Evidence suggests that selective serotonin reuptake inhibitors (SSRIs, a class of antidepressant medications) may contribute to increased breast cancer risk by stimulating the secretion of prolactin, a potential tumour promoter. The main objective of this study was to determine breast cancer risk associated with the duration, dosage and timing of SSRI use among women, with control for a limited set of confounders. This thesis project, conducted within the context of a population-based two-stage case-control study, consisted of a record linkage study utilizing three Saskatchewan health services databases. Cases included 1,273 women with primary breast cancer diagnosed between January 1, 2003 and December 31, 2005, and controls consisted of 12,730 subjects randomly selected from the province’s population registry. Data on SSRI use was compiled from the Saskatchewan prescription drug plan database. Information on a limited set of established risk factors for breast cancer that may confound this relationship was ascertained from the population registry and the prescription database. Cases and controls were similar in terms of age, total number of consecutive years eligible for prescription coverage and indicators of socioeconomic status. Compared to controls, cases were more likely to be married and to have used hormone therapy and/or oral contraceptives. Compared to nonusers, results indicated that the use of SSRIs for three or more years (as estimated by having filled 36 or more prescriptions for all SSRIs combined during the main exposure window more than two years prior to index date) was not associated with an increased risk of breast cancer (OR= 1.08, 95% CI: 0.74-1.58), controlling for age, marital status, oral contraceptive and hormone therapy use. In addition, no suggestion of increased risk was detected for long-term exposures to individual SSRIs (24 or more prescriptions filled during the main exposure window) and in relation to total combined SSRI use 2-7 years and more than seven years prior to index date. However, these risk estimates may have been affected by potential sources of information bias and confounding. In summary, these results do not provide evidence to suggest that the risk of breast cancer is increased with the use of SSRIs. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2008-01-08 13:51:38.74

Complementary and alternative medication (CAM) use during menopause is a growing public and women's health issue. The use of CAMs is increasing and evidence of CAM use in the general population suggests that women in the menopausal age range are more likely to use CAMs. In the context of menopause, preliminary research has indicated that women are using a number of CAMs to address symptoms. In a study of American women aged 45 to 65 years, 22% of women used CAMs during menopause, specifically herbal or naturopathic remedies (13%), relaxation techniques (9%) and dietary soy supplements (7%). Fourteen percent (14%) of women strongly agreed with the proposition that approaches such as nutrition and vitamins were better than hormones (Newton et al., 2002). The term 'menopause' is a concept of varying perceptions and perspectives. From the biological perspective, menopause is constant, however from the individual perspective, menopause is a unique experience shaped by cultural, emotional, psychological and physical characteristics. Symptoms commonly cited during menopause include hot flushes, night sweats palpitations, irregular menses and muscle and bone pain. The use of CAMs during menopause has the potential to address current symptoms and promote long term health and wellness. The reviewed literature indicated that while a preliminary understanding of CAM use during menopause is evident, further research is needed to clarify and contextualise current prevalence rates and types used. In addition, an understanding of the reasons and factors that influence women to use CAMs during this transition is crucial to understanding women's menopausal experience. This project aimed to explore the prevalence of CAM use during menopause and to identify the reasons that influence women to use these therapies during the transition. To address this question, a two phase study was designed to incorporate both quantitative and qualitative research methods. For Phase 1, a secondary data analysis was undertaken on a dataset that explored women's menopausal experiences and therapies used to address symptoms and for phase 2, focus groups were used to explore women's personal experiences and perceptions of CAM use during menopause. The secondary data analysis was undertaken on a population based sample of 886 women aged 47-67 years. Women were randomly selected from the electoral roll on the basis of gender, age and postcode, which were selected to ensure representation of urban and rural and varying socioeconomic status. From this analysis, the findings indicated that 80% of women used at least one type of CAM with therapeutic techniques (activities such as walking and swimming) the most commonly used (83.0%), followed by nutrition (66.8%), phytoestrogens (55.8%), herbal therapies (41.3%) and CAM medications (25.1%). Women who used CAMs were more likely to experience anxiety and vasomotor (hot flushes and night sweats) symptoms, have higher education levels, be low to middle income earners, be aged under 55 years, be previous users of hormone therapy (HT) and have participated in self breast examinations. CAM users were 40 to 90% less likely to be currently using HT or to smoke more than 20 cigarettes per day. The results of the secondary data analysis indicated the prevalence and factors associated with CAM use, however the factors that influence women to use CAMs during the menopause were unclear. A series of three focus groups and two telephone interviews were undertaken with a group of 15 women, who were current users of CAMs, aged 47-67 years and fluent in English. Women were recruited through an advertisement placed in a newsletter distributed by a large metropolitan hospital; a flyer displayed on noticeboards of libraries and shopping centres; and a media release through the local community newspaper and on a state wide radio station. Analysis of the transcripts indicated that a number of factors interact to influence a woman's decision to use CAMs. Influences included relationships with family, friends and health practitioners, effects of symptoms, information on CAMs and menopause, current menopause research, personal perceptions of health, wellness and effectiveness of CAM therapies to alleviate symptoms. Taken together, the results of the Phase 1 and 2 combined with the literature indicated that women were using multiple forms of CAMs. A post hoc analysis was undertaken and the CAM questions analysed in Phase 1 were critiqued within this new knowledge of CAM use. As a consequence, CAMs were redefined into four groups to enhance current understandings. After reclassification, the use of at least one CAM was 71.6%, with the most commonly used dietary phytoestrogens (60.0%), followed by dietary supplements (47.0%), herbal therapies (35.9%) and phytoestrogen supplements (33.0%). Sociodemographic, health and symptom characteristics were further profiled against the redefined categories of dietary phytoestrogens, dietary supplements, herbal therapies, phytoestrogen supplements and users of multiple CAMs. The consistency of associations varied according to the CAM category with no significant association present across all four CAM categories. This post hoc analysis clarified CAM categorisation and highlighted the high prevalence of women who were using multiple forms of CAMs. Additionally, multivariable analysis validated and confirmed the results of Phase 1 as similar profiles of a CAM user were found. This research has identified the prevalence of CAM use during menopause in Queensland women and has begun to elucidate the reasons that influence women to use these therapies during this transition. The utilisation of both quantitative and qualitative methods has provided a comprehensive and holistic depiction of women's use of CAMs during menopause. The results and conclusions drawn from this research have highlighted areas that need addressing within the research and health service domain. For future research, development of a comprehensive CAM survey instrument is required and clarification of the definition of CAMs is also needed. Multiple definitions are currently used to describe CAM use, creating confusion in classifying types of CAMs and comparing prevalence rates between studies. With regard to health service recommendations, there is a need for increased access to information on menopause and alternative therapies for women. Open, active and participatory relationships between health practitioners and menopausal women are essential and health practitioners need to be aware women are using a variety of CAMs during the menopause and are likely to continue to do so even if health practitioner support is not apparent.

Η παρούσα εργασία πραγματοποιήθηκε στο Πανεπιστήμιο Πατρών στα πλαίσια της κατεύθυνσης «Φαρμακευτικό Μάρκετινγκ» του Μεταπτυχιακού Προγράμματος Σπουδών του Τμήματος Φαρμακευτικής του Πανεπιστημίου Πατρών. Η προσπάθεια για την κατανόηση του ρόλου των διαφημίσεων των φαρμάκων στο αγοραστικό κοινό αποτελεί το ουσιαστικό αντικείμενο της παρούσας διπλωματικής εργασίας. Οι φαρμακευτικές εταιρίες αύξησαν τα τελευταία ειδικά χρόνια το ενδιαφέρον τους για την ελεύθερη διαφήμιση των προϊόντων τους, αξιοποιώντας μια καταναλωτική-αγοραστική τάση για αυτοδιαχείριση εκ μέρους των καταναλωτών ήπιων και καθημερινά εμφανιζόμενων προβλημάτων υγείας. Συνεπώς είναι ενδιαφέρον να επιχειρηθεί η μελέτη του μεγέθους της επιρροής αυτού του τύπου των διαφημίσεων και επιμέρους θέματα που σχετίζονται με την επικοινωνία αυτή. Η μελέτη αυτή έχει καθαρά πιλοτικό χαρακτήρα και τα αποτελέσματα της θα μπορούσαν κυρίως να κατευθύνουν νέες ερευνητικές προσπάθειες σε συγκεκριμένους τομείς, ενώ παράλληλα θα μπορούσε να χρησιμοποιηθεί από τις φαρμακευτικές εταιρίες ως δείγμα και μέτρο της αποτελεσματικότητας και του «καθαρού» μηνύματος που τέτοιου τύπου διαφημίσεις οφείλουν να εκπέμπουν. / This Thesis was performed at the University of Patras, Department of Pharmacy for completion of the Master's program in “Pharmaceutical Marketing”. The role of the drug advertising on the market behavior is the main purpose of this study. Recently, pharmaceutical companies have increased the advertising of their products exploiting trends in patient self-management of simple diseases. Thus, it is of great interest to study the influence of the drug advertising on the market, as well as similar topics related with this policy of the pharmaceutical companies. This is a preliminary study in the field and the obtained results may guide future and more extended research efforts. On the other hand, the pharmaceutical companies may use the results of the present study in order to improve the effectiveness and clarity of the advertising message.

O uso de medicamentos representa um dos recursos terapêuticos mais utilizados na resolução de grande parte dos problemas e situações em saúde. Nesse contexto, o interesse na forma como os pacientes gerem suas doenças e tratamentos farmacológicos tem crescido em importância. Esta tese objetivou compreender as dimensões da autogestão do uso de medicamentos e variáveis associadas na população brasileira. Para isso, foram analisados três comportamentos relacionados ao uso de medicamentos: a automedicação, a não-adesão intencional e as alterações das doses prescritas. Os dados analisados são provenientes da Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM), estudo transversal realizado entre os meses de setembro de 2013 e janeiro de 2014 em 245 municípios brasileiros distribuídos nas cinco regiões geográficas do país. A população do estudo foram os indivíduos residentes em domicílios permanentes na zona urbana do território brasileiro. Nesta tese, foram analisados os dados de 31.573 indivíduos com idade igual ou superior a 20 anos. Modelos de Regressão de Poisson com ajuste robusto da variância foram utilizados a fim de estimar o efeito independente de cada variável nos três comportamentos estudados. Entre os entrevistados, 73,6% declararam utilizar algum medicamento sem indicação médica quando já fizeram uso do mesmo produto anteriormente, 73,8% declararam utilizar medicamentos sem prescrição médica quando já tem o medicamento em casa e 35,5% declararam utilizar algum medicamento sem prescrição quando conhecem alguém que já tomou o mesmo medicamento. As variáveis que se mostraram associadas à maior probabilidade de uso de medicamentos por automedicação foram: região geográfica do Brasil, sexo, faixa etária, renda per capita, auto avaliação da saúde, declaração de que usa medicamento sem prescrição médica quando já usou o mesmo medicamento anteriormente e declaração de que usa medicamento sem prescrição médica quando já tem o medicamento em casa. Mais da metade dos entrevistados relataram alguma situação de automedicação, enquanto que 38% relataram deixar intencionalmente de tomar medicamentos prescritos em alguma situação. Com relação às alterações nas prescrições, 8,8% dos entrevistados relataram amentar a dose dos medicamentos em alguma situação e mais de 21% relataram diminuir a dose. Nos modelos de regressão ajustados, as variáveis sexo, idade e autoavaliação de saúde mostraram-se associadas à não-adesão intencional. As alterações de dose aparecem associadas à idade, renda e autoavaliação de saúde. Os resultados indicam, portanto, que um percentual significativo da população brasileira utiliza medicamentos não exclusivamente da forma como são prescritos pelo médico. Buscando contemplar esses diferentes comportamentos cotidianos dos indivíduos em relação aos medicamentos, a presente tese propôs o conceito de “autogestão do uso de medicamentos”. Esse conceito visa ampliar a compreensão do uso de medicamentos para além da adesão às prescrições médicas como já indicado no conceito de medication self-management e de compliance. A partir dessa perspectiva, destaca-se a necessidade de adoção de outros paradigmas nos cuidados em saúde, como o dos cuidados colaborativos e da corporalidade (lived body), onde o próprio indivíduo, com a colaboração dos profissionais da saúde, tome as decisões sobre as estratégias mais adequadas de tratamento e promoção da saúde. / The use of medications represents one of the most utilized therapeutic resources to the resolution of most health problems and situations. In this context, the interest in how patients manage their diseases and pharmacological treatment has increased. This thesis had as main objective to comprehend the self-management of medications use and related variables on the Brazilian population. Three behaviors related to the use of medications were analyzed: self-medication, intentional non-adherence and prescribed doses changes. Analyzed data are part of the “Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM)”, a cross-sectional study performed between September 2013 and January 2014 in 245 Brazilian cities in the five geographic regions. Study population were individuals living permanently in the urban area of Brazil. In this thesis, data from 31.573 individuals aged 20 years or above were analyzed. Poisson Regression Models with robust variance adjustment were used to estimate independent effect of each variable on the three studied behaviors. Among the interviewed, 73.6% have declared the use of any medication without medical prescription when they have used the same product previously, 73.8% have declared the use of not prescribed drugs when the medication is available at home and, 35.5% have declared to use any drug without medical prescription when someone they know have used the same medication. Variables related to higher probability of drug use by self-medication were: geographic region, gender, age, per capita income, health self-evaluation, the use without medical prescription of the same drug used before and the use without medical prescription when the drug is available at home declarations. More than half of the interviewed reported any situation of self-medication while 38% reported to, intentionally, stop taking prescribed medications in any situation. Regarding prescription alterations, 8.8% of the interviewed reported to increase the medication dose in any situation and more than 21% reported to decrease medication dose. On the adjusted regression models variables as gender, age and health self-evaluation showed to be related to intentional nonadherence. Dose changes are related to age, income and health self-evaluation. Therefore, results show that a significant percentage of the Brazilian population uses medications not exclusively as they are prescribed by the physician. Seeking to address these different daily behaviors of individuals regarding medications, this thesis has proposed the concept of “self-management of medications use”. This concept aims to amplify the comprehension of medications use beyond medical prescriptions adherence as already indicated in the concept of medication self-management and compliance. From this perspective stands out the need of other paradigms introduction on health care, such as collaborative care and lived body, in which the individual himself, with health professionals’ collaboration, take the decisions about the most adequate treatment strategies and health promotion.

Existem vários métodos para medir tipo e grau de uso de medicamentos. Esse estudo teve como objetivo caracterizar a prescrição médica para idosos, por meio de indicadores, em diferentes ambientes de atendimento à saúde em 4 municípios do Rio Grande do Sul. Buscou-se caracterizar a prescrição em locais de formação e atuação universitária, estabelecendo a prevalência de intervenções nãofarmacológicas e farmacológicas em prescrições para idosos, avaliando diferentes indicadores quanto a sua aplicabilidade em idosos e realizando inferências em relação ao uso racional de medicamentos. Fizeram parte do estudo serviços de atenção básica em saúde, além daqueles de média e alta complexidade, vinculados a ambientes de formação universitária na área da saúde, no sul do Brasil. A amostra foi constituída por prescrições médicas, obtidas diretamente dos pacientes, em nível de atenção primária em saúde e ambientes de média complexidade, ou por meio de prontuários hospitalares, durante o período de um ano. Para caracterização dos idosos, foram considerados aqueles com idade igual ou superior a 65 anos. A coleta de dados foi realizada ao longo de doze meses, em semanas, dias e turnos definidos por meio de sorteio. sorteio. Como resultados, observou-se que, nos ambientes de atenção básica em saúde e nos ambientes de média complexidade estudados, os idosos do Rio Grande do Sul apresentaram maior média de medicamentos prescritos e prevalência considerável de medicamentos inapropriados, em comparação com outros estudos que envolveram dados da população em geral em outros estados do país. Em contrapartida, esses idosos receberam menor percentual de prescrições com antimicrobianos e baixo percentual de prescrições com agentes injetáveis. As classes de medicamentos mais comumente prescritas no ambiente ambulatorial foram aquelas de uso contínuo, provavelmente em função das enfermidades crônicas apresentadas por pacientes desta faixa etária. Destacaram-se os fármacos que agem no sistema cardiovascular, no sistema nervoso e no trato gastrintestinal e metabolismo. Por sua vez, na internação de idosos nos hospitais estudados, independentemente de município, sazonalidade, gênero ou faixa etária mais avançada, identificou-se um perfil elevado de utilização de medicamentos, com polifarmácia (n=345, 85,4%) e prescrição de medicamentos inapropriados (n=325, 80,4%) em número significativo de idosos. Os medicamentos que mais apareceram nas prescrições hospitalares foram aqueles prescritos sob regime de demanda (se necessário). A prescrição inadequada aos idosos é frequentemente atribuída à falta de treinamento de uma equipe especializada em geriatria e gerontologia, além da deficiência da formação universitária. Nesse sentido, considerando-se o contexto demográfico e epidemiológico brasileiro e a caracterização da prescrição para o paciente idoso realizada no estudo, é importante priorizar ações multidisciplinares relacionadas a promoção, prevenção e recuperação de enfermidades e padronizar procedimentos, para evitar erros de prescrição, transcrição e dispensação. A educação continuada dos profissionais da área da saúde, a divulgação e a atualização de listas de medicamentos essenciais e das listas de medicamentos inapropriados para idosos podem ser ferramentas úteis para a qualificação da prescrição e a promoção do uso racional de medicamentos em idosos. A partir dos pontos vulneráveis da prescrição para idosos que foram levantados, podem ser estabelecidas mudanças nos ambientes de formação em saúde estudados, visando a construção de um perfil profissional que paute suas ações pela comunicação efetiva, interdisciplinar e compromisso social. / There are several methods to measure type and degree of drug use. This study aimed to characterize the prescription for the elderly by means of indicators in different environments of health care and 4 cities of Rio Grande do Sul. It was characterized the prescription in academic and training environments, establishing the prevalence of non-pharmacological interventions and pharmacotherapy prescriptions for the elderly, assessing the applicability of different indicators to the elderly prescriptions, and making inferences about the rational use of medicines. Participants of the study were elderly people attended in primary health care services and in medium and high complexity health care services, linked to universities located in the south of Brazil. The sample consisted of prescriptions obtained directly from patients, at the level of primary health care and environments of medium complexity, or through hospital records, during the period of one year. It was considered elderly patients those with age over 65 years. Data collection was conducted over twelve months, in weeks, days and shifts defined by lot. It was observed that in primary health care and medium complexity services the Rio Grande do Sul elderly prescriptions had a higher mean number of medications and a considerable prevalence of inappropriate medications, compared to other studies involving data from the general population. However, these elderly received a lower percentage of prescriptions with antibiotics and injectable drugs. The classes of drugs most commonly prescribed in the outpatient setting were those of continuous use, probably due to the chronic diseases that frequently occurred in the old age. Those classes involved drugs that act on the cardiovascular system, nervous system and gastrointestinal tract and metabolism. In the hospitals studied, independently of the city, seasonality, gender or older age, it was identified high profile drug utilization, with polypharmacy (n = 345, 85.4%) and inappropriate prescription of medications (n = 325, 80.4%) in great number of elderly. The drugs that most appeared in the hospital prescriptions were those prescribed under the demand scheme ("if necessary"). Inappropriate prescribing for the elderly is often attributed to the lack of training in geriatrics and gerontology and disability of university education. Considering the Brazilian epidemiological and demographic context and the prescription pattern for the elderly observed in this study, it is important to prioritize disciplinary actions related to the promotion, prevention and recovery from illness and standardize procedures to avoid errors in prescribing, transcribing, and dispensing. The continuing education of professionals in the health, distribution and update of essential drugs lists and use of lists of inappropriate drugs for elderly may be useful tools for the improvement of the prescription and promotion of rational drug use in the elderly. Based on the vulnerabilities of the prescription for the elderly that have been raised, it is possible to establish changes in the studied healthy education environments, aiming to build a professional profile that bases its actions on effective communication, interdisciplinary and social commitment.

A percepção de risco teratogênico equivocada pode levar à privação de uso de medicamentos seguros e à relutância ou não adesão ao tratamento farmacológico durante a gestação. Estudos prévios realizados em países desenvolvidos sugerem que a percepção de risco teratogênico ao uso de medicamentos é superestimada por gestantes, não gestantes e profissionais de saúde. Grande parte destes estudos foi realizada em centros de aconselhamento teratogênico e utilizou apenas uma técnica de aferição da percepção de risco (Escalas Visuais Analógicas). Com o objetivo de caracterizar a percepção de risco teratogênico por gestantes e mulheres em idade fértil, conduzimos um estudo que combinou métodos qualitativos e quantitativos de investigação. Participaram da pesquisa usuárias de serviços de saúde da rede básica municipal de Porto Alegre. Em termos qualitativos, foram realizados dois grupos focais com gestantes. Os dados quantitativos resultaram da realização de entrevistas estruturadas com 287 mulheres em idade fértil divididas em dois grupos: gestantes e não gestantes. A percepção de risco de malformações congênitas na população geral e as percepções de risco teratogênico das exposições a paracetamol, metoclopramida, misoprostol e radioterapia na gestação foram aferidas por duas técnicas: Escalas Visuais Analógicas (EVA) e perguntas numéricas. A concordância entre as duas técnicas de aferição foi avaliada pela análise gráfica de Bland-Altman. Não encontramos concordância entre as medidas obtidas por EVA e por pergunta para nenhuma das percepções de risco em estudo. As medianas das percepções de risco teratogênico medidas por EVA foram superiores às obtidas através da pergunta numérica, para todas as variáveis. Para ambas as técnicas de aferição, as medianas das percepções de risco teratogênico ao paracetamol e à metoclopramida foram mais baixas que para o risco de malformações congênitas na população geral. Já as medianas das percepções de risco ao misoprostol e à radioterapia apresentaram os maiores valores. Não foram encontradas diferenças significativas nas percepções de risco entre gestantes e não gestantes. A lógica acionada pelas mulheres na estimação do risco teratogênico é a da classificação dos medicamentos em fortes e fracos. Dentro desta lógica, os medicamentos e as exposições percebidos por elas como fracos não apresentam riscos, enquanto que aqueles percebidos como fortes são vistos como perigosos e devem ser evitados na gestação. Concluímos que o uso de EVA leva à superestimação das percepções de risco teratogênico. Além disso, frente à dificuldade em operar a lógica probabilística na estimação de risco, as mulheres operam uma lógica própria, classificando os medicamentos em fortes ou fracos. / An erroneous perception of teratogenic risk can lead to the non-use of safe medications and reluctance to or abstaining from pharmacological treatment during pregnancy. Previous studies conducted in developed countries suggest that the perception of teratogenic risk in the use of medications is overestimated by pregnant women, non-pregnant women and health professionals. Most of these studies were performed in teratogen counseling centers and only used one technique for measuring risk perception (Visual Analogue Scales). In order to characterize the perception of teratogenic risk by pregnant women and women of childbearing age, we conducted a study that combined qualitative and quantitative research methods. Public health care users from the city of Porto Alegre participated in the research. In qualitative terms, two focus groups were carried out with pregnant women. The quantitative data was derived from structured interviews with 287 women of childbearing age divided into two groups: pregnant and non-pregnant women. The perception of risk of congenital malformations in the general population and the perception of teratogenic risk through exposure to acetaminophen, metoclopramide, misoprostol and radiation therapy during pregnancy were measured via two techniques: Visual Analogue Scales (VAS) and numerical questions. The agreement between the two measurement techniques was evaluated using Bland-Altman graphic analysis. We did not find an agreement between the measurements obtained through VAS and those obtained through questions for any of the risk perceptions in the study. The medians of the perceptions of teratogenic risk measured by VAS were higher than those obtained by numerical questions, for all variables. For both measurement techniques, the medians of the perceptions of teratogenic risk with acetaminophen and metoclopramide were lower than those for the risk of congenital malformations in the general population. However, the medians of the perceptions of risk with misoprostol and radiation therapy presented the highest values. There were no significant differences in risk perceptions among pregnant and non-pregnant women. The logic employed by women in estimating teratogenic risk is the classification of drugs according to strong and weak. According to this logic, the drugs and exposure to them, perceived by these women as weak, do not present risks, while those perceived as strong are seen as hazardous and should be avoided during pregnancy. Our conclusion is that the use of VAS leads to the overestimation of teratogenic risk perceptions. Moreover, given the difficulty to engage in probabilistic logic for estimating risk, women engage in their own logic, classifying medications as strong or weak.

The present study attempted to predict the serious side effects of akathisia and parkinsonism on the basis of individualized measurement of changes in visuomotor functioning. The following were the hypotheses for this investigation. 1. A deterioration of visuomotor ability as measured by a modification of Haase and Janssen' s (1965) Handwriting Test will predict which patients undergoing neuroleptic therapy will experience the extrapyramidal symptoms of akathisia and parkinsonism (symptom group) and which will not (no-symptom group). 2. A deterioration of visuomotor ability as measured by the Bender-Gestalt will predict which patients undergoing neuroleptic therapy will experience the extrapyramidal symptoms of akathisia and parkinsonism (symptom group) and which will not (no-symptom group). It was not possible to predict the symptom group as a whole on the basis of the Handwriting Test scores since a t test of the difference was not significant between group means. However, inspection of these scores showed clear deterioration of performance among the patients who experienced parkinsonian reactions as opposed to those who experienced akathisia or who did not experience extrapyramidal symptoms at all. The symptom group was separated into akathisic and parkinsonian groups and compared to the subjects who did not experience extrapyramidal side effects (no-symptom group). A one-way ANOVA showed a nonsignificant difference between the three groups. Similar analysis of the Bender-Gestalt scores failed to support the second hypothesis since no significant difference was found between groups.

O uso de medicamentos representa um dos recursos terapêuticos mais utilizados na resolução de grande parte dos problemas e situações em saúde. Nesse contexto, o interesse na forma como os pacientes gerem suas doenças e tratamentos farmacológicos tem crescido em importância. Esta tese objetivou compreender as dimensões da autogestão do uso de medicamentos e variáveis associadas na população brasileira. Para isso, foram analisados três comportamentos relacionados ao uso de medicamentos: a automedicação, a não-adesão intencional e as alterações das doses prescritas. Os dados analisados são provenientes da Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM), estudo transversal realizado entre os meses de setembro de 2013 e janeiro de 2014 em 245 municípios brasileiros distribuídos nas cinco regiões geográficas do país. A população do estudo foram os indivíduos residentes em domicílios permanentes na zona urbana do território brasileiro. Nesta tese, foram analisados os dados de 31.573 indivíduos com idade igual ou superior a 20 anos. Modelos de Regressão de Poisson com ajuste robusto da variância foram utilizados a fim de estimar o efeito independente de cada variável nos três comportamentos estudados. Entre os entrevistados, 73,6% declararam utilizar algum medicamento sem indicação médica quando já fizeram uso do mesmo produto anteriormente, 73,8% declararam utilizar medicamentos sem prescrição médica quando já tem o medicamento em casa e 35,5% declararam utilizar algum medicamento sem prescrição quando conhecem alguém que já tomou o mesmo medicamento. As variáveis que se mostraram associadas à maior probabilidade de uso de medicamentos por automedicação foram: região geográfica do Brasil, sexo, faixa etária, renda per capita, auto avaliação da saúde, declaração de que usa medicamento sem prescrição médica quando já usou o mesmo medicamento anteriormente e declaração de que usa medicamento sem prescrição médica quando já tem o medicamento em casa. Mais da metade dos entrevistados relataram alguma situação de automedicação, enquanto que 38% relataram deixar intencionalmente de tomar medicamentos prescritos em alguma situação. Com relação às alterações nas prescrições, 8,8% dos entrevistados relataram amentar a dose dos medicamentos em alguma situação e mais de 21% relataram diminuir a dose. Nos modelos de regressão ajustados, as variáveis sexo, idade e autoavaliação de saúde mostraram-se associadas à não-adesão intencional. As alterações de dose aparecem associadas à idade, renda e autoavaliação de saúde. Os resultados indicam, portanto, que um percentual significativo da população brasileira utiliza medicamentos não exclusivamente da forma como são prescritos pelo médico. Buscando contemplar esses diferentes comportamentos cotidianos dos indivíduos em relação aos medicamentos, a presente tese propôs o conceito de “autogestão do uso de medicamentos”. Esse conceito visa ampliar a compreensão do uso de medicamentos para além da adesão às prescrições médicas como já indicado no conceito de medication self-management e de compliance. A partir dessa perspectiva, destaca-se a necessidade de adoção de outros paradigmas nos cuidados em saúde, como o dos cuidados colaborativos e da corporalidade (lived body), onde o próprio indivíduo, com a colaboração dos profissionais da saúde, tome as decisões sobre as estratégias mais adequadas de tratamento e promoção da saúde. / The use of medications represents one of the most utilized therapeutic resources to the resolution of most health problems and situations. In this context, the interest in how patients manage their diseases and pharmacological treatment has increased. This thesis had as main objective to comprehend the self-management of medications use and related variables on the Brazilian population. Three behaviors related to the use of medications were analyzed: self-medication, intentional non-adherence and prescribed doses changes. Analyzed data are part of the “Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM)”, a cross-sectional study performed between September 2013 and January 2014 in 245 Brazilian cities in the five geographic regions. Study population were individuals living permanently in the urban area of Brazil. In this thesis, data from 31.573 individuals aged 20 years or above were analyzed. Poisson Regression Models with robust variance adjustment were used to estimate independent effect of each variable on the three studied behaviors. Among the interviewed, 73.6% have declared the use of any medication without medical prescription when they have used the same product previously, 73.8% have declared the use of not prescribed drugs when the medication is available at home and, 35.5% have declared to use any drug without medical prescription when someone they know have used the same medication. Variables related to higher probability of drug use by self-medication were: geographic region, gender, age, per capita income, health self-evaluation, the use without medical prescription of the same drug used before and the use without medical prescription when the drug is available at home declarations. More than half of the interviewed reported any situation of self-medication while 38% reported to, intentionally, stop taking prescribed medications in any situation. Regarding prescription alterations, 8.8% of the interviewed reported to increase the medication dose in any situation and more than 21% reported to decrease medication dose. On the adjusted regression models variables as gender, age and health self-evaluation showed to be related to intentional nonadherence. Dose changes are related to age, income and health self-evaluation. Therefore, results show that a significant percentage of the Brazilian population uses medications not exclusively as they are prescribed by the physician. Seeking to address these different daily behaviors of individuals regarding medications, this thesis has proposed the concept of “self-management of medications use”. This concept aims to amplify the comprehension of medications use beyond medical prescriptions adherence as already indicated in the concept of medication self-management and compliance. From this perspective stands out the need of other paradigms introduction on health care, such as collaborative care and lived body, in which the individual himself, with health professionals’ collaboration, take the decisions about the most adequate treatment strategies and health promotion.

The widespread use of antibiotics has led to dramatic increases in the incidence and severity of Clostridium difficile infection (CDI). No group of patients suffers more from CDI than the elderly. Nursing homes (NH) represent the perfect storm of a vulnerable group of frail elders living in confined communities. Nursing home residents suffer from increased morbidity and mortality from CDI and corresponding high rates of C. difficile colonization. Upwards of 40 to 50% of CDI current cases originate from NHs and the prevalence of colonization rates remain high within these facilities, with as many as half of the residents being colonized with C. difficile at any given time. One factor that has become of increasing interest and a target of preventive strategies is the human intestinal microbiome. A healthy, diverse microbiome interacts with the host immune system and contributes to pathogen resistance. In this investigation, we first examine elder specific variables to determine if the associated risks of CDI differ by home living environment (nursing home versus community-dwelling). We then go on explore the relationships of NH environment, frailty, nutritional status, and residents’ age with microbiome composition and potential metabolic function. Finally, we describe the C. difficile colonization patterns among elderly NH residents and the associated risk of colonization based on clinical variables and microbiome determinants. A better understanding of the microbiome’s contribution to C. difficile colonization will provide the basis for informing rational interventions and public health policies to better combat CDI in the nursing home.

Existem vários métodos para medir tipo e grau de uso de medicamentos. Esse estudo teve como objetivo caracterizar a prescrição médica para idosos, por meio de indicadores, em diferentes ambientes de atendimento à saúde em 4 municípios do Rio Grande do Sul. Buscou-se caracterizar a prescrição em locais de formação e atuação universitária, estabelecendo a prevalência de intervenções nãofarmacológicas e farmacológicas em prescrições para idosos, avaliando diferentes indicadores quanto a sua aplicabilidade em idosos e realizando inferências em relação ao uso racional de medicamentos. Fizeram parte do estudo serviços de atenção básica em saúde, além daqueles de média e alta complexidade, vinculados a ambientes de formação universitária na área da saúde, no sul do Brasil. A amostra foi constituída por prescrições médicas, obtidas diretamente dos pacientes, em nível de atenção primária em saúde e ambientes de média complexidade, ou por meio de prontuários hospitalares, durante o período de um ano. Para caracterização dos idosos, foram considerados aqueles com idade igual ou superior a 65 anos. A coleta de dados foi realizada ao longo de doze meses, em semanas, dias e turnos definidos por meio de sorteio. sorteio. Como resultados, observou-se que, nos ambientes de atenção básica em saúde e nos ambientes de média complexidade estudados, os idosos do Rio Grande do Sul apresentaram maior média de medicamentos prescritos e prevalência considerável de medicamentos inapropriados, em comparação com outros estudos que envolveram dados da população em geral em outros estados do país. Em contrapartida, esses idosos receberam menor percentual de prescrições com antimicrobianos e baixo percentual de prescrições com agentes injetáveis. As classes de medicamentos mais comumente prescritas no ambiente ambulatorial foram aquelas de uso contínuo, provavelmente em função das enfermidades crônicas apresentadas por pacientes desta faixa etária. Destacaram-se os fármacos que agem no sistema cardiovascular, no sistema nervoso e no trato gastrintestinal e metabolismo. Por sua vez, na internação de idosos nos hospitais estudados, independentemente de município, sazonalidade, gênero ou faixa etária mais avançada, identificou-se um perfil elevado de utilização de medicamentos, com polifarmácia (n=345, 85,4%) e prescrição de medicamentos inapropriados (n=325, 80,4%) em número significativo de idosos. Os medicamentos que mais apareceram nas prescrições hospitalares foram aqueles prescritos sob regime de demanda (se necessário). A prescrição inadequada aos idosos é frequentemente atribuída à falta de treinamento de uma equipe especializada em geriatria e gerontologia, além da deficiência da formação universitária. Nesse sentido, considerando-se o contexto demográfico e epidemiológico brasileiro e a caracterização da prescrição para o paciente idoso realizada no estudo, é importante priorizar ações multidisciplinares relacionadas a promoção, prevenção e recuperação de enfermidades e padronizar procedimentos, para evitar erros de prescrição, transcrição e dispensação. A educação continuada dos profissionais da área da saúde, a divulgação e a atualização de listas de medicamentos essenciais e das listas de medicamentos inapropriados para idosos podem ser ferramentas úteis para a qualificação da prescrição e a promoção do uso racional de medicamentos em idosos. A partir dos pontos vulneráveis da prescrição para idosos que foram levantados, podem ser estabelecidas mudanças nos ambientes de formação em saúde estudados, visando a construção de um perfil profissional que paute suas ações pela comunicação efetiva, interdisciplinar e compromisso social. / There are several methods to measure type and degree of drug use. This study aimed to characterize the prescription for the elderly by means of indicators in different environments of health care and 4 cities of Rio Grande do Sul. It was characterized the prescription in academic and training environments, establishing the prevalence of non-pharmacological interventions and pharmacotherapy prescriptions for the elderly, assessing the applicability of different indicators to the elderly prescriptions, and making inferences about the rational use of medicines. Participants of the study were elderly people attended in primary health care services and in medium and high complexity health care services, linked to universities located in the south of Brazil. The sample consisted of prescriptions obtained directly from patients, at the level of primary health care and environments of medium complexity, or through hospital records, during the period of one year. It was considered elderly patients those with age over 65 years. Data collection was conducted over twelve months, in weeks, days and shifts defined by lot. It was observed that in primary health care and medium complexity services the Rio Grande do Sul elderly prescriptions had a higher mean number of medications and a considerable prevalence of inappropriate medications, compared to other studies involving data from the general population. However, these elderly received a lower percentage of prescriptions with antibiotics and injectable drugs. The classes of drugs most commonly prescribed in the outpatient setting were those of continuous use, probably due to the chronic diseases that frequently occurred in the old age. Those classes involved drugs that act on the cardiovascular system, nervous system and gastrointestinal tract and metabolism. In the hospitals studied, independently of the city, seasonality, gender or older age, it was identified high profile drug utilization, with polypharmacy (n = 345, 85.4%) and inappropriate prescription of medications (n = 325, 80.4%) in great number of elderly. The drugs that most appeared in the hospital prescriptions were those prescribed under the demand scheme ("if necessary"). Inappropriate prescribing for the elderly is often attributed to the lack of training in geriatrics and gerontology and disability of university education. Considering the Brazilian epidemiological and demographic context and the prescription pattern for the elderly observed in this study, it is important to prioritize disciplinary actions related to the promotion, prevention and recovery from illness and standardize procedures to avoid errors in prescribing, transcribing, and dispensing. The continuing education of professionals in the health, distribution and update of essential drugs lists and use of lists of inappropriate drugs for elderly may be useful tools for the improvement of the prescription and promotion of rational drug use in the elderly. Based on the vulnerabilities of the prescription for the elderly that have been raised, it is possible to establish changes in the studied healthy education environments, aiming to build a professional profile that bases its actions on effective communication, interdisciplinary and social commitment.