High frequency of methotrexate intolerance in longstanding rheumatoid arthritis: using the methotrexate intolerance severity score (MISS)

Abstract Background: Methotrexate (MTX) intolerance is frequent, and its early identification may impact treatment, leading to timely changes in medication that may promote patient compliance and better control of rheumatoid arthritis (RA). The objective of this study was to identify the frequency of, and risk factors for, MTX intolerance using the Brazilian Portuguese version of the Methotrexate Intolerance Severity Score (MISS) questionnaire in patients with RA. Methods: This cross-sectional study was performed between April 2018 and April 2019 and enrolled patients with RA in regular use of oral or subcutaneous MTX for at least 3 months. Patients were invited to answer the Brazilian Portuguese version of the MISS questionnaire, and MTX intolerance was defined by a score ≥ 6 points. Age, sex, disease duration, time of MTX use, dose, route of administration, concomitant medications, comorbidities, smoking, and Disease Activity Score for 28joint (DAS28) data were collected from institutional medical records. Results: Among 120 patients, 103 (85.8%) were female, the mean age was 61 (±12.5) years, the mean duration of disease was 16 (±10.3) years, and the average duration of MTX use was 7 (±5.5) years. The frequency of MTX intolerance was 21.6%. The most frequent symptoms reported after the use of MTX were nausea (92.3%), abdominal pain (46.1%), and vomiting (30.7%). Behavioral symptoms occurred in 96.1% of patients with MTX intolerance, the most frequent being restlessness and irritability. Patients who used corticosteroids were more likely to develop MTX intolerance than those not using corticosteroids (odds ratio = 2.73; 95% confidence interval, 1.06 to 7.06; p = 0.038). Conversely, increasing age showed marginally significant association with decreased risk of MTX intolerance (p = 0.059). Conclusions: The use of the MISS questionnaire disclosed high frequencies of anticipatory, associative, and behavioral symptoms in MTX-intolerant patients, and the use of corticosteroid increases the risk of MTX intolerance. We suggest that the MISS questionnaire be used routinely in clinical practice.(AU)

Professional practice of nurses and influences on moral sensitivity / Práctica profesional del enfermero e influencias sobre la sensibilidad moral / Prática profissional do enfermeiro e influências sobre a sensibilidade moral

ABSTRACT Objective: To understand the professional practice of nurses and their influence on the development of moral sensibility. Methods: A qualitative and descriptive study, conducted between November 2015 and February 2016 in the hospitalization units of the medical clinic of two large hospitals located in Belo Horizonte, Minas Gerais. 14 nurses participated. Data collection was done through interviews, guided by semi-structured scripts. The data were submitted to content analysis. Results: Two categories emerged: Professional practice of the nurse: internal and external goods and Moral sensitivity and the interface with the professional practice of nurses. The development of the moral sensitivity of nurses is influenced by factors related to professional practice, such as interpersonal relations, ethical education and management activities. Final considerations: In the professional practice, moral sensibility is an integral part of the ethical decision-making process in services, being essential for quality care.

RESUMEN Objetivo: Comprender la práctica profesional de la enfermera y su influencia en el desarrollo de la Sensibilidad moral. Métodos: Estudio cualitativo y descriptivo realizado entre noviembre de 2015 y febrero de 2016 en unidades de internación de la clínica médica de dos hospitales de gran porte, ubicados en Belo Horizonte, Minas Gerais. Participaron 14 enfermeras. La recolección de datos se efectuó por medio de entrevistas, guiadas por guiones semiestructurados. Los datos se sometieron a análisis de contenido. Resultados: Surgieron dos categorías: Práctica profesional de la enfermera: bienes internos y externos y Sensibilidad moral y la interfaz con la práctica profesional de las enfermeras. El desarrollo de la sensibilidad moral de las enfermeras sufre la influencia de factores relacionados con la práctica profesional, como las relaciones interpersonales, la educación ética y las actividades de gestión. Consideraciones finales: En la práctica profesional, la Sensibilidad moral es parte integrante del proceso de toma de decisiones éticas en los servicios, siendo esencial para un cuidado de calidad.

RESUMO Objetivo: Compreender a prática profissional do enfermeiro e suas influências para o desenvolvimento da sensibilidade moral. Métodos: Estudo qualitativo, descritivo, realizado entre novembro de 2015 e fevereiro de 2016, em unidades de internação da clínica médica, de dois hospitais de grande porte, localizados em Belo Horizonte, Minas Gerais. Participaram 14 enfermeiros. A coleta de dados ocorreu por meio de entrevistas, guiadas por roteiros semiestruturados. Os dados foram submetidos à análise de conteúdo. Resultados: Emergiram duas categorias: Prática profissional do enfermeiro: bens internos e externos e; Sensibilidade moral e a interface com a prática profissional de enfermeiros. O desenvolvimento da Sensibilidade moral dos enfermeiros, sofre influência de fatores relacionados à prática profissional, como as relações interpessoais, a educação ética e as atividades de gestão. Considerações finais: Na prática profissional, a Sensibilidade moral é parte integrante do processo de tomada de decisão ética nos serviços, sendo essencial para o cuidado de qualidade.