and older patient population, anemia is present at the time of diagnosis and is thus a major therapeutic challenge. High rates of primary resistance to erythropoiesis-stimulating agents (ESAs), the currently only approved standard therapy to treat anemia in lower-risk MDS, demand the development of novel and effcient drugs with a good safety profile. Luspatercept, a ligand trap of activin receptor II, is able to promote late stage erythropoiesis even in patients failing prior ESA treatment. The presence of ring sideroblastic phenotype defines a subgroup of patients with higher response rates. Additionally, recent developments in clinical research using HIF-1 or telomerase modulation by roxadustat or imetelstat are promising. Other areas of translational research involve targeting the inflammasome by anti-inflammatory drugs in order to improve anemia. These efforts will hopefully pave the way for new targeted treatment options for anemic low-risk MDS patients.

Immunologic monitoring is part of the standard care for patients on antiretroviral treatment. Yet, little is known about the routine implementation of immunologic monitoring in Ethiopia. This study assessed the pattern of immunologic monitoring, immunologic response, level of immunologic treatment failure and factors related to it among patients on antiretroviral therapy in selected hospitals in southern Ethiopia. A retrospective longitudinal analytic study was conducted using documents of patients started on antiretroviral therapy. A total of 1,321 documents of patients reviewed revealed timely immunologic monitoring were inadequate. Despite overall adequate immunologic response, the prevalence of immunologic failure was 11.5% (n=147). Having WHO Stage III/IV of the disease and a higher CD4 (cluster differentiation 4) cell count at baseline were identified as risks for immunologic failure. These findings highlight the magnitude of the problem of immunologic failure. Prioritizing monitoring for high risk patients may help in effective utilisation of meager resources / Health Studies / M.A. (Public Health)