The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

https://repositorio.ufba.br/ri/bitstream/ri/3028/1/Per%20int%202011.12.pdf

The Brazilian health system: history, advances, and challenges

Statistical Methods in Medical Research.

Background: There is increasing recognition that the use of certain medications contributes to falls in seniors. Our objective was to update a previously completed meta-analysis looking at the association of medication use and falling to include relevant drug classes and new studies that have been completed since a previous meta-analysis. Methods: Studies were identified through a systematic search of English-language articles published from 1996 to 2007. We identified studies that were completed on patients older than 60 years, looking at the association between medication use and falling. Bayesian methods allowed us to combine the results of a previous metaanalysis with new information to estimate updated Bayesian odds ratios (ORs) and 95% credible intervals (95% CrIs) Results: Of 11 118 identified articles, 22 met our inclusion criteria. Meta-analyses were completed on 9 unique drug classes, including 79 081 participants, with the following Bayesian unadjusted OR estimates: antihypertensive agents, OR, 1.24 (95% CrI, 1.01-1.50); diuretics, OR, 1.07 (95% CrI, 1.01-1.14); -blockers, OR, 1.01 (95% CrI, 0.86-1.17); sedatives and hypnotics, OR, 1.47 (95% CrI, 1.35-1.62); neuroleptics and antipsychotics, OR, 1.59 (95% CrI, 1.37-1.83); antidepressants, OR, 1.68 (95% CrI, 1.47-1.91); benzodiazepines, OR, 1.57 (95% CrI, 1.431.72); narcotics, OR, 0.96 (95% CrI, 0.78-1.18); and nonsteroidal anti-inflammatory drugs, OR, 1.21 (95% CrI, 1.01-1.44). The updated Bayesian adjusted OR estimates for diuretics, neuroleptics and antipsychotics, antidepressants, and benzodiazepines were 0.99 (95% CrI, 0.78-1.25), 1.39 (95% CrI, 0.94-2.00), 1.36 (95% CrI, 1.13-1.76), and 1.41 (95% CrI, 1.20-1.71), respectively. Stratification of studies had little effect on Bayesian OR estimates, with only small differences in the stratified ORs observed across population (for -blockers and neuroleptics and antipsychotics) and study type (for sedatives and hypnotics, benzodiazepines, and narcotics). An increased likelihood of falling was estimated for the use of sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, and nonsteroidal anti-inflammatory drugs in studies considered to have “good” medication and falls ascertainment. Conclusion: The use of sedatives and hypnotics, antidepressants, and benzodiazepines demonstrated a significant association with falls in elderly individuals.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/485251/ira90005_1952_1960.pdf

Meta-analysis of the impact of 9 medication classes on falls in elderly persons.

Background. Falls in older people are associated with poor prognosis. Medication use is a potential cause of falls. Our aim was to systemically review all original articles examining medication use as a risk factor for falls or fall-related fractures in people aged � 60 years. Methods. We searched English articles in Medline (1996–2004) indexed under ‘‘falls’’ or ‘‘accidental falls’’ and ‘‘pharmaceutical preparations’’ or specific groups of drugs. We excluded studies not meeting the age criterion, not controlled with nonusers of target medicines or nonfallers, or with no clear definition of target medication. Results. Twenty-eight observational studies and one randomized controlled trial met the inclusion criteria. The number of participants ranged from 70 to 132,873. The outcome measure was a fall in 22 studies and a fracture in 7 studies. The main group of drugs associated with an increased risk of falling was psychotropics: benzodiazepines, antidepressants, and antipsychotics. Antiepileptics and drugs that lower blood pressure were weakly associated with falls. Conclusions. Central nervous system drugs, especially psychotropics, seem to be associated with an increased risk of falls. The quality of observational studies needs to be improved, for many appear to lack even a clear definition of a fall, target medicines, or prospective follow-up. Many drugs commonly used by older persons are not systematically studied as risk factors for falls.

Medication as a Risk Factor for Falls: Critical Systematic Review

Objective. To evaluate the incidence of adverse events in Brazilian hospitals. Design. Retrospective cohort study based on patient record review. Setting. Three teaching hospitals in the State of Rio de Janeiro, Brazil. Participants. Random sample (1103) of 27 350 adult patients admitted in 2003. Patients under 18 years old, psychiatric patients and patients whose length of stay was less than 24 hr were excluded, and obstetric cases were included. Main Outcome Measure(s). Incidence of patients with adverse events; proportion of preventable adverse events; number of adverse events per 100 patients and incidence density of adverse events per 100 patient-days. Results. The incidence of patients with adverse events was 7.6% (84 of 1103 patients). The overall proportion of preventable adverse events was 66.7% (56 of 84 patients). The incidence density was 0.8 adverse events per 100 patient-days (103 of 13 563 patient-days). The patient’s ward was the most frequent location of adverse events (48.5%). In regard to classification, surgical adverse events were the most frequent ones (35.2%). Conclusions. The incidence of patients with adverse events at the three hospitals was similar to that in international studies. However, the proportion of preventable adverse events was much higher in the Brazilian hospitals.

http://www.aeciherj.org.br/publicacoes/evento-adverso-Brasil-2009.pdf

The assessment of adverse events in hospitals in Brazil.

Most elderly people use at least one medication, and about one-third use more than five drugs simultaneously. Many patients have no access to the drugs they most need, and others use unnecessary or dangerous drugs. The mean number of drugs used by the elderly, as quoted in different studies, varies from 2 to 5. Significant predictors for such misuse of medication are older age, female gender, precarious health conditions, and depression. Cardiovascular drugs, anti-rheumatics, and analgesics are the most frequently consumed therapeutic classes. Multiple use, prescription of contraindicated drugs, redundant use, and inadequate training of the health care team are associated with adverse drug effects and interactions. Better quality of prescriptions and research on drug use can bring benefits to people aged 60 years or older.

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Prevalence, associated factors, and misuse of medication in the elderly: a review

Inappropriate medication use (IMU) by elderly people is a public health problem associated with adverse effects on health. There are a number of methods for identifying IMU, some involving clinical judgment and others, consensually generated lists of drugs to be avoided. This review aims to describe studies that used information from insurance company and social security administrative databases to assess IMU among community-dwelling elderly and to present the risk factors most often associated with IMU. The paper search was conducted in Medline and Embase, using descriptors combined with free terms in the title or abstract. The limits applied were: publication date from January 1990 to June 2010, species (human) and publication type (excluding editorials, letters and reviews). Excluded were: case studies; studies in hospitals, nursing homes, or hospital emergency departments; studies of specific drugs or groups of drugs; studies exclusively of subgroups of ill, frail elderly or rural populations. Additional studies were identified from reference lists. Data were selected and extracted after independent reading by two of the authors, with disagreements resolved by a third author. The primary outcome assessed was prevalence of IMU, defined as the proportion of elderly who received at least one inappropriate medication. Of the 628 studies, 19 met the inclusion criteria, 78.9% of them conducted in the USA. All papers included used explicit criteria of inappropriateness, most commonly Beers criteria (73.7%) in their three versions (1991, 1997 and 2002). Other methods used included Zhan, which is derived from on Beers criteria and was applied in 21% of the papers selected. The study found that prevalence of IMU ranged from 11.5% to 62.5%. Only 68.4% of the studies included examined inappropriate use-related factors, the most important being female sex, advanced age and larger number of drugs. The results show that the prevalence of IMU among community-dwelling elderly is high and depends partly on the method used to evaluate improper use. Besides the diversity of methods, other factors, such as patient sex, age and number of drugs used concurrently, appear to have influenced the estimates of IMU.

/pdf/inappropriate-medication-use-among-the-elderly-a-systematic-nck4glttzd.pdf

Inappropriate medication use among the elderly: a systematic review of administrative databases

OBJECTIVE: To describe drug utilization by Brazilian retirees with an emphasis on inappropriate use. METHODS: Cross-sectional study with a simple random sample of 800 retirees of the Brazilian Institute of Social Security, 60 years of age and older, residing in Rio de Janeiro City, through face-to-face interviews. RESULTS:Medication use in the 15 days before the study was reported by 85% of the sample, with a mean of 3.7 products per person (standard deviation = 2.9). About half the sample used one to four medications and a third used five or more. The highest number of drugs used per patient was 24. More women than men used multiple medications. There is a tendency toward positive association (P < 0.001) between drug use and variables relating to disease and health care. This trend continues in the analysis by gender. Men who reported five or more diseases were five times more likely to use multiple drugs than men with up to two (zero, one, or two) diseases (prevalence ratio 5.21, 95% confidence interval = 2.48-10.90). Women who reported five or more diseases were nearly four times more likely to use multiple drugs than women with up to two diseases (prevalence ratio 3.67, 95% confidence interval = 2.24-6.02). Of the active substances used by the sample, 10% were considered inappropriate. CONCLUSIONS:To improve drug therapy for the elderly, health practitioners can take measures to reduce unwarranted use of medication and to optimize the benefits from important drugs. Further studies should be conducted to adjust lists of medications inappropriate for the elderly to the situation in developing countries.

/pdf/drug-utilization-and-polypharmacy-among-the-elderly-a-survey-w3n860j1v5.pdf

Drug utilization and polypharmacy among the elderly: a survey in Rio de Janeiro City, Brazil

OBJETIVO: Caracterizar o uso de medicamentos por aposentados e pensionistas idosos, com enfase nas diferencas entre generos. METODOS: Inquerito domiciliar conduzido com amostra aleatoria simples de 667 individuos com 60 anos ou mais, residentes em Belo Horizonte, MG, em 2003. Os idosos foram entrevistados por farmaceuticos, utilizando questionario padronizado. Foram estimadas a prevalencia de uso e a media de medicamentos usados nos ultimos 15 dias anteriores a entrevista, as quais foram estratificadas de acordo com o genero segundo variaveis sociodemograficas e de saude. RESULTADOS: A prevalencia de uso de medicamentos foi de 90,1%, significativamente maior entre as mulheres (93,4%) do que entre os homens (84,3%). Mulheres utilizaram em media 4,6±3,2 produtos e homens 3,3±2,6 (p<0,001). Os principios ativos mais usados pelos idosos pertenciam aos sistemas cardiovascular, nervoso, e do trato alimentar e metabolismo. O consumo foi superior entre as mulheres nesses tres grupos, assim como as medias de uso de medicamentos segundo variaveis sociodemograficas e de saude selecionadas. CONCLUSOES: O estudo identificou uso mais intenso de medicamentos pelas mulheres, fato que as torna mais vulneraveis aos prejuizos de polifarmacia, como risco de interacoes e uso inadequado.

/pdf/inquerito-sobre-uso-de-medicamentos-por-idosos-aposentados-1f4ihd8soi.pdf

Suely Rozenfeld

Papers

The assessment of adverse events in hospitals in Brazil.

Prevalence, associated factors, and misuse of medication in the elderly: a review

Inappropriate medication use among the elderly: a systematic review of administrative databases

Drug utilization and polypharmacy among the elderly: a survey in Rio de Janeiro City, Brazil

Inquérito sobre uso de medicamentos por idosos aposentados, Belo Horizonte,MG