La Autoenografía como un instrumento de (trans)formación profesional en la práctica del Pharmaceutical Care / Autoethnography as an Instrument for Professional (Trans) Formation in Pharmaceutical Care Practice

La inclusión reciente de farmacéuticos en atención primaria en Brasil a través del Equipo de Apoyo de Salud Familiar los ha alentado a reflexionar sobre la necesidad de dejar de ser un profesional enfocado en los medicamentos a un profesional enfocado en las personas. La autoetnografía le permitió a una farmacéutica confrontar sus perspectivas sobre la práctica clínica entre 2014 y 2016, período en el que ella decidió desafiar, como farmacéutica, su formación tradicional centrada en los medicamentos. Utilizando como marco teórico la práctica del Pharmaceutical Care que había impulsadoa la profesión farmacéutica a cambiar su enfoque hacia el paciente, los autores colaboraron en la construcción de un monólogo sobre lo que significa centrarse en el paciente,de manera que éste cautivara a los lectores. Los hallazgos de la investigación también respaldan la versatilidad de la aplicación del proceso reflexivo proporcionado por la autoetnografía. Durante el trabajo de campo, a través de una redacción reflexiva y la realización de entrevistas, la farmacéutica descubrió una nueva forma de relacionarse con el "cuidado" y los "pacientes" en su rutina diaria

The recent inclusion of pharmacists in primary healthcare in Brazil through the Family Health Support Team has encouraged them to reflect on the need to change from a professional focused on medications to one focusedon individuals. This autoethnography allowed a pharmacist to confront her perspectives on clinical practice between 2014 and 2016, a period when she decided to challenge her traditional training as a pharmacist centered on medications. Using pharmaceutical care practice as the theoretical framework that prompted the profession of pharmacy to change its focus to the patient, the authors collaborated to construct a monologue that engages readers in the meanings of becoming patient centered. The research findings also support the versatility of application of the reflective process provided by autoethnography. Through fieldwork, reflective writing and interviews, the pharmacist discovered a new way to relate to "caring" and "patients" in her daily routine

Minimally invasive plate osteosynthesis in type B fibular fractures versus open surgery.

BACKGROUND: In traumatology, the search for better surgical access points has led to the increased use of the minimally invasive plate osteosynthesis (MIPO) technique. There are few studies on the treatment of distal fibular fractures with MIPO. Locking compression plates (LCP) for distal fibular fractures is generally applied after open reduction, but may involve complications to the surgical wound. In this study, we compared two groups of patients receiving either ORIF or MIPO, in order to analyse the advantages and disadvantages of the two techniques. MATERIALS AND METHODS: Two homogeneous groups of patients (18 + 18) received LCP for distal fractures of the fibula, type B, according to AO. Group A patients underwent open surgery, whereas Group B patients received plates applied with the MIPO technique. Both groups were examined physically and radiographically 1 and 3 months after the two types of procedure and then 1 year later, with functional assessment according to Olerud and Molander. RESULTS: ROM Group A: 5° reduction in tibiotarsal extension in 8 patients and 5° in supination in 1 patient; Group B: 5° reduction in extension in 7 cases. Mean healing time: 3 months (range 2-4) in Group A and 2.9 (range 2-4) in Group B. Dehiscence of the surgical wound was observed in five Group A patients, but none in Group B. Functional assessment according to Olerud and Molander was 87.4 points in Group A (range 80-100) and 95.6 in Group B (range 82-100). CONCLUSIONS: We believe that the MIPO technique for distal fractures of the fibula should be used more often, especially if soft tissue is in a critical condition. Healing times should be reduced in the more complex cases. It is important that the learning curve should be improved, to minimize exposure to radioscopy and possible damage to the superficial fibular nerve.

Efecto del seguimiento farmacoterapéutico en pacientes con hiperparatiroidismo secundario tratados con cinacalcet / Effect of pharmaceutical follow-up in patients with secondary hyperparathyroidism treated with cinacalcet

Objetivos: Evaluar el efecto de la intervención farmacéutica en la identificación de los problemas relacionados con medicamentos y en la mejora de los resultados clínicos deseados; evaluar la efectividad del cinacalcet para alcanzar los objetivos clínicos recomendados por la Guía Clínica KDOQI. Método Estudio cuasi experimental pre-post intervención. Pacientes con hiperparatiroidismo secundario a enfermedad renal crónica, con edad ≥ 18 años y en tratamiento con cinacalcet han sido seleccionados en la farmacia externa hospitalaria entre 2007-2009. El Método Dáder de Seguimiento Farmacoterapéutico y los cuestionarios de SMAQ y Moriski, para evaluar la adherencia, han sido usados en la primera entrevista. Tras el análisis de cada caso, el farmacéutico diseñaba la intervención adecuada. Los parámetros clínicos han sido consultados en la base de datos del laboratorio del hospital. Resultados Se incluyeron 34 pacientes, detectándose al inicio 29 problemas relacionados con medicamentos, entre ellos, la no adherencia ha sido el más común (15). Tras la intervención, restaron 9 problemas relacionados con medicamentos, lo que significa que 68,9% de ellos han sido resueltos (p < 0,001), alcanzando una adherencia del 80%. Los valores séricos de parathormona, calcio y CaxP disminuyeron significativamente tras 3 meses de tratamiento (p < 0,001, < 0,001 y 0,045, respectivamente), alcanzando las recomendaciones de la Guía Clínica KDOQI. Conclusión Esta intervención farmacéutica, simple y de fácil aplicabilidad, es efectiva en prevenir y resolver los problemas relacionados con medicamentos en estos pacientes, además de mejorar la adherencia al tratamiento y confirmar que cinacalcet es efectivo para lograr los resultados terapéuticos recomendados por la guía clínica KDOQI (AU)

Objectives: To assess the effect of pharmaceutical intervention in the identification of drug related problems, to improve desired clinical outcomes, and to evaluate the effectiveness of cinacalcet in achieving clinical outcomes recommended by the KDOQI Clinical Guidelines. Method: Quasi-experimental pre-post intervention study. Patients with Secondary Hyperparathyroidism due to Chronic Kidney Disease, aged ≥18 years and under treatment with cinacalcet were recruited at the hospital outpatient pharmacy between 2007 and 2009. Dáder follow-up method and SMAQ and Moriski questionnaires were used to verify adherence at the first interview. Then, the pharmacist analyzed each case and designed an adequate intervention. Clinical parameters were consulted in the hospital laboratory data base. Results: Thirty four patients were included, 29 drug-related problems were found before pharmacist intervention, and among these, non-adherence was the most common (15). After the intervention, 9 drug-related problems remained, which means that 68.9% of them were resolved (P<0.001), reaching an adherence of 80%. Parathyroid hormone, calcium and calcium phosphorus product serum levels decreased significantly after 3 months of treatment (P<0.001,<0.001 and 0.045, respectively), achieving the KDOQI Clinical Guideline recommendations. Conclusion: These results suggest that this simple and easy-to-apply intervention was effective in preventing and resolving drug-related problems in these patients. Moreover, it improved patient adherence and confirmed that cinacalcet treatmentis effective for achieving the clinical outcomes recommended by KDOQI clinical guidelines (AU)

[Effect of pharmaceutical follow-up in patients with secondary hyperparathyroidism treated with cinacalcet]. / Efecto del seguimiento farmacoterapéutico en pacientes con hiperparatiroidismo secundario tratados con cinacalcet.

OBJECTIVES: To assess the effect of pharmaceutical intervention in the identification of drug-related problems, to improve desired clinical outcomes, and to evaluate the effectiveness of cinacalcet in achieving clinical outcomes recommended by the KDOQI Clinical Guidelines. METHOD: Quasi-experimental pre-post intervention study. Patients with Secondary Hyperparathyroidism due to Chronic Kidney Disease, aged ≥18 years and under treatment with cinacalcet were recruited at the hospital outpatient pharmacy between 2007 and 2009. Dáder follow-up method and SMAQ and Moriski questionnaires were used to verify adherence at the first interview. Then, the pharmacist analyzed each case and designed an adequate intervention. Clinical parameters were consulted in the hospital laboratory data base. RESULTS: Thirty four patients were included, 29 drug-related problems were found before pharmacist intervention, and among these, non-adherence was the most common (15). After the intervention, 9 drug-related problems remained, which means that 68.9% of them were resolved (P<0.001), reaching an adherence of 80%. Parathyroid hormone, calcium and calcium-phosphorus product serum levels decreased significantly after 3 months of treatment (P<0.001, <0.001 and 0.045, respectively), achieving the KDOQI Clinical Guideline recommendations. CONCLUSION: These results suggest that this simple and easy-to-apply intervention was effective in preventing and resolving drug-related problems in these patients. Moreover, it improved patient adherence and confirmed that cinacalcet treatment is effective for achieving the clinical outcomes recommended by KDOQI clinical guidelines.

Implantación de un protocolo Farmacogenético del polimorfismo del GENE CYP3A5 y la respuesta a Tacrolimus en el trasplante renal / Implementation of a pharmacogenetics protocol of the CYP3A5 GENE polymorphisms and Tacrolimus response in kidney transplantation

Introducción: La monitorización de fármacos revela una gran variabilidad interindividual en la farmacocinética del Tacrolimus, principalmente en la dosis requerida para atingir los niveles sanguíneos terapéuticos y evitar la nefrotoxicidad tras el trasplante renal. La presencia del polimorfismo genético rs776746 del gene CYP3A5 resulta en la reducción de la actividad enzimática y, consecuentemente en la disminución del aclaramiento renal, aumentando su biodisponibilidad, la posibilidad de toxicidad y rechazo agudo del riñón. Objetivo: Generar una base de datos farmacogenéticos personalizada y complementaria a los datos clínicos estándares de los pacientes. Pacientes y método: Estudio observacional descriptivo transversal, pacientes mayores de 18 años en la lista de espera para el trasplante renal en el periodo de Enero a Mayo de 2010 en el Hospital Virgen de las Nieves de Granada. El ADN ha sido extraído de una muestra de sangre total y el polimorfismo del gen e CYP3A5 ha sido determinado por PCR seguida por secuenciación. Resultados: Setenta y nueve pacientes fueron genotipados, edad media de 57±13.4, 60% hombres. Los resultados del genotipado fueron: 77.2% CYP3A5 *3/*3 (homocigoto mutado) y 22.8% *1/*3(heterocigoto). Discusión: El 77.2% de los pacientes en la lista de espera para el trasplante de riñón en este hospital van a necesitar una dosis inicial de Tacrolimus cerca de 2 veces menor que los demás pacientes. Por lo tanto, con la traslación de este protocolo farmacogenético a la práctica clínica, se espera optimizar la terapia con Tacrolimus, así como contribuir al aumento de casos de éxito en los trasplantes renales(AU)

INTRODUCTION: drug monitoring reveals a great variability in the pharmacokinetics of tacrolimus, mainly in order to reach the required dose therapeutic blood levels and prevent nephrotoxicity after renal transplantation. The genetic polymorphism rs776746 of the CYP3A5 gene results in reduced enzymatic activity and consequently in decreased renal clearance, increasing its bioavailability, the possibility of toxicity and kidney acute rejection. OBJECTIVE: To create a personalized pharmacogenetic data base to complement the patient's standard clinical data. METHOD: Descriptive study, patients over 18 years in the waiting list for renal transplantation in the period from January to May 2010 at the Hospital Virgen de las Nieves de Granada. The DNA was extracted from a sample of whole blood and CYP3A5 gene polymorphism was determined by PCR followed by sequencing. RESULTADOS: Seventy-nine patients were genotyped, mean age 57±13.4, 60% men. The results of the genotyping were: 77.2% CYP3A5 *3/*3 (homozygous mutant) and 22.8% *1/*3 (heterozygous). DISCUSSION: The 77.2% of patients on the waiting list for kidney transplantation in this hospital will need an initial dose of tacrolimus about 2 times lower than other patients. Therefore, the translation of this protocol pharmacogenetics into clinical practice, is expected to optimize therapy with Tacrolimusand contribute to increased cases of successful kidney transplants(AU)

Dialysis water treated by reverse osmosis decreases the levels of C-reactive protein in uremic patients.

Atherosclerosis is a major complication of chronic renal failure. Microinflammation is involved in atherogenesis and is associated with uremia and dialysis. The role of dialysate water contamination in inducing inflammation has been debated. Our aim was to study inflammatory markers in patients on chronic dialysis, before and 3 to 6 months after switching the water purification system from deionization to reverse osmosis. Patients had demographic, clinical and nutritional information collected and blood drawn for determination of albumin, ferritin, C-reactive protein (CRP), interleukin-6, and tumor necrosis factor-alpha in both situations. Acceptable levels of water purity were less than 200 colony-forming units of bacteria and less than 1 ng/ml of endotoxin. Sixteen patients died. They had higher median CRP (26.6 vs 11.2 mg/dl, P = 0.007) and lower median albumin levels (3.1 vs 3.9 g/l, P < 0.05) compared to the 31 survivors. Eight patients were excluded because of obvious inflammatory conditions. From the 23 remaining patients (mean age +/- SD: 51.3 +/- 13.9 years), 18 had a decrease in CRP after the water treatment system was changed. Overall, median CRP was lower with reverse osmosis than with deionization (13.2 vs 4.5 mg/l, P = 0.022, N = 23). There was no difference in albumin, cytokines, subjective global evaluation, or clinical and biochemical parameters. In conclusion, uremic patients presented a clinically significant reduction in CRP levels when dialysate water purification system switched from deionization to reverse osmosis. It is possible that better water treatments induce less inflammation and eventually less atherosclerosis in hemodialysis patients.

Dialysis water treated by reverse osmosis decreases the levels of C-reactive protein in uremic patients

Atherosclerosis is a major complication of chronic renal failure. Microinflammation is involved in atherogenesis and is associated with uremia and dialysis. The role of dialysate water contamination in inducing inflammation has been debated. Our aim was to study inflammatory markers in patients on chronic dialysis, before and 3 to 6 months after switching the water purification system from deionization to reverse osmosis. Patients had demographic, clinical and nutritional information collected and blood drawn for determination of albumin, ferritin, C-reactive protein (CRP), interleukin-6, and tumor necrosis factor-alpha in both situations. Acceptable levels of water purity were less than 200 colony-forming units of bacteria and less than 1 ng/ml of endotoxin. Sixteen patients died. They had higher median CRP (26.6 vs 11.2 mg/dl, P = 0.007) and lower median albumin levels (3.1 vs 3.9 g/l, P < 0.05) compared to the 31 survivors. Eight patients were excluded because of obvious inflammatory conditions. From the 23 remaining patients (mean age ± SD: 51.3 ± 13.9 years), 18 had a decrease in CRP after the water treatment system was changed. Overall, median CRP was lower with reverse osmosis than with deionization (13.2 vs 4.5 mg/l, P = 0.022, N = 23). There was no difference in albumin, cytokines, subjective global evaluation, or clinical and biochemical parameters. In conclusion, uremic patients presented a clinically significant reduction in CRP levels when dialysate water purification system switched from deionization to reverse osmosis. It is possible that better water treatments induce less inflammation and eventually less atherosclerosis in hemodialysis patients.

Chronic evolution of acute hepatitis type B: prevalence and predictive markers.

During a prospective study of acute symptomatic viral hepatitis, started in 1978, 664 consecutive adult patients, including 223 drug abusers, fulfilled the diagnostic criteria (anti-HBc IgM positivity) for acute type B hepatitis. In order to evaluate the outcome of the disease, 443 patients were followed for up to 12 months after the onset. 2.4% of the infections became chronic; the rate did not significantly differ between drug addicts and non-drug abusers, suggesting that chronic hepatitis is a rare complication of acute symptomatic hepatitis type B. Ongoing liver damage after clearance of HBsAg from serum was observed in drug abusers only (14% of the cases). Clinical, biochemical and virological features of the acute phase in patients with ongoing infection were compared with those of uncomplicated cases. Anicteric hepatitis and lower transaminase values were significantly (p less than 0.05) associated to a chronic evolution of the disease, as well as a higher prevalence of HBV-DNA, DNA polymerase and HBcAg positivity in serum. Testing HBV-DNA and DNA polymerase early in the course of the infection appeared to be of high predictive value for the subsequent outcome of the illness.