Enhancing health care for type 2 diabetes in Northern Brazil: A pilot study of pharmaceutical care in community pharmacy

To evaluate the impact of a medication therapy management (MTM) program on the clinical outcomes and the quality of life (QoL) of a group of elderly patients with type 2 diabetes mellitus (DM). The study was conducted in a community pharmacy in Aracaju, Brazil, from February to November 2009. A quasi-experimental, longitudinal, prospective study was conducted by intervention. The group patients received medication therapy management from a clinical pharmacist. A sample of convenience was obtained for patients of both genders aged from 60 to 75 years. Monthly visits were scheduled over 10 months. At these consultations, sociodemographic, clinical data were obtained. QoL assessment was conducted using a generic instrument-the Medical Outcomes Studies 36-item Short Form Survey (SF-36 (R)). In total, 34 completed the study. The mean age of the patients was 65.9 (4.7) years. In total, 117 DRPs were identified. Patients' baseline and final evaluation measures for glycosylated hemoglobin, capillary blood glucose, blood pressure, and waist circumference were significantly different (p < 0.05). The domains of QoL assessed by the SF-36 (R) also shows significant differences between patients' baseline and final evaluation scores. The co-responsibility and active participation on the part of the elderly may have helped pharmacotherapy achieve its clinical and humanistic aims.

Percutaneous laser ablation under ultrasound guidance for fetal hyperechogenic microcystic lung lesions with hydrops: a single center cohort and a literature review

Objective To evaluate the perinatal outcomes in hydropic fetuses with congenital microcystic pulmonary lesions that underwent percutaneous, invasive, laser therapy. Method This retrospective study reviews the literature and our experience between 2004 and 2010. Characteristics of the cystic lung lesions, liquor volume (presence of polyhydramnios or not), localization of ablation (vascular vs interstitial) and gestational age at which the procedure was performed were related to outcome (survival). Results In total, 16 fetuses with congenital lung lesions underwent invasive percutaneous laser ablation, seven performed in our center and nine published cases. Survival rate was higher in fetuses with a subsequent postnatal diagnosis of bronchopulmonary sequestration (87.5%) compared with congenital adenomatoid malformation (28.6%; p?=?0.04). The technique of vascular ablation was more successful (100%) than interstitial ablation (25.0%, p?<?0.01). Conclusion Percutaneous vascular laser ablation seems to be effective for bronchopulmonary sequestration in hydropic fetuses. Outcomes were worst following interstitial ablation for microcystic congenital adenomatoid with hydrops. (C) 2012 John Wiley & Sons, Ltd.

Low Level Laser Therapy as an Adjunctive Technique In the Management of Temporomandibular Disorders

The purpose of this study was to assess the effect of low level laser therapy on subjects with intra-articular temporomandibular disorders (IA-TMD), and to quantify and compare severity of signs and symptoms before, during, and after the laser applications. The sample consisted of 45 subjects randomly divided into three groups (G) of 15 subjects each: G-I: 15 individuals with IA-TMD submitted to an energy dose of 52.5 J/cm(2); G-II: dose of 105.0 J/cm(2); and G-III: placebo group (0 J/cm(2)). In all groups, the applications were performed on condylar points on the masseter and anterior temporalis muscles. Two weekly sessions were held for five weeks, totaling 10 applications. The assessed variables were: mandibular movements and painful symptoms evoked by muscle palpation. These variables were measured before starting the study, then immediately after the first, fifth, and tenth laser application, and finally, 32 days after completing the applications. The results showed that there were statistically significant differences for G-I and G-II at the level of 1% between the doses, as well as between assessments. Therefore, it was concluded that the use of low level laser increased the mean mandibular range of motion and reduced painful symptoms in the groups that received effective treatment, which did not occur in the placebo group.

Cost-effectiveness and budget impact of saxagliptine as additional therapy to metformin for the treatment of diabetes mellitus type 2 in the Brazilian private health system

Cost-effectiveness and budget impact of saxagliptine as additional therapy to metformin for the treatment of diabetes mellitus type 2 in the Brazilian private health system Objectives: To compare costs and clinical benefits of three additional therapies to metformin (MF) for patients with diabetes mellitus type 2 (DM2). Methods: A discrete event simulation model seas built to estimate the cost-utility ratio (cost per quality-adjusted life years [QALY)) of saxagliptine as an additional therapy to MF when compared to rosiglitazone or pioglitazone. A budget impact model (BIM) was built to simulate the economic impact of saxagliptine use in the context of the Brazilian private health system. Results: The acquiring medication costs for the hypothetical patient group analyzed in a time frame of three years, were R$ 10,850,185, R$ 14,836,265 and R$ 14,679,099 for saxagliptine, pioglitazone and rosiglitazone, respectively. Saxagliptine showed lower costs and greater effectiveness in both comparisons, with projected savings for the first three years of R$ 3,874 and R$ 3,996, respectively. The BIM estimated cumulative savings of R$ 417,958 with the repayment of saxagliptine in three years from the perspective of a health plan with 1,000,000 covered individuals. Conclusion: From the perspective of private paying source, the projection is that adding saxagliptine with MF save costs when compared with the addition of rosiglitazone or pioglitazone in patients with DM2 that have not reached the HbA1c goal with metformin monotherapy. The BIM of including saxagliptine in the reimbursement lists of health plans indicated significant savings on the three-year horizon.

Pain in photodynamic therapy: mechanism of action and management strategies

Photodynamic therapy involves administration of a photosensitizing drug and its subsequent activation by irradiation with a light source at wavelengths matching the absorption spectrum of the photosensitizer. In many countries around the world, topical photodynamic therapy has been approved for treatment of cutaneous oncologic conditions such as actinic keratosis, Bowen's disease, and superficial basal cell carcinoma. Multicenter, randomized, controlled studies have confirmed its efficacy and superior cosmetic outcomes compared to conventional therapies. Nevertheless, this therapeutic method presents some adverse effects, such as erythema, edema, pigmentation, pustules, and pain. There is no doubt that pain is the most severe of the adverse effects, being sometimes responsible for definitive treatment interruption. The pain mechanism has not yet been fully understood, which makes complete pain control a challenge to be conquered. In spite of that, this literature review presents some useful pain management strategies as well as the most important pain-related factors in photodynamic therapy.

Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease

To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross-sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne-GERD (162: 67.5%) or e-GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in Sao Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.

Medication adherence in frail elderly outpatients with dementia

Since drug therapy in the elderly is complex and longterm and aged people commonly present some level of impairment and disability, medication adherence tend to decrease with age. Cognitive function is a key factor associated with medication adherence and professional or caregiver assistance may be necessary to maintain correct drug use. This study aims to analyze frail elderly outpatients aged 80 years or over diagnosed with dementia. The study is cross-sectional and is being conducted at the Ambulatory of Frailty of the University Hospital of the University of São Paulo (AF-UH). It is being based on information collected through an interview conducted with the patient or its caregiver. Medication adherence is assessed by the proportion of the prescribed drugs used in concordance with the prescription. Here it is presented the results of a pilot study. Thirty patients were included in the pilot study of which 23 (76.7%) were female and 7 (23.3%) males. The mean(SD) age, number of dwelling relatives, living children and prescribed drugs was, respectively, 86(5) years, 3(2), 3(2) and 6(3). The AF-UH consultation is the only regular physician encounter for 60.7% of the patients. Out of 30 patients, 5 (16.7%) live alone. Medication is a caregiver responsibility in 22 (73.4%) patients; the others (26.6%) self-administer their medicines. 13 (43.3%) of patients regularly use at least one drug not prescribed. Dementia was present in 8 patients all of which have a caregiver responsible for the management and,or the administration of the medicines; on the other hand, only 4 of the 22 nondemented patients (18.2%) have assistance of a caregiver (p<.001). The mean(SD) number of prescribed drugs was higher in nondemented patients [6.5(2.4)] than in those with dementia[3.5(2.3)] (p=.004). Educational level was similar between caregivers and patients (p=.503) as well as between caregivers of demented and non demented patients (p=.582). Among patients without dementia, those with caregiver assistance pre-presented the same mean(SD) medication adherence [0.93(0.14)] than those without it [0.78(0.28)] (p=.305). When compared to nondemented patients without caregivers, demented patients showed higher medication adherence [1.00(0.00)] (p=.013) since all of them used their drugs as recommended. The lower number of prescribed drugs and caregiver assistance seem to play an important role in the adherence of pharmacotherapy of demented patients in the studied population.

Warfarin doses for anticoagulation therapy in elderly patients with chronic atrial fibrillation

OBJECTIVE: Anticoagulation is a challenge for the prophylaxis of thromboembolic events in elderly patients with chronic atrial fibrillation. Stable anticoagulation is defined as the time within > 70% of the therapeutic range. However, the dosage required to achieve stable anticoagulation remains unknown. The aim of this study was to analyze the warfarin dose necessary for the maintenance of stable oral anticoagulation therapy in elderly patients. METHODS: We analyzed 112 consecutive outpatients with atrial fibrillation who were >= 65 years of age, had received anticoagulation therapy with warfarin for more than 1 year and had a stable international normalized ratio between 2.0 and 3.0 for >= 6 months. The international normalized ratio was measured in the central laboratory using the traditional method. RESULTS: The patients were stratified according to the following age groups:,75 or >= 75 years and <80 or >= 80 years. The mean daily doses of warfarin were similar for patients, <75 or >= 75 years (3.34 +/- 1.71 versus 3.26 +/- 1.27 mg/day, p = 0.794) and <80 or >= 80 years (3.36 +/- 1.49 versus 3.15 +/- 1.23 mg/day, p = 0.433). In 88 (79%) patients, the daily warfarin dose was between 2 and 5 mg/day; in 13 (11%) patients, the daily warfarin dose was,2.0 mg/day; and in 11 (10%) patients, the daily warfarin dose was >5.0 mg/day. The correlation between the daily warfarin dose and the international normalized ratio was 0.22 (p = 0.012). CONCLUSION: Stable anticoagulation was achieved in 80% of patients who received doses of 2 to 5 mg/day of warfarin, and the mean daily dose was similar across the age groups analyzed.

Histomorphometric analysis of inflammatory response and necrosis in re-implanted central incisor of rats treated with low-level laser therapy

Low-level laser therapy is a tool employed in the management of post-operative inflammation process and in the enhancement of reparative process. The aim of the study was to perform histological evaluation of dental and periodontal ligament of rats central upper-left incisor teeth re-implanted and irradiated with low-level laser (InGaAl, 685 nm, 50 J/cm(2)) 15, 30, and 60 days after re-implantation. Seventy-two male rats had the central upper left incisor removed and kept for 15 min on dry gauze before replantation. Laser was irradiated over the root surface and empty alveolus prior replantation and over surrounding mucosa after the re-implantation. After histological procedures, all slices were analyzed regarding external resorption area and histological aspects. We observed an increase of root resorption (p < 0.05) in the control group compared to the laser group at 15, 30, and 60 days. These results showed that the laser groups developed less root resorption areas than the control group in all experimental periods. Additionally, histological analysis revealed less inflammatory cells and necrotic areas in laser groups.

Management of desmoid-type fibromatosis involving peripheral nerves

Desmoid-type fibromatosis is an uncommon and aggressive neoplasia, associated with a high rate of recurrence. It is characterized by an infiltrative but benign fibroblastic proliferation occurring within the deep soft tissues. There is no consensus about the treatment of those tumors. We present a surgical series of four cases, involving the brachial plexus (two cases), the median nerve and the medial brachial cutaneous nerve. Except for the last case, they were submitted to multiple surgical procedures and showed repeated recurrences. The diagnosis, the different ways of treatment and the prognosis of these tumoral lesions are discussed. Our results support the indication of radical surgery followed by radiotherapy as probably one of the best ways to treat those controversial lesions.

Advancing the management of primary immunodeficiency diseases in Latin America: Latin American Society for Immunodeficiencies (LASID) Initiatives

Primary immunodeficiency diseases (PIDD) are associated with significant morbidity and mortality and result in a significant public health burden. This is in part due to the lack of appropriate diagnosis and treatment of these patients. It is critical that governments become aware of this problem and provide necessary resources to reduce this impact on health care systems. Leading physicians in their respective countries must be supported by their own governments in order to implement tools and provide education and thus improve the diagnosis and treatment of PIDD. The Latin American Society of Primary Immunodeficiencies (LASID) has initiated a large number of activities aimed at achieving these goals, including the establishment of a PIDD registry, development of educational programmes and guidelines, and the introduction of a PIDD fellowship programme. These initiatives are positively impacting the identification and appropriate treatment of patients with PIDD in Latin America. Nevertheless, much remains to be done to ensure that every person with PIDD receives proper therapy. (C) 2011 SEICAP. Published by Elsevier Espana, S.L. All rights reserved.

Treatment of central giant cell lesions using bisphosphonates with intralesional corticosteroid injections

Central giant cell lesions are benign intraosseous proliferative lesions that have considerable local aggressiveness. Nonsurgical treatment methods, such as intralesional corticosteroid injections, systemic calcitonin and interferon have been reported. Recently, bisphosphonates have been used to treat central giant cell lesions. A case of a 36-year-old male with a central giant cell lesion crossing the mandibular midline was treated with intralesional corticosteroids combined with alendronate sodium for the control of systemic bone resorption. The steroid injections and the use of bisphosphonates were stopped after seven months when further needle penetration into the lesion was not possible due to new bone formation. After two years, the bony architecture was near normal, and only minimal radiolucency was present around the root apices of the involved teeth. The patient was followed up for four years, and panoramic radiography showed areas of new bone formation. Thus far, neither recurrence nor side effects of the medication have been detected.

Behavioural changes and occlusal splints are effective in the management of masticatory myofascial pain: a short-term evaluation

The aim of this research was to test the hypothesis that treatment with intra-oral appliances with different occlusal designs was beneficial in the management of pain of masticatory muscles compared with a control group. A total of 51 patients were analysed according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to obtain the diagnosis of masticatory myofascial pain (MMP). The sample was then randomly divided into three groups: group I (n = 21) wore a full coverage acrylic stabilisation occlusal splint; group II (n = 16) wore an anterior device nociceptive trigeminal inhibitory (NTI) system; and group III (n = 14) only received counselling for behavioural changes and self-care (the control group). The first two groups also received counselling. Follow-ups were performed after 2 and 6 weeks and 3 months. In these sessions, patients were evaluated by means of a visual analogue scale (VAS) and pressure pain threshold (PPT) of the masticatory muscles. Possible adverse effects were also recorded, such as discomfort while using the appliance and occlusal changes. The results were analysed with KruskalWallis, anova, Tukeys and Friedman tests, with a significance level of 5%. Group I showed improvement in the reported pain at the first follow-up (2 weeks), whereas for groups II and III, this progress was detected only after 6 weeks and 3 months, respectively. The PPT values did not change significantly. It was concluded that behavioural changes are effective in the management of pain in MMP patients. However, the simultaneous use of occlusal devices appears to produce an earlier improvement.

Infrared (810 nm) Low-Level Laser Therapy in Experimental Model of Strain-Induced Skeletal Muscle Injury in Rats: Effects on Functional Outcomes

Muscle strains are among the most prevalent causes for athletes absence from sport activities. Low-level laser therapy (LLLT) has recently emerged as a potential contender to nonsteroidal anti-inflammatory drugs in muscle strain treatment. In this work we investigated effects of LLLT and diclofenac on functional outcomes in the acute stage after muscle strain injury in rats. Muscle strain was induced by overloading the tibialis anterior muscle of rats during anesthesia. The injured groups received either no treatment, or a single treatment with diclofenac 30 min prior to injury, or LLLT (810 nm, 100 mW) with doses of 1, 3, 6 or 9 J, at 1 h after injury. Functional outcome measures included a walking index and assessment of electrically induced muscle performance. All treatments (except 9 J LLLT) significantly improved the walking index 12 h postinjury compared with the untreated group. The 3 J group also showed a significantly better walking index than the drug group. All treatments significantly improved muscle performance at 6 and 12 h. LLLT dose of 3 J was as effective as the pharmacological agent in improving functional outcomes in the early phase after a muscle strain injury in rats.

Antimicrobial Photodynamic Therapy in the Treatment of Oral Candidiasis in HIV-Infected Patients

Objective: Antimicrobial photodynamic therapy (aPDT) has been used to combat local infections, and it consists of the combination of a photosensitizer, a light source, and reactive oxygen species (ROS) to kill microbial cells. In this study, we evaluated the effectiveness of aPDT in the treatment of candidiasis in HIV-infected patients. Methods: Twenty-one patients were divided into three groups. Control group (CG) was treated with the conventional medication for candidiasis (fluconazole 100 mg/day during 14 days). Laser group (LG) was subjected to low-level laser therapy (LLLT), wavelength 660 nm, power of 30 mW, and fluence of 7.5 J/cm(2), in contact with mucosa during 10 sec on the affected point. An aPDT group (aPDTG) was treated with aPDT, that is, combination of a low-power laser and methylene blue 450 mu g/mL. Pre-irradiation time was 1 min. Parameters of irradiation were the same ones as for the LG, and patients were single irradiated. Patients were clinically evaluated and culture analysis was performed before, immediately after, and 7, 15, and 30 days after the treatment. Results: Our results showed that fluconazole was effective; however, it did not prevent the return of the candidiasis in short-term. LLLT per se did not show any reduction on Candida spp. aPDT eradicated 100% of the colonies of this fungus and the patients did not show recurrence of candidiasis up to 30 days after the irradiation. Conclusions: These findings suggest that aPDT is a potential approach to oral candidiasis treatment in HIV-infected patients.