M.Sc. (Med), Faculty of Health Sciences,University of the Witwatersrand, 2011 / Background: Many factors affect the prescribing of medication to patients with schizophrenia including variables that relate to physicians and may result in marked variance in the choice of drugs, dosages, drug combinations, route of administration and the use of antipsychotic, anticholinergic, sedative and other adjuvant drugs. Clinical practice guidelines were developed to address this variance and for other reasons, including the management of side-effects, drug innovation, rising costs, information overload, changes in treatment goals and the management of medication non-adherence. There are advantages and disadvantages to using clinical practice guidelines including those pertaining to context and cultural norms, but they remain the best method of assessing prescribing quality. Many guidelines are based on the results of randomised clinical trials (with a single drug) or are the consensus of experts in the field. Despite the development and publication of these guidelines over the past two decades, they are frequently not adhered to resulting in much variance in treatment. Aims and objectives: The aim of the study was to determine to what extent the prescribing of psychotropic drugs in the treatment of schizophrenia was consistent with the most recent version of each of five guidelines that originate outside South Africa (two from the United States and one each from Canada, the United Kingdom, and Australia and New Zealand); and one that was developed locally. Methodology: A retrospective, cross-sectional prescription chart review with data sampling at three time points (on hospital admission, at fourteen days thereafter and on hospital discharge) was undertaken. A sample population was drawn over a three year period during which the patients’ physician had access to the same drug formulary. Seventy patients met the study selection criteria in terms of age, diagnosis and receipt of antipsychotic medication during hospital stay and on discharge. Seventy patients met the study selection criteria, and their prescriptions for psychotropic medication (exclusively) were examined for a number of parameters including: drug class, drug name, dose, route of administration and whether the medication was to be administered routinely or ‘as needed’. Findings and discussion: As compared with the recommendations made in some or all of the guidelines, first generation antipsychotic agents were over-prescribed especially early on in the patients’ hospital stay, whereas second generation antipsychotics were under-prescribed. The profile changed after fourteen days and on discharge there were more patients on second generation drugs than on the older drugs. More patients were discharged on depot antipsychotic treatment than were admitted which is considered a favourable finding, however, many patients receiving the depot form continued to be prescribed the oral drug on a routine basis and for an indefinite period, resulting in antipsychotic polypharmacy. Anticholinergic drugs were prescribed as prophylaxis for the extra-pyramidal side-effects of the first generation antipsychotic drugs and more than a quarter of the sample received these drugs on discharge, after which they were to be taken routinely and indefinitely. A similar finding was made with the use of benzodiazepine sedatives, where nearly a quarter of patients received these drugs on discharge - again to be taken routinely and for an unspecified period. Sodium valproate was given increasingly to many patients in the sample and was prescribed to over a quarter of those upon discharge, without an indication of duration. Limitations: The study was retrospective in design, without the benefit of the patients’ clinical histories and treatment progress, and the findings were compared with guidelines whose age spanned more than a decade and some of which had become redundant. Conclusions: The study demonstrated some prescribing habits that were not in accord with the guidelines used for comparison in the study. The extent of the disagreement reveals the need for a prospective pilot study that will include the patients’ clinical progress in the study design which will provide greater insight into why specific medication parameters were chosen by the physician for the individual patient. If the findings justify it, then a programme promoting better adherence to the most current guidelines should be commenced.

<p>Increasing diabetes prevalence rates, poor involvement of and limited knowledge among health care professionals in disease management, and poor implementation of guidelines are barriers to quality diabetes care. This thesis aimed to develop, implement and evaluate an on-site diabetes pharmacotherapy program for public sector pharmacists. Qualitative and quantitative research methods were used inthe pre- and post-intervention study.</p>

Rationale: Methodological quality of systematic reviews (SRs) remains an area of concern with no consensus on the optimal appraisal instrument to assess quality of published research. Hypothesis: The Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a feasible and useful methodology to assess quality of evidence in pediatric pharmacotherapy. Aim: To demonstrate the applicability of the GRADE to selected topics. Methods: To perform two SRs to illustrate the practical use of the GRADE, highlight methodological challenges encountered and compare the GRADE to the alternative appraisal tool. Results: the GRADE was implemented to conduct two SRs. Judgments on imprecision were challenging. Comparison of the GRADE to alternative tool demonstrated that GRADE may generate different conclusions on overall quality assessment. Conclusion: The GRADE is a valuable innovative tool for assessing quality of evidence, applicable to the field of pediatric pharmacotherapy, with a potential to impact inferences drawn after applying alternative instruments.

<p>Increasing diabetes prevalence rates, poor involvement of and limited knowledge among health care professionals in disease management, and poor implementation of guidelines are barriers to quality diabetes care. This thesis aimed to develop, implement and evaluate an on-site diabetes pharmacotherapy program for public sector pharmacists. Qualitative and quantitative research methods were used inthe pre- and post-intervention study.</p>

Rationale: Methodological quality of systematic reviews (SRs) remains an area of concern with no consensus on the optimal appraisal instrument to assess quality of published research. Hypothesis: The Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a feasible and useful methodology to assess quality of evidence in pediatric pharmacotherapy. Aim: To demonstrate the applicability of the GRADE to selected topics. Methods: To perform two SRs to illustrate the practical use of the GRADE, highlight methodological challenges encountered and compare the GRADE to the alternative appraisal tool. Results: the GRADE was implemented to conduct two SRs. Judgments on imprecision were challenging. Comparison of the GRADE to alternative tool demonstrated that GRADE may generate different conclusions on overall quality assessment. Conclusion: The GRADE is a valuable innovative tool for assessing quality of evidence, applicable to the field of pediatric pharmacotherapy, with a potential to impact inferences drawn after applying alternative instruments.

Magister Pharmaceuticae - MPharm / Increasing diabetes prevalence rates, poor involvement of and limited knowledge among health care professionals in disease management, and poor implementation of guidelines are barriers to quality diabetes care. This thesis aimed to develop, implement and evaluate an on-site diabetes pharmacotherapy program for public sector pharmacists. Qualitative and quantitative research methods were used inthe pre- and post-intervention study. / South Africa

Orientador: Ana Valéria Barros de Castro / Resumo: Os adenomas hipofisários são lesões relativamente comuns, representando 10 a 15% de todos os tumores intracranianos. Dentre os tumores secretores, os produtores de prolactina (prolactinoma), são os mais freqüentes. O tratamento de escolha é o medicamentoso, que ocorre de modo prolongado e, geralmente múltiplo, elevando, portanto, os riscos de interações medicamentosas (IM), reações adversas a medicamentos (RAM) e outros problemas relacionados com medicamentos (PRM). O objetivo desse estudo foi aplicar a Atenção Farmacêutica no tratamento de pacientes portadores de prolactinomas, para investigar e descrever as possíveis IM, RAM e PRM e auxiliar na orientação farmacoterapêutica e melhorar a qualidade de vida do paciente. Utilizamos a metodologia Dáder para o seguimento farmacoterapêutico e a metodologia de Minessota para a classificação dos PRM. Foram utilizadas as técnicas da análise de variância não-paramétrica para o modelo de medidas repetidas em dois grupos independentes e o teste do qui-quadrado de Mc Neman e Mann-Whitney para comparações dos resultados, com nível de significância de 5%. Observamos diminuição dos custos dos medicamentos, dos níveis séricos de prolactina dos pacientes e da automedicação; houve detecção e resolução de RAM, PRM e IM. Concluímos que o seguimento farmacoterapêutico mediante a aplicação da AF foi útil para o tratamento de portadores de prolactinoma. / Abstract: Pituitary adenomas are relatively common disorders, representing 10 to 15% of all intracranious tumors. Among the secreting tumors, prolactinomas, which secrete prolactina, are the most frequent ones. The treatment of choice of prolactinoma is clinical and generally involves multiple and long-term pharmacotherapy which may predispose to drug-related problems (DRP) such as drug interactions (DI) or adverse drug reactions (ADR). The objective of this study was to apply Pharmaceutical Care in the pharmacotherapy follow-up of patients with prolactinoma in order to investigate and describe possible DI, ADR and other DRP that could modify the success and insurance of treatment and assist on the pharmacoterapy orientation. We used Dader’s methodology to apply Pharmaceutical Care and methodology of Minessota to classify the DRP. For statistical analysis we used non-parametric analysis of variance for repeated measurements in two independent groups and the test of chi-square of Mc Neman and Mann-Whitney for comparisons of the results, with level of significance of 5%. We detected and/or resolved the majority of ADR, DRP and DI and reduced medical-costs, prolactinemia levels and frequency of self-medication practice. We conclude that pharmaceutical care is an important approach to the pharmacotherapy follow-up of patients with prolactinoma. / Mestre

FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / rianÃas acompanhadas nos Centro de Apoio Psicossocial Infantojuvenil - CAPSi de Fortaleza. E um estudo transversal, de fevereiro à dezembro de 2012. Os dados foram coletados por estudantes da saÃde, onde os entrevistados foram os responsÃveis pelas crianÃas. Participaram da pesquisa 292 crianÃas. A maioria das crianÃa sÃo do sexo masculino (74,3%), a mÃdia de idade 8,1 anos e recebem benefÃcios social. As famÃlias pertencem a classe socioeconÃmica D e E (89,3%), o chefe das famÃlias sÃo os pais das crianÃas (78,6%), com apenas o nÃvel fundamental (62,9%), desenvolve atividade renumerada (77,6%), possui renda familiar (95,5%), menor ou igual a 622,00 (58,5%), moram em casa (94,1%), prÃpria (61,1%) e o nÃmero de moradores entre 1 a 4 (88,3%). A maior parte das crianÃas acompanhadas (81,5%) apresenta algum tipo de problema de saÃde, onde (46,6%) referia ser saÃde mental. Entre as hipÃteses a mais frequente à o transtorno de comportamento (44,9%). A maioria das crianÃas à encaminhada da atenÃÃo primÃria (33,2%), frequentam uma vez ou mais por mÃs (69,1%), realizam mais tratamentos individuais (83,3%), com os mÃdicos (92,9%), realizando mais abordagem medicamentosa (44,5%) e nÃo sÃo acompanhadas em outros locais (65,4%). Em relaÃÃo a abordagem medicamentosa, melhoram com o tratamento (83,1%), nÃo relatam problema (70,%). A abordagem nÃo medicamentosa revela melhora (58,8%), nÃo sente problema (97,1%). A proporÃÃo de utilizaÃÃo dos medicamentos nas crianÃas foi de 88,4%. A mÃdia de utilizaÃÃo de medicamentos foi de 1,2 fÃrmacos por crianÃas, os mais prescritos foram: risperidona (20,5%), carbamazepina (17,1%), amitriptilina (4,8%), clorpromazina (3,9%), fluoxetina (8,4%), haloperidol (8,7%), imipramina (7,2%), metilfenidato (6,6%), periciazina (7,5%) e valproato de sÃdio (5,1%). A maior parte dos responsÃveis (72,7%) afirma conhecer os medicamentos, o uso terapÃutico (60,7), sÃo orientados pelo mÃdico (96,3%), relatam gostar (60,7%), recebem gratuitamente (54,7%) e quando falta, compram (56,7%). Os fatores que relacionou-se ao uso dos psicofÃrmacos foram: as crianÃas do sexo masculino, mais jovens, beneficiadas, acompanhadas pelas mÃes, de estado civil casado, escolaridade ensino fundamental e com atividades renumeradas, crianÃas de famÃlias pobres, moram em casas, prÃprias, com um a quatro moradores no domicÃlio. Em relaÃÃo aos serviÃos de saÃde, a maior utilizaÃÃo associou-se as crianÃas que possuÃam problema de saÃde, nÃo acompanhadas em outros locais, encaminhadas por outros serviÃos, as crianÃas que frequentam uma vez ou mais por mÃs o CAPSi, as crianÃas acompanhadas pelos mÃdicos, nÃo participam dos grupos, das atividades do terapeuta ocupacional e do acompanhamento do psicÃlogo. O estudo revelou um elevado uso de psicofÃrmacos em crianÃas acompanhadas nos CAPSi de Fortaleza, sugerindo uma urgÃncia em intervenÃÃes famacoterapÃuticas na promoÃÃo de uso racional dos medicamentos. / This thesis aims to evaluate the use of psychotropic drugs in children followed in Psychosocial Support Center infantojuvenil - CAPSi of Fortaleza. And a cross-sectional study, from February to December 2012. Data were collected by students of health, where the respondents were responsible for the children. Participants were 292 children. Most of the children were male (74.3%), mean age 8.1 years and receive social benefits. The families belong to socioeconomic class D and E (89.3%), the head of the families are the parents of the children (78.6%), with only the basic level (62.9%), renumbered develops activity (77, 6%), a family income (95.5%), less than or equal to 622.00 (58.5%) living at home (94.1%), very (61.1%) and the number of residents between 1 to 4 (88.3%). Most of the infants (81.5%) have some type of health problem, where (46.6%) reported mental health. Among the hypotheses is the most common behavior disorder (44.9%). Most children are referred from primary care (33.2%), attending once or more per month (69.1%) performed more individual treatments (83.3%), doctors (92.9%) , performing more medication approach (44.5%) and were not followed in other locations (65.4%). Regarding medication approach, improve with treatment (83.1%) report no problems (70%). The non-drug approach reveals improvement (58.8%), feels no problem (97.1%). The proportion of use of medicines in children was 88.4%. The average use of medications was 1.2 drugs by children, the most frequently prescribed were: risperidone (20.5%), carbamazepine (17.1%), amitriptyline (4.8%), chlorpromazine (3.9% ), fluoxetine (8.4%), haloperidol (8.7%), imipramine (7.2%), methylphenidate (6.6%), periciazina (7.5%) and sodium valproate (5.1% ). Most responsible (72.7%) say they know the drugs, the therapeutic use (60.7), are guided by the physician (96.3%) reported liking (60.7%) receive free (54, 7%) and lack when they buy (56.7%). Factors related to the use of psychotropics were the male children, younger beneficiaries, accompanied by their mothers, the married state, schooling and school activities renumbered, children from poor families, live in houses, own with one to four household members. In relation to health services, greater use was associated with children who had health problems, unaccompanied elsewhere, referred by other services, children who attend once a month or more the CAPSi, children accompanied by doctors , not participating groups, the activities of the occupational therapist and psychologist monitoring. The study reveals a high use of psychotropic drugs in children followed us CAPSi Fortaleza, suggesting an urgency in famacoterapÃuticas interventions in promoting rational use of medicine

This study evaluated a treatment program for anxiety disordered children, ages five to twelve years, utilizing both qualitative and quantitative methodologies. The treatment program integrated Imipramine pharmacotherapy and brief psychotherapy. The participants' nuclear and extended family histories were examined in terms of the occurrence of psychopathology and endemic transactional patterns. The examination of family patterns utilized Murray Bowen's Generational Model, as well as the T-F-A model of Hutchins and Cole, as a means of explaining the transmission of anxiety in the family. Ten children suspected of experiencing anxiety disorders were referred by pediatric physicians for treatment. Following an initial diagnostic assessment, children were placed on 25 milligrams of Imipramine per day for four to six weeks, while participating in weekly conjoint psychotherapy with their mothers for a six to eight-week period. A post-treatment evaluation was conducted by selecting ten prototypic participants. Selection was based upon age, diagnosis of overanxious disorder or separation anxiety disorder in childhood, and a time interval of no more than one year or less than one week following treatment. Semi-structured interviews were conducted with mother-child pairs separately to evaluate participants' perceptions of pre- and post-treatment symptom levels and family dynamics. DSM-III diagnostic criteria, Bowenian and T-F-A models served as the frameworks for organizing and evaluating qualitative data. All child participants experienced a dramatic and lasting resolution of both OAD and SAD symptomology. A quantitative analysis was performed utilizing the Wilcoxon sign rank to compare pre- and post-treatment symptom levels, with a significant effect by treatment occurring at the .005 level of significance. Cross-validation of treatment outcome was achieved through review of medical records, original psychotherapy notes, and videotapes of the interviews. Qualitative data regarding transgenerational medical and psychological disorders and family dynamics was generated. The data supported the Unitary model of generational family pathology. Six of seven Bowenian constructs were confirmed in this sample. The T-F-A model was used to demonstrate a cyclical pattern of reassurance, anxiety reduction, and child dependency between anxious children and their mothers. These results were discussed to provide a better understanding of the etiology and treatment of childhood anxiety disorders (OAD and SAD). The term "anxogenic family" was suggested to convey the interaction of genetics and generational learning in the families of anxiety disordered children. Implications for future research and modification of the DSM-IV regarding childhood anxiety disorders were discussed. / Ph. D.

Class of 2010 Abstract / OBJECTIVES:The main purpose of this study was to review recent and good quality studies of the antimicrobial therapy of for moderate to severe (“limb threatening”) DFI. The analysis of these studies was to conclude with one or two “standard” approach to the routine management of this clinical entity. METHODS: This literature review study consisted of an evaluation of clinical trials that compare two or more active systemic antimicrobial regimens for the treatment of moderate to severe (i.e., “limb-threatening”) diabetic foot infections in human patients. Literature sources were identified primarily from OVID MEDLINE, but also included additional tertiary sources. The primary criteria for the clinical studies were: prospective, controlled, randomized and investigator blinded. Studies had to be published after the year 2003, and be available in full-text in English. RESULTS: Ultimately, only four studies were found that met the criteria for consideration. Trials differed in numerous features. All four studies were sponsored by the manufacturer of one of the comparator drugs. Three of the four were non-inferiority design. Evidence is lacking that any of the suggested regimens are superior. CONCLUSIONS: Instead of meeting our original goal of concluding that one or two regimens could be the “standard” management of DFI, we were limited to commentary on the quality and applicability of the current literature on this clinical entity. Numerous suggestions for improvement in the clinical information provided by DFI studies were offered. We eagerly anticipate the publication of the updated IDSA guideline document on DFI.