Institution/department: Charles University, Faculty of Pharmacy in Hradec Kralove, Department of Social and Clinical Pharmacy Title of diploma thesis: The rational use of proton pump inhibitors among geriatric patients in the Czech Republic Supervisor: Assoc. Prof. Daniela Fialova, PharmDr. Ph.D. Author: Ivana Geletova Introduction: The dynamic process of ageing requires adequate attention at a global level, mainly in the area of providing a proper healthcare. Ageing process is specific by significant involutional changes and is often complicated by higher polymorbidity and polypharmacotherapy. Therefore, it is necessary to eliminate the negative impact of possible drug-related and nondrug-related risk factors and to ensure the rational use of medicines. Proton pump inhibitors (PPIs) are one of the most frequently prescribed classes of drugs in older adults, administered especially for the treatment of gastrointestinal tract (GIT) disorders associated with increased secretion of gastric acid and/or impairment of GIT or as a preventive treatment of potential drug-related and other gastropathies. This diploma thesis focused on evaluating the prevalence of use of PPIs among geriatric patients in acute, ambulatory and pharmacy settings of healthcare in the Czech Republic, in the EUROAGEISM H2020...

Strongyloidiasis stercoralis hyperinfection presenting as vasculitic-like skin lesions is rare. An autoinfection cycle allows intestinal strongyloidiasis, usually a benign infection, to persist for many decades. We report a woman with disseminated S stercoralis infection presenting as nonpalpable purpuric skin rash and syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Upon admission, she was treated with corticosteroids for her vasculitic skin lesions, which then worsened her status. When the diagnosis was recognized, steroids were stopped, thiabendazole treatment was instituted, and she gradually recovered. Serious or fatal infection can occur in patients with strongyloidiasis who were treated with immunosuppressive drugs. Stool specimen screening and/or serological tests for S stercoralis infection in patients who require immunosuppressive therapy helps to prevent complications before embarking on such treatment. Unexplained hyponatremia, severe hypoalbuminemia without proteinuria, and unusual skin rashes, especially over the lower aspect of the abdomen and upper aspects of the thighs, in persons living in areas endemic to S stercoralis should raise suspicion of S stercoralis infection.

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A critical first step in addressing problem behavior is to identify the function of the problem, or reason for engaging in the problem behavior, using systematic assessment procedures known as a functional analysis (FA). The literature consistently demonstrates the effectiveness of FAs, and variations of FAs (e.g., trial-based functional analysis [TBFA]) for assessing a variety of topographies of problem behaviors across populations, age groups, and settings; however, the use of TBFAs for assessing the function of inappropriate mealtime behavior (IMB) has been documented in the literature only once. The purpose of the current study was to contribute to the research examining the efficacy of using TBFAs to identify functions of IMB. Results from the current study are mixed. TBFAs lead to the identification of functions of IMB for 1 out of 3 participants. When comparing TBFA results to traditional FA results, partial correspondence was observed for one participant, and no correspondence was observed for the other two participants. Future research should continue to evaluate the efficacy of TBFAs for IMB as well as evaluate the validity of TBFAs for IMB when results yield evidence of functional relationships.

No / There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. OBJECTIVES: The objective of the review was to determine the effect of interventions to optimise prescribing for older people living in care homes. SEARCH METHODS: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library (Issue 11, 2012); Cochrane Database of Systematic Reviews, The Cochrane Library (Issue 11, 2012); MEDLINE OvidSP (1980 on); EMBASE, OvidSP (1980 on); Ageline, EBSCO (1966 on); CINAHL, EBSCO (1980 on); International Pharmaceutical Abstracts, OvidSP (1980 on); PsycINFO, OvidSP (1980 on); conference proceedings in Web of Science, Conference Proceedings Citation Index - SSH & Science, ISI Web of Knowledge (1990 on); grey literature sources and trial registries; and contacted authors of relevant studies. We also reviewed the references lists of included studies and related reviews (search period November 2012). We included randomised controlled trials evaluating interventions aimed at optimising prescribing for older people (aged 65 years or older) living in institutionalised care facilities. Studies were included if they measured one or more of the following primary outcomes, adverse drug events; hospital admissions;mortality; or secondary outcomes, quality of life (using validated instrument); medication-related problems; medication appropriateness (using validated instrument); medicine costs. Two authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. A narrative summary of results was presented. The eight included studies involved 7653 residents in 262 (range 1 to 85) care homes in six countries. Six studies were cluster-randomised controlled trials and two studies were patient-randomised controlled trials. The interventions evaluated were diverse and often multifaceted. Medication review was a component of seven studies, three studies involved multidisciplinary case-conferencing, two studies involved an educational element for care home staff and one study evaluated the use of clinical decision support technology. Due to heterogeneity, results were not combined in a meta-analysis. There was no evidence of an effect of the interventions on any of the primary outcomes of the review (adverse drug events, hospital admissions and mortality). No studies measured quality of life. There was evidence that the interventions led to the identification and resolution of medication-related problems. There was evidence from two studies that medication appropriateness was improved. The evidence for an effect on medicine costs was equivocal. Robust conclusions could not be drawn from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems, however evidence of an effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.

Background Based on changes in pharmacokinetics and –dynamics in elderly patients, there are potentially inappropriate medications (PIM) that should be avoided in patients aged ≥ 65 years. Current studies showed prescription rates of PIM between 22.5 and 28.4 % in the primary care setting. The evidence concerning reasons for PIM prescription by FPs is limited. Methods This mixed method study consisted of three research parts: 1) semi-standardized content analysis of patients’ records, 2) qualitative interviews with FPs using a) open questions and b) selected patient-specific case vignettes and 3) qualitative interviews with FPs’ medical assistants. The integration of qualitative interviews was used to explain the quantitative results (triangulation design). PIM were identified according to the German PRISCUS list. Descriptive and multivariate statistical analysis was done using SPSS 22.0. Qualitative content analysis of interviews was used to classify the content of the interviews for indicating pertinent categories. All data were pseudonymously recorded and analyzed. Results Content analysis of 1846 patients’ records and interviews with 7 related FPs were conducted. Elderly patients [n = 1241, mean age: 76, females: 56.6 %] were characterized in average by 8.3 documented chronic diagnosis. 23.9 % of elderly patients received at least one PIM prescription. Sedatives/hypnotics were the most frequent prescribed PIM-drugs (13.7 %). Mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Common reported reasons for PIM prescription by FPs concerned limited knowledge regarding PIM, limited applicability of PIM lists in daily practice, lack of time, having no alternatives in medication, stronger patient-related factors than age that influence prescription, own bad experiences regarding changes of medication or refusal of following prescriptions of sedative/hypnotics. Conclusions It is essential to see FPs in a complex decision making situation with several influencing factors on their prescribing, including: patient-oriented prioritization, FPs’ experiences in daily practice, FPs’ knowledge regarding existing recommendations and their trust in it and organizational characteristics of FPs’ daily medical practice. These pros and cons of PIM prescription in elderly patients should be considered in FPs’ advanced training.

Depuis plusieurs années le système éducatif français peine à remplir sa mission auprès de tous les élèves. En outre, les comportements indisciplinés de ces derniers en classe viennent contrarier la tâche des enseignants et par conséquent la réussite scolaire des élèves. En l’absence de données sur la gestion par les enseignants de l’indiscipline des élèves en classe à l’île de La Réunion, cette recherche qualitative descriptive interroge, après les vagues successives de plans de lutte ministériels contre les comportements déviants à l’école initiée il y a plus de 20 ans, la place accordée au domaine de la gestion de classe dans le système éducatif français. Cette recherche vise à documenter : 1- le comportement des collégiens en classe ; 2- les connaissances et les pratiques de gestion de classe des enseignants ; et 3- leurs représentations quant à leur formation dans ce domaine. L’échantillon est composé de 47 enseignants de collège de Réseau d’Éducation Prioritaire renforcée (REP+) de La Réunion. Les résultats de cette recherche montrent l’ampleur du phénomène d’indiscipline dans certaines classes et semblent indiquer chez les enseignants, indépendamment de leur âge, de leur sexe et de leur ancienneté, un manque de connaissances au regard du phénomène d’indiscipline scolaire et des pratiques efficaces de gestion de classe. L’analyse des données suggère que ces lacunes s’expliquent entre autres par une formation insuffisante dans le domaine de la gestion de classe. Si cette recherche souligne l’importance majeure de la gestion de classe dans l’exercice du métier d’enseignant, elle invite également la communauté scientifique française à investir ce thème de recherche peu étudié en France et pourtant constitutif des sciences de l’éducation. / For several years, the French school system has shown some dysfunctions and has struggled to follow its school mission in instructing and educating all its students. Moreover, middle school students’ behavioural problems in class tend to interfere with teachers’ teaching task and as a consequence they tend to obstruct students’ success at school. This research takes place after the last 20 years of successive waves of plans undertaken from the French Ministry of education to address inappropriate behaviours at school. Since there is a lack of data in Reunion Island about teachers’ skills in dealing with students’ inappropriate behaviour in class, this descriptive and qualitative doctoral thesis questions the place given to classroom management in the French school system. This research aims at documenting: 1- middle school students’ behaviour in class; 2- teachers’ theoretical knowledge and practices in classroom management; 3- teachers’ representations pertaining to their training in classroom management. The sample ofrespondents includes 47 teachers in French public middle schools part of the Priority Education Network in Reunion Island. Results show the extent of the phenomenon of behavioural problems in some classes and seem to indicate a lack of teachers’ skills and teachers’ knowledge in classroom management regardless of their age, their gender and their length of service. The data analysis also indicates that one of the possible reasons for these results could be a lack of reservice and in-service teachers’ training in classroom management. This research joints to the fact that classroom management is a crucial part of the teaching profession. It also invites the French scientific community to invest the theme of classroom management since this theme is currently barely studied in France.

Made available in DSpace on 2016-07-27T14:20:37Z (GMT). No. of bitstreams: 1 Brunah Pasa Rockenbach.pdf: 1026581 bytes, checksum: ecbac5fd285aab3ebd942d247151b701 (MD5) Previous issue date: 2014-12-11 / The present study analyzed functionally inappropriate verbal responses of a person who had been diagnosed with schizophrenia in a psychiatric service (CAPS) located in Cuiabá, MT. The participant, male, single, 25 years old. To investigate the antecedent and consequent events from inappropriate verbal responses, was used the functional assessment process being interviewed staff CAPS and family; also direct observations of their behavior. This information supported the functional analysis with the conditions: (1) attention, (2) demand, (3) alone and (4) control. The condition (1) attention was divided into: (1.1) attention-team, (1.2) attention-comment, (1.3) attention-doubt and (1.4) attention-reprimand. The condition (2) demand was subdivided into (2.1) and activitydemand (2.2) demand group. The results showed that under the conditions of attention and demand was highest occurrences of inappropriate verbal than in other conditions: alone and control. It is inferred from these findings that inappropriate verbal responses were maintained by the sources of positive reinforcement and negative reinforcement. To intervene, was used the design of type AB1B2A followed by follow-up, was applied to the differential reinforcement of alternative behavior (DRA) procedure, allowing a reduction of inappropriate words and increasing appropriate. Such studies enable the development of more effective interventions aimed at increasing desired from people who have psychiatric diagnosis of schizophrenia behaviors. / O presente estudo analisou funcionalmente as respostas verbais inapropriadas de uma pessoa que possuía o diagnóstico de esquizofrenia em um Centro de Atenção Psicossocial (CAPS) localizado em Cuiabá, MT. O participante, sexo masculino, solteiro e idade de 25 anos. Para investigar os eventos antecedentes e consequentes das respostas verbais inapropriadas empregou-se o processo de avaliação funcional sendo entrevistadas a equipe do CAPS e familiares do participante e também observações diretas de seus comportamentos. Essas informações subsidiaram a análise funcional com as condições: (1) atenção, (2) demanda, (3) sozinho e (4) controle. A condição de (1) atenção foi subdividida em: (1.1) atenção-equipe, (1.2) atenção-comentário, (1.3) atenção-dúvida e (1.4) atenção-reprimenda. A condição de (2) demanda foi subdividida em: (2.1) demanda atividade e (2.2) demanda grupo. Os resultados apontaram que nas condições de atenção e demanda houve maiores ocorrências de falas inapropriadas do que nas demais condições: sozinho e controle. Infere-se a partir desses achados que as respostas verbais inapropriadas foram mantidas pelas fontes de reforçamento positivo e reforçamento negativo. Para intervir utilizou-se o delineamento do tipo AB1B2A seguido por follow-up, em que foi aplicado procedimento de reforçamento diferencial de comportamento alternativo (DRA), que possibilitou a redução de falas inapropriadas e aumento das apropriadas. Estudos como esse possibilitam o desenvolvimento de intervenções mais eficazes, visando o aumento de comportamentos desejados de pessoas que possuem o diagnóstico psiquiátrico de esquizofrenia.

Made available in DSpace on 2016-07-27T14:22:15Z (GMT). No. of bitstreams: 1 Gabriela Rodrigues Felipe.pdf: 537826 bytes, checksum: de46b5d0fea1c3688de8fe8c2afe513e (MD5) Previous issue date: 2009-05-29 / The objective of this study was to investigate the verbal behavior of a person diagnosed as schizophrenic for 28 years in a mental health unit, using the principles of behavior analysis. The participant was a person of the female, married, mother of three children, lived with her husband and with a history of two admissions to psychiatric institutions, with the first 24 years of age and last for 35 years. The participant had daily use of drugs: haloperidol 5mg, 25mg and Pamergan Risperidone 2mg. The participant was selected among patients in care in CAPS. The research activities included experimental sessions in the form of clinical care in the home of the participant. All sessions were recorded on video and transcribed in full, which allowed the analysis of verbal behavior of the participant and their categorization into appropriate words and inappropriate words. For the control procedures were used two experimental designs. In the design of interventions in alternate format ABAC. The design of alternative interventions was the alternation between the conditions of the baseline (A) which was free and talk to different interventions, and (B) Functional analysis, (C) training of social skills has been divided into two phases, the first with the participant and the second with a family member to guide the family to deal with these difficulties. In all, during this design were seventeen sessions. The design of withdrawal or reversal in the ABA. The design consisted of withdrawal or reversal of the baseline phase (A) before the intervention phase, (B) which is characterized by alternative differential reinforcement (DRA) of verbal behavior and appropriate procedures for withdrawal of social attention to the behavior inappropriate verbal (EXT) and (A) a kind of 'return to the baseline. " Other nine sessions were held until the final period of data collection. The results showed that the strengthening influence the social behavior of verbal participant and that the procedures for the analysis of behavior intervention were effective in reduction of inappropriate words and increase the appropriate lines. The results were discussed in terms of applied methodology, principles of behavior, the effects achieved and the corroboration of data. You can say to this study that the behavioral changes made by the participant were relevant. / O objetivo do presente estudo foi o de investigar o comportamento verbal de uma pessoa diagnosticada como esquizofrênica há 28 anos, em uma unidade de saúde mental, utilizando-se dos princípios da análise do comportamento. A participante era uma pessoa do sexo feminino, casada, mãe de três filhos, residia com o marido e com um histórico de duas internações em instituições psiquiátricas, sendo a primeira aos 24 anos de idade e a última aos 35 anos. A participante fazia uso diário dos medicamentos: Haloperidol 5mg, Pamergan 25mg e Risperidona 2mg. A participante foi selecionada entre os pacientes em atendimento no CAPS. As atividades da pesquisa incluíram sessões experimentais no formato de atendimento clínico na casa da participante. Todas as sessões foram registradas em vídeo e transcritas na íntegra, o que possibilitou a análise do comportamento verbal da participante e sua categorização em falas apropriadas e falas inapropriadas. Para o controle dos procedimentos foram utilizados dois delineamentos experimentais. No delineamento de intervenções alternadas no formato A-B-A-C-A. O delineamento de intervenções alternadas consistiu na alternância entre as condições de linha de base (A) que foi conversas livres e de diferentes intervenções, sendo (B) análises funcionais, (C) treinamento das habilidades sociais que foi dividido em duas fases, a primeira com a participante e a segunda com um membro da família para orientar a família como lidar com essas dificuldades existentes. Ao todo, durante esse delineamento foram realizadas dezessete sessões. O delineamento de retirada ou reversão no formato AB- A. O delineamento de retirada ou reversão consistiu de uma fase de linha de base (A) antes da fase de intervenção, (B) que se caracterizou pelo reforçamento diferencial alternativo (DRA) dos comportamentos verbais apropriados e procedimentos de retirada da atenção social para os comportamentos verbais inapropriados (EXT) e (A) uma espécie de retorno à linha de base . Outras nove sessões foram realizadas até ao prazo final da coleta de dados. Os resultados demonstraram que o reforço social influenciou no comportamento verbal da participante e que os procedimentos de intervenção da análise do comportamento foram efetivos para diminuição das falas inapropriadas e aumento das falas apropriadas. Os resultados foram discutidos em termos da metodologia aplicada, dos princípios comportamentais, dos efeitos alcançados e da corroboração dos dados da literatura. Pode-se afirmar com este estudo que as modificações comportamentais apresentadas pela participante foram relevantes.

Estados e municípios puderam definir seu próprio elenco de medicamentos a ser ofertados aos seus cidadãos com a Política Nacional de Medicamentos (1998), e a consequente descentralização da Assistência Farmacêutica. Percebeu-se a oportunidade de realizar um estudo para analisar peculiaridades de um conjunto de Relações Municipais de Medicamentos Essenciais (Remumes) de municípios paulistas, visando a racionalidade das listas como instrumento norteador da aquisição, distribuição, prescrição e planejamento da AF municipal. Considerou-se as possibilidades de diferentes cenários, dependente da qualidade da gestão, organização e do perfil dos recursos humanos locais e que uma equipe farmacêutica competente e qualificada prove uma melhor gestão da AF. Além disso, considerando os impactos da transição demográfica e epidemiológica da população brasileira em que os idosos utilizam mais medicamentos, gestores e profissionais da saúde precisam selecionar medicamentos criteriosamente para atender necessidades dessa faixa etária. O emprego de medicamentos potencialmente inapropriados (MPI) para idosos requer cuidado e estudos tem procurado lista-los e criar instrumentos de seleção. Aqueles inclusos nos critérios Beers definidos com apoio da Sociedade Americana de Geriatria encontram-se associados a desfechos desfavoráveis de saúde e mortalidade. OBJETIVOS: Analisar Remumes disponibilizadas para este estudo visando alertar profissionais de saúde e gestores sobre MPIs que podem comprometer a segurança dos pacientes no processo de utilização de medicamentos. MÉTODOS: Trata-se de um estudo transversal de análise das Remumes dos municípios sedes dos 17 Departamentos Regionais de Saúde (DRSs) e das Remumes dos 27 municípios do Departamento Regional de Saúde (DRS) XIII enfatizando aqueles MPIs contidos nelas. Obtiveram-se 100% das 17 Remumes dos municípios sedes dos DRSs e 92,3% das 27 Remumes dos municípios do DRS XIII, formando um banco de dados com 9063 medicamentos, discriminados pela classificação ATC e pelos diversos critérios de Beers. RESULTADOS E DISCUSSÃO: Os municípios sedes apresentaram Remumes contendo de 128 (Piracicaba) a 396 (Santos) medicamentos, com média de 272,3 (DP=71,1) medicamentos. As Remume dos municípios da DRS XIII apresentaram entre 32 (Luiz Antônio) e 403 (Cássia dos Coqueiros) medicamentos, com média de 198 (DP=111,4). Predominaram os medicamentos que atuavam no sistema nervoso seguidos pelos cardiovasculares e anti-infecciosos sistêmicos. Quando os medicamentos contidos nas Remumes foram submetidos à aplicação dos critérios de Beers, foram identificados 59,9% de MPIs, sendo que do total de 77 classes terapêuticas 39 (53,6%) classes tinham pelo menos um representante na lista dos Critérios de Beers. Os achados foram discutidos comparando dados dos municípios, outros critérios para medicamentos inapropriados para idosos, à luz de evidências clíncas mais recentes. CONCLUSÃO: As Remumes mostraram elevada variação no número de medicamentos e grupos farmacológicos e elenco considerável de medicamentos dos critérios de Beers. Apontou para necessidade de qualificação da assistência farmacêutica municipal e a elaboração de um guia norteador que contribuam para o fortalecimento da Atenção Básica e da Assistência Farmacêutica. Este aprimoramento da utilização de medicamentos em geral e para idosos, envolvendo a prescrição, dispensação, administração e uso pelo paciente, reduzem morbimortalidade relacionada aos medicamentos. / States and municipalities were able to define their own list of medicines to be offered to their citizens with the National Drug Policy (1998) and the consequent decentralization of Pharmaceutical Assistance (PA). It was noticed the opportunity to carry out a study to analyze the peculiarities of a set of Municipal Lists of Essential Medicines (Remumes) of São Paulo state municipalities, aiming at the rationality of lists as a guiding instrument for the acquisition, distribution, prescription and planning of the municipal PA. Consideration was given to the possibilities of different scenarios, depending on the quality of management, organization and the profile of local human resources, and that a competent and qualified pharmaceutical team provides a better management of PA. In addition, considering the impact of the demographic and epidemiological transition of the Brazilian population in which the elderly use more drugs, managers and health professionals need to select medicines carefully to meet the needs of this age group. The employment of potentially inappropriate medications (PIM) for the elderly require care and studies have sought to list them and develop screening tools . Those included in the Beers criteria, defined with support from the American Society of Geriatrics, are associated with unfavorable health and mortality outcomes. OBJECTIVES: To analyze Remumes made available for this study in order to alert health professionals and managers about MPIs that may compromise patients\' safety in the medication use process. METHODS: This is a cross-sectional study of the Remumes of the municipalities of the 17 Regional Health Departments (DRSs) and of the Remumes of the 27 municipalities of the Regional Health Department (DRS) XIII emphasizing those MPIs contained in them. 100% of the 17 Remumes of the municipalities of the DRSs and 92.3% of the 27 Remumes of the municipalities of the DRS XIII were formed, forming a database with 9063 medicines, discriminated by the ATC classification and by the diverse criteria of Beers. RESULTS AND DISCUSSION: The municipal districts presented Remumes containing from 128 (Piracicaba) to 396 (Santos) medications, with an average of 272.3 (SD = 71.1) medications. Remume of DRS XIII municipalities presented medications between 32 (Luiz Antônio) and 403 (Cássia dos Coqueiros), with a mean of 198 (SD = 111.4). Predominant drugs that worked in the nervous system followed by cardiovascular and systemic anti-infectious. When medicinal products contained in Remumes were submitted to the Beers criteria, 59.9% of PIMs were identified. Of the total of 77 therapeutic classes, 39 (53.6%) classes had at least one representative in the list of Criteria of Beers. The findings were discussed comparing data from the municipalities, other criteria for PIMs for the elderly, in light of more recent clinical evidence. CONCLUSION: Remumes showed high variation in the number of drugs and pharmacological groups and considerable list of drugs of the Beers criteria. He pointed to the need for qualification of municipal pharmaceutical assistance and the elaboration of a guiding guide that contribute to the strengthening of Primary Care and Pharmaceutical Assistance. This improvement in the utilization of medications in general and for the elderly, involving prescription, dispensing, administration and use by the patient, reduces drug-related morbidity and mortality.