[Assisting diabetics in Portugal: the structuring role of the Association to Protect Poor Diabetics, 1926-1946]

Assistance to diabetics in Portugal was quintessentially linked to the 1926 foundation of the Association to Protect Poor Diabetics (Associação Protetora dos Diabéticos Pobres) which was decisive in structuring diabetology in Portugal. This article shows how during the first half of the twentieth century, this association helped create a model of assistance for diabetics in this country based on the principles of modern diabetology. First, we examine its functional and clinical organization to comply with assistance policy during the New State period in Portugal. Next, we depict the organization of the assistance model, which included treatment and education of poor patients with diabetes.

Cost-Effectiveness of Inpatient Continuous Glucose Monitoring

Introduction Our department conducted a retrospective cohort study to compare the efficacy of continuous glucose monitoring devices versus capillary blood glucose in the glycemic control of inpatient type 2 diabetes on intensive insulin therapy in a Portuguese hospital. The use of continuous glucose monitoring devices was associated with improved glycemic control, including an increased number of glucose readings within target range and reduced hyperglycemic events, being safe concerning hypoglycemias. This is the cost-effectiveness analysis associated with these results. Aim The primary objective was to compare the cost-effectiveness of achieving glycemic control, defined as the number of patients within glycemic goals, between groups. Secondary endpoints included cost-effectiveness analyses of each time in range goal, and each percentual increment in time in range. Methods We defined each glycemic goal as: "readings within range (70-180 mg/dL) >70%", "readings below range (below 70 mg/dL) <4%", "severe hypoglycemia (below 54 mg/dL) <1%", "readings above range (above 180 mg/dL) <25%", "very high glycemic readings (above 250 mg/dL) <5%". Results Continuous glucose monitoring showed lower median cost per effect for the primary outcome (€11.1 vs. €34.9/patient), with lower cost for readings in range (€7.8 vs. €11.6/patient) and for both readings above range goals ("above 180mg/dL": €7.4 vs. €9.9/patient, and "above 250mg/dL": €6.9 vs. €17.4/patient). Conclusions There are no published data regarding the cost-effectiveness of continuous glucose monitoring devices in inpatient settings. Our results show that continuous glucose monitoring devices were associated with an improved glycemic control, at a lower cost, and endorse the feasibility of incorporating these devices into hospital settings, presenting a favorable cost-effective option compared to capillary blood glucose.

Chronic Infection by Plasmodium falciparum

Malaria by Plasmodium falciparum (P. falciparum) usually does not exceed one year, but chronic infection, although rare, is a possibility. We present the clinical case of a 37-year-old male who came to the emergency department with intermittent fever, chills, and malaise. He had malaria more than 1 year ago while working in Huíla province, Angola. On admission, Plasmodium testing by light microscopy and antigens was negative. Doxycycline was started empirically, but on the third day of hospitalization, he had a new fever spike. Plasmodium DNA and antibodies were tested, confirming P. falciparum. The therapy with artemether-lumefantrine, already after discharge, allowed the consolidation of the treatment and eradicator of the parasite. Detection of parasite DNA by PCR should not be routine, but it is a more sensitive method, which confirmed this chronic infection by P. falciparum after one year.

Snapshot of the Phylogenetic Relationships among Avian Poxviruses Circulating in Portugal between 2017 and 2023

Avipoxvirus (APV), a linear dsDNA virus belonging to the subfamily Chordopoxvirinae of the family Poxviridae, infects more than 278 species of domestic and wild birds. It is responsible for causing avian pox disease, characterized by its cutaneous and diphtheric forms. With a high transmission capacity, it can cause high economic losses and damage to the ecosystem. Several diagnostic methods are available, and bird vaccination can be an effective preventive measure. Ten APV-positive samples were analyzed to update the molecular characterization and phylogenetic analysis of viruses isolated in Portugal between 2017 and 2023. A P4b gene fragment was amplified using a PCR, and the nucleotide sequence of the amplicons was determined using Sanger sequencing. The sequences obtained were aligned using ClustalW, and a maximum likelihood phylogenetic tree was constructed. With this study, it was possible to verify that the analyzed sequences are distributed in subclades A1, A2, B1, and B3. Since some of them are quite similar to others from different countries and obtained in different years, it is possible to conclude that there have been several viral introductions in Portugal. Finally, it was possible to successfully update the data on Avipoxviruses in Portugal.

Subcentimetric papillary thyroid carcinoma with extensive lymph node and brain metastasis: case report and review of literature

Summary

We report a 61-year-old male patient without personal history of thyroid carcinoma or radiation exposure. In 2011, he presented with a cervical mass whose biopsy diagnosed a papillary thyroid carcinoma (PTC) in a lymph node metastasis (LNM). Total thyroidectomy with lymphadenectomy of central and ipsilateral compartment was performed. Histopathology identified a 2 mm follicular variant of PTC and LNM in 25/25 lymph nodes. The patient was treated with 150 mCi of radioactive iodine (RAI), followed by levothyroxine suppressive therapy. In 2016, a retrotracheal mass was diagnosed, suggesting local recurrence; patient was submitted to surgical excision and RAI therapy (120 mCi). Due to seizures, in 2019, a brain CT was performed that diagnosed brain metastases. The patient underwent debulking of the main lesion. Histopathology analysis confirmed a metastatic lesion with variated morphology: classical PTC and follicular pattern and hobnail and tall cell features. Molecular analysis revealed BRAFV600E in LNM at presentation and BRAFV600E and TERT promoter (TERTp) mutations in the recurrent LNM and brain metastasis. Based upon this experience we review the reported cases of subcentimetric PTC with brain metastases and discuss the molecular progression of the present case.

Learning points

Papillary microcarcinoma (PMCs) usually have very good prognosis with low impact on patient survival. PMCs presenting in elderly patients with LNM at diagnosis may carry a guarded outcome. Brain metastasis although rare indicate aggressive phenotypic features. Patient risk stratification of PMCs based on histopathological analysis and genetic testing may have a significant impact on prognosis providing therapeutic markers, that may predict disease progression and overall outcome.

HER2 Status in RAS and BRAF Wild-Type Metastatic Colorectal Cancer: A Portuguese Study

INTRODUCTION

Colorectal cancer (CRC) is the second-most deadly cancer worldwide. However, there remains a scarcity of precision treatments available for this type of cancer. Amplification or overexpression of human epidermal growth factor receptor 2 (HER2+) is a well-established therapeutic target in gastric and breast cancer. HER2 is positive in approximately 5% of CRC cases and has been implicated in resistance to therapy with anti-epidermal growth factor receptor antibodies. The aim of this study was to evaluate HER2 status in RAS and BRAF wild-type metastatic CRC (mCRC) and its correlation with survival outcomes.

MATERIALS AND METHODS

A single-center retrospective analysis of RAS and BRAF wild-type mCRC patients undergoing systemic treatment was conducted from July 2014 to September 2020. Tissue HER2 status was determined by immunohistochemistry (IHC) and/or fluorescence in situ hybridization (FISH) and/or chromogenic in situ hybridization (CISH). HER2+ was defined as IHC3 (+) or IHC2 (+) through FISH or CISH (+).

RESULTS

Fifty-nine patients were included. The median age of all the included patients was 64 years (33-82). Four patients had HER2+ tumors (7%). Four patients had HER2+ tumors (7%). The majority of HER2+ mCRC cases were males (n=3) and left-sided CRC (n=3). All patients received FOLFIRI plus cetuximab as first-line treatment. At the median follow-up of 24.0 months, patients with HER2-negative mCRC presented with a median overall survival (mOS) of 39.4 months (95% confidence interval (CI) 32.7-46.0) and the four patients with HER2+ mCRC had a mOS of 20.4 months (95% CI; 9.5-31.3; p=0.07). In HER2-negative patients, the median PFS (mPFS) was 11.3 months (95% CI; 9.2-13.4) vsHER2-positive patients with a mPFS of 10.9 months (95% CI; 1.3-20.4; p=0.47).

CONCLUSIONS

To our knowledge, this is the first study reporting HER2+ in mCRC patients in a Portuguese population and the HER2+ rate was consistent with previous studies. Our study suggests that HER2+ may potentially be a marker that is able to predict poor prognosis in RAS and BRAF wild-type mCRC.

Vulnerability in context; hard numbers, tricky words and grey areas for gerontology

At the start of the COVID-19 pandemic, the Portuguese government identified those aged 70 or more as a risk group, placing a special duty of protection on them to shelter-at-home. This paper asks how Portuguese municipalities, using Facebook posts, communicated the risk to older adults and to what extent ageist stereotypes were found in the language and frames employed. Over 3800 Facebook posts made by Portuguese municipalities concerning older adults and COVID-19 published between March and July 2020 were analyzed. Language counts for age-related words were used in a first round of content analysis followed by a process of thematic analysis. Findings indicate that the language used to address Portuguese older adults could be understood as ageist in terms of homogenizing older people as a fixed group. The communication of risk was often conflated with the vulnerability narrative already observed in the extant literature. However, context- and culture-specific themes of ‘solidarity’, ‘inter-relatedness’, ‘duty of care’ and ‘support for those living in isolation’ were also found. The study highlights the extent to which language, culture and context are intertwined with our understanding of age, aging and ageism. It provides a culturally-specific case study, which challenges both gerontological interpretations of vulnerability and neoliberal frames which focus responsibility on the individual regardless of age. We argue that these alternative frames echo the emerging discourse of mutual aid and solidarity, providing a wider context for addressing vulnerability in a health crisis.

Campylobacter fetus Cellulitis

Campylobacter fetus, a bacteria of the Campylobacter genus that are a group of bacteria known to cause intestinal infections, is a particular microbial agent due to its most common presentation being as a non-intestinal systemic infection and rarely as a focal infection, most frequently cellulitis. C. fetus's main reservoirs are cattle and sheep. Humans are usually infected by consuming raw milk and/or meat. Infection in humans is rare and generally related to immune deficiencies, malignancy, chronic liver disease, diabetes mellitus and elderly age, among other factors. Diagnosis is usually achieved by blood cultures due to the lack of focalized signs/symptoms and the pathogen's endovascular tropism. The authors present a case of cellulitis due to Campylobacter fetus, a microbial agent that affects susceptible patients with a mortality rate of up to 14%. We aim to emphasize the importance of potential bacterial seeding sites secondary to bacteremia given the agent tropism for vascular tissue. The medical diagnosis was performed by the identification of bacteria in blood cultures. Campylobacter spp. infections are more frequently related to undercooked poultry or meat, but in this case, the consumption of fresh cheese was considered the most likely source of infection. A literature review showed that, in patients with previous antibiotic cycles, a combination of carbapenem and gentamicin had better outcomes and lower relapse rates. Due to typical surface antigenic variation, immune control may not be attainable and may account for relapsing infections, even after appropriate therapy. The duration of treatment has yet to be well established. Based on other reported cases, we considered a four-week treatment to be sufficient, given clinical improvement and absence of recurrence in the follow-up time.

Peripheral Nerve Block Practice in Portugal: A National Survey

Regional anesthesia (RA) has several benefits and its use has increased with the advent of ultrasound-guided techniques. Opioid-sparing anesthesia and reduced use of general anesthesia are some of the mainstay advantages of RA. Although anesthetic practices differ deeply between countries, RA has assumed a crucial role in the daily practice of anesthesiologists, particularly during the COVID-19 pandemic period. This cross-sectional study provides an overview of peripheral nerve block (PNB) techniques performed in Portuguese hospitals. An online survey was reviewed by members of Clube de Anestesia Regional (CAR/ESRA Portugal) and then sent to a national mailing list of anesthesiologists. The survey focused on specific topics related to RA techniques such as the importance of training and experience, and the relevance of logistical limitations during the execution of RA. All data were collected anonymously and included in a Microsoft Excel (Microsoft Corp., Redmond, WA, USA) database, for further analysis. A total of 335 valid answers were obtained. All participants considered RA as a key competence in their daily practice. Half of those inquired performed PNB techniques once to twice per week. The main limitations identified for performing RA in Portuguese hospitals were the absence of block rooms and insufficiently trained personnel for the appropriate and safe execution of these techniques. This survey provides a comprehensive overview of RA in the Portuguese setting and could serve as a baseline for further studies.

Follicular lymphoma of the thyroid and the role of core needle biopsy

Summary

Primary thyroid lymphoma (PTL) is a rare malignancy, accounting for less than 5% of all thyroid neoplasms. The follicular subtype is even more rare, accounting for approximately 10% of all PTL cases. We report a case of a 64-year-old woman, who presented with a rapidly growing goitre with mass effect and B symptoms. She had a history of Hashimoto's thyroiditis and her thyroid ultrasound revealed diffuse goitre with a dominant nodule (56 × 63 × 60 mm) within the right thyroid lobe. Ultrasound-guided percutaneous fine-needle aspiration of the right thyroid nodule was classified as benign, according to Bethesda System, with lymphocytic thyroiditis. A CT scan of the neck showed diffuse enlargement of the thyroid gland extending towards the anterior mediastinum with tracheal deviation and lymphadenopathy within levels VII and right II-IV. The core needle biopsy of the right thyroid nodule revealed a follicular non-Hodgkin's B cell lymphoma with a Ki67 of 60%. According to the Ann Arbor staging system, she was at stage IIIE. She underwent chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) with remarkable clinical improvement and is currently in remission 2 years after the diagnosis. PTL is an extremely rare malignancy that usually arises in a lymphocytic thyroiditis background, presenting as a rapidly enlarging goitre, which can lead to compressive symptoms or airway comprise.

Learning points

Primary thyroid lymphoma (PTL) is a rare malignancy, accounting for less than 5% of thyroid neoplasms. PTL should be suspected when a patient presents with a rapidly enlarging goitre, especially in the setting of Hashimoto's thyroiditis. Fine-needle aspiration has a limited capacity for PTL diagnosis due to similar cytomorphological features of lymphoma with thyroiditis. Therefore, in case of clinical suspicion and if fine needle aspiration fails to diagnose PTL, a tissue biopsy should be performed. Treatment is dependent on both the stage and histology of PTL. Chemotherapy and local radiotherapy remain the mainstay treatment for PTL.

A serious and unusual presentation of congenital isolated ACTH deficiency due to TBX19 mutation, beyond the neonatal period

Summary

Congenital isolated adrenocorticotrophic hormone (ACTH) deficiency due to T-box transcription factor-19 (TBX19 mutation) (MIM 201400; ORPHA 199296) usually presents in the neonatal period with severe hypoglycemia, seizures, and sometimes prolonged cholestatic jaundice. We report a case with an unusual presentation that delayed the diagnosis. A 9-month-old female patient with no relevant personal history was admitted to the emergency department due to a hypoglycemic seizure in the context of acute gastroenteritis. There was rapid recovery after glucose administration. At age 4, she presented with tonic-clonic seizures, fever, and gastrointestinal symptoms and came to need support in an intensive care unit. Low serum cortisol was documented and hydrocortisone was initiated. After normalization of inflammatory parameters, the patient was discharged with hydrocortisone. The genetic investigation was requested and compound heterozygous mutations in TBX19 were detected. This is a rare case of presentation of TBX19 mutation outside the neonatal period and in the setting of acute disease, which presented a diagnostic challenge.

Learning points

Congenital isolated adrenocorticotrophic hormone deficiency due to TBX19 mutation usually presents with neonatal hypoglycemia and prolonged cholestatic jaundice. An uneventful neonatal period, however, does not exclude the diagnosis as the disease may be asymptomatic at this stage. In the context of idiopathic hypoglycemia, even in the context of acute disease, hypocortisolism must always be excluded. Genetic evaluation should be performed in cases of congenital central hypocortisolism to allow proper counselling.

Early onset obesity due to a mutation in the human leptin receptor gene

Summary

Leptin is secreted by adipocytes in response to fat storage and binds to its receptor (LEPR), which is ubiquitously expressed throughout the body. Leptin regulates energy expenditure and is anorexigenic. In this study, we describe the clinical and hormonal findings of three siblings with a personal history of rapid weight gain during the first months of life. They had delayed puberty, high levels of FSH (15.6 ± 3.7 mUI/mL; reference: 1.5-12.4) and LH (12.3 ± 2.2 mUI/mL; reference: 1.7-8.6), normal oestradiol and total testosterone and successful fertility. None of the patients had dyslipidemia, diabetes or thyroid disease. Next-generation sequencing identified a pathogenic homozygous variant c.2357T>C, p.(Leu786Pro) in LEPR. Their parents and children were heterozygous for this mutation. We compared clinical and biochemical findings of homozygous carriers with first-degree heterozygous family members and ten randomly selected patients with adult-onset morbid obesity. Homozygous carriers of the mutation had significantly higher BMI (32.2 ± 1.7 kg/m2 vs 44.5 ± 7.1 kg/m2, P = 0.023) and increased serum levels of leptin (26.3 ± 9.3 ng/mL vs 80 ± 36.4 ng/mL, P = 0.028) than their heterozygous relatives. Compared with the ten patients with adult-onset morbid obesity, serum levels of leptin were not significantly higher in homozygous carriers (53.8 ± 24.1 ng/mL vs 80 ± 36.4 ng/mL, P = 0.149), and thus serum levels of leptin were not a useful discriminative marker of LEPR mutations. We described a rare three-generation family with monogenic obesity due to a mutation in LEPR. Patients with early onset obesity should be considered for genetic screening, as the identification of mutations may allow personalized treatment options (e.g. MC4R-agonists) and targeted successful weight loss.

Learning points

The early diagnosis of monogenic forms of obesity can be of great interest since new treatments for these conditions are becoming available. Since BMI and leptin levels in patients with leptin receptor mutations are not significantly different from those found in randomly selected morbid obese patients, a careful medical history is mandatory to suspect this condition. Loss of leptin receptor function has been associated with infertility. However, our patients were able to conceive, emphasizing the need for genetic counselling in affected patients with this condition.

Turner syndrome and neurofibromatosis type 1: the unusual combination of two common genetic disorders

Summary

The coexistence of neurofibromatosis type 1 (NFT1) and Turner syndrome (TS) has only been reported in a few patients and may represent a diagnostic challenge. We describe the case of a 16-year-old girl, with a prior clinical diagnosis of NFT1, who was referred to Endocrinology appointments for the etiological study of primary amenorrhea. Evaluation of the anterior pituitary function was requested and hypergonadotropic hypogonadism was detected. During the etiological study, a 45X karyotype was found and TS was diagnosed. The fact that NFT1 can also be associated with short stature, short broad neck and hypertelorism was likely responsible for TS being diagnosed in late adolescence. As both TS and NFT1 are relatively common genetic disorders, it is important to be alert to the possibility that the presence of one disease does not invalidate the other.

Learning points

The concomitant presence of two syndromes in the same patient is unlikely and represents a diagnostic challenge. Some phenotypic characteristics and clinical manifestations may be shared by several syndromes. Some syndromes, such as neurofibromatosis type 1 may have very heterogeneous presentations. It is important to be alert to the characteristics that are not explained by the initial diagnosis. If such features are present, diagnostic work-up must be performed regardless of the initial syndromic diagnosis.

New onset autoimmune diabetes mellitus and hypothyroidism secondary to pembrolizumab in a patient with metastatic lung cancer

SUMMARY

Immunotherapy has become an important pillar for the management of advanced cancer. Immune-related adverse events including endocrinopathies have been well described with programmed cell death 1 inhibitors such as pembrolizumab. While thyroid dysfunction is the most common endocrinopathy associated with pembrolizumab, new-onset autoimmune diabetes mellitus (DM) is extremely rare. The authors report a case of pembrolizumab-induced primary hypothyroidism and type 1 diabetes mellitus presenting with diabetic ketoacidosis (DKA). A 59-year-old female patient was treated with pembrolizumab for a stage 4 lung adenocarcinoma. She presented to the emergency department with hyperglycaemia-related signs and symptoms, such as polyuria, polydipsia, weight loss, vomiting, asthenia and dehydration, 3 weeks after her first dose of pembrolizumab. Laboratory evaluation revealed hyperglycaemia, hyperketonaemia and high anion gap metabolic acidaemia consistent with DKA. After prompt and adequate treatment of DKA, she transitioned to s.c. basal-bolus insulin. The diagnose of autoimmune DM was established based on the undetectable C-peptide levels and seropositivity for antiglutamic acid decarboxylase antibodies. Additional hormonal parameters revealed overt hypothyroidism and levothyroxine therapy was initiated. This case highlights the importance of blood glucose and thyroid function monitoring as an integral part of cancer treatment protocols for pembrolizumab and other immune checkpoint inhibitors.

LEARNING POINTS

Programmed cell death 1 (PD1) inhibitors such as pembrolizumab can cause endocrine immune-related adverse events (irAE), including thyroid dysfunction and type 1 diabetes mellitus (T1DM). Thyroid dysfunction is the most frequent endocrine irAE secondary to PD1 inhibitors. Autoimmune diabetes and possible resultant diabetic ketoacidosis are rare, but life-threatening adverse events associated with pembrolizumab. Pembrolizumab-induced T1DM often present with relatively low HbAlc levels, reflecting the fulminant onset of β-cell destruction. Patients treated with pembrolizumab and other immune checkpoints inhibitors should be monitored regularly for hyperglycaemia and thyroid dysfunction.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Auditory Processing Intervention Program for school-aged children - development and content validation

PURPOSE

The study aimed at the development and content validation of an Auditory Processing Intervention Program for school-aged European Portuguese speaking children with Auditory Processing Disorder.

METHODS

The first step was the program's development and its instructions manual, which includes objectives, activities, procedures, materials, reinforcement, instructions, and verbal stimuli used, for the following auditory skills: auditory discrimination, auditory attention; auditory memory; auditory closure; figure-ground; auditory separation; auditory integration; binaural fusion; content validation was performed next, with two expert panels analyzing the program, through the use of a questionnaire. Content validity was calculated using the content validity index.

RESULTS

Program evaluation shows an excellent content validity. Some items were modified after analyzing the experts' comments and suggestions (e.g. instructions, intensity differences, main character).

CONCLUSION

This work allowed the development and content validation of an auditory processing intervention program, with verbal stimuli, selected according to strict linguistic criteria. In the future, the acceptability and efficacy of this program with the target population should be analyzed.

Q Fever: An Emerging Reality in Portugal

Q fever is a zoonosis caused by Coxiella burnetii with worldwide distribution at the increasing expression in Europe and endemic in Portugal. It is transmitted by inhalation of aerosols containing spores, main reservoir being cattle, goats and sheep as by ingesting cottage cheese or unpasteurized milk. The majority of patients are asymptomatic; however, they may present with fever, atypical pneumonia, acute hepatitis, cutaneous manifestations and rarely with cardiac or neurological involvement. Although most cases are self-limited, focal persistent or chronic Q fever can manifest years after the onset, wherefore follow-up is essential. The clinical heterogeneity may be so variable that the disease is often diagnosed only if it has been systematically considered. It should be especially taken into account in the presence of risk factors as valvular or joint prostheses, immunocompromised patients, pregnant women and epidemiological setting. The authors present a rare case of Coxiella burnetii pneumonia with cutaneous and hepatic manifestations without any risk factor. This case aims to emphasize the importance of Q fever in the differential diagnosis of fever or atypical pneumonia, even in the absence of known risk factors. The diagnosis is often challenging for clinicians and it is necessary to maintain a high index of suspicion. In Europe and specifically in Portugal is mandatory to report the cases to establish the real impact of this disease.

A variant in the CASR gene (c.368T>C) causing hypocalcemia refractory to standard medical therapy

SUMMARY

Hypoparathyroidism is characterized by low or inappropriately normal parathormone production, hypocalcemia and hyperphosphatemia. Autosomal dominant hypocalcemia (ADH) type 1 is one of the genetic etiologies of hypoparathyroidism caused by heterozygous activating mutations in the calcium-sensing receptor (CASR) gene. Current treatments for ADH type 1 include supplementation with calcium and active vitamin D. We report a case of hypoparathyroidism in an adolescent affected by syncope without prodrome. The genetic testing revealed a variant in the CASR gene. Due to standard therapy ineffectiveness, the patient was treated with recombinant human parathyroid hormone (1-34), magnesium aspartate and calcitriol. He remained asymptomatic and without neurological sequelae until adulthood. Early diagnosis and treatment are important to achieve clinical stability.

LEARNING POINTS

Autosomal dominant hypocalcemia (ADH) type 1 is one of the genetic etiologies of hypoparathyroidism caused by heterozygous activating mutations in the calcium-sensing receptor (CASR) gene. The variant c.368T>C (p.Leu123Ser) in heterozygosity in the CASR gene is likely pathogenic and suggests the diagnosis of ADH type 1. Teriparatide (recombinant human parathyroid hormone 1-34) may be a valid treatment option to achieve clinical stability for those individuals whose condition is poorly controlled by current standard therapy.

#COVID#BACKTOSCHOOL: Qualitative study based on the voice of Portuguese adolescents

Due to the COVID-19 pandemic and the exponential increase in cases, educational institutions worldwide were forced to close, making way for digital learning. After a period of confinement and an online teaching methodology, a new school year has begun. However, this new school year included the application of a wide range of measures that transformed the educative setting. The present study aimed to understand the health consequences for adolescents and young adults (AYA) during the back to school period after the COVID-19 lockdown. This mixed-method study included 304 participants between 16 and 24 years old (M = 18.4, SD = 2.12), female (71.1%), Portuguese (90.8%) and students (85.2%). In general, it was with a pessimistic perspective that young people in general, particularly girls and university students, understood the new school reality postconfinement, the effects on friendship relations, leisure activities and physical activity. By demonstrating AYA's ability and competence to identify and expose their problems, this study intends to raise awareness of the need for their involvement in the issues that affect them.

Burnout among nurses: a multicentric comparative study

OBJETIVO

to identify and compare burnout levels between Portuguese, Spanish and Brazilian nurses.

METHOD

quantitative, descriptive, correlational, comparative and cross-sectional study conducted using a sample of 1,052 nurses working in hospitals and primary care centers. A sociodemographic questionnaire and the Maslach Burnout Inventory were applied to nurses in Porto, Portugal (n=306), Oviedo, Spain (n=269) and S. Paulo, Brazil (n=477). Data analysis was performed using descriptive, inferential and multivariate analysis.

RESULTS

approximately 42% of the nurses showed moderate/high levels of burnout, with no differences found between countries (Portugal and Brazil 42%, Spain 43%). Only depersonalization showed differences between countries, presenting Spain the highest level and Portugal the lowest one. Comparative analysis showed higher burnout levels in young nurses and those working by shifts. Considering job schedules, burnout was associated to shift work in Portugal, while in Spain and Brazil it was associated with fixed schedules.

CONCLUSION

these results suggest that this syndrome among nurses is a global phenomenon. The daily stressors and higher demands of the nursing profession are crucial in the preparation of nurses to deal with complex situations, to avoid burnout, and to reduce the negative impact on nurses' health and on the quality of care they provide.

‘There was no freedom to leave’: Global South international students in Portugal during the COVID-19 Pandemic

This article looks at the impact of the COVID-19 pandemic on international students, focusing on Portuguese-speaking African and Brazilian students during the lockdown of spring 2020. Using evidence from interviews conducted with 27 students domiciled in Portugal, we illustrate some of the challenges faced by students when coping with the pandemic, including difficulties in meeting the cost of tertiary education and the centrality of working to sustain their stays abroad, alongside the emotional impact of prolonged domestic confinement and separation from families. We also consider the paradoxes of online teaching, which have made visible the digital gap between local and international Global South students in the context of their stays. In this sense, pre-existing inequalities are more at the centre of students’ concerns than new issues raised by COVID-19, a pandemic that served to reveal former injustice in the context of global capitalism. In our conclusion, we argue that there is a need for greater recognition of the vulnerabilities facing certain African and Brazilian students at Global North universities in the context of contemporary neo-liberalism, including their dependence upon precarious work. Policy responses include the need for a more serious involvement and responsibility by both home and host higher education institutions in the lives of their students abroad.

Late diagnosis of classic congenital adrenal hyperplasia: long-term consequences during adulthood

SUMMARY

Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders related to enzyme deficiencies in the adrenal steroidogenesis pathway leading to impaired corticosteroid biosynthesis. Depending on the extension of enzyme defect, there may be variable severities of CAH - classic and non-classic. We report the case of a 37-year-old male patient with a previously unknown diagnosis of classic CAH referred to Endocrinology evaluation due to class III obesity and insulin resistance. A high diagnostic suspicion was raised at the first Endocrinology consultation after careful past medical history analysis especially related to the presence of bilateral adrenal myelolipomas and primary infertility. A genetic test confirmed the presence of a variant of the CYP21A2 in homozygous with an enzymatic activity of 0-1%, corresponding to a classic and severe CAH form. Our case represents an unusually late definitive diagnose of classic CAH since the definition was established only during adulthood in the fourth decade of life. The missing diagnosis of classic 21 hydroxylase deficiency during infancy led to important morbidity, with a high impact on patients' quality of life.

LEARNING POINTS

Congenital adrenal hyperplasia (CAH) refers to a group of autosomal recessive enzyme disorders responsible for an impaired cortical adrenal hormonal synthesis. CAH may be divided into two major forms: classic and non-classic CAH. If untreated, CAH may be fatal or may be responsible for important multi-organ long-term consequences that can be undervalued during adulthood. Adrenal myelolipomas are associated with chronic exposure to high ACTH levels and continuous androgen hyperstimulation typically found in undertreated CAH patients. Testicular adrenal rest tumours (TART) and primary infertility can be the first manifestation of the disease during adulthood.

Pituitary metastasis unveiling a lung adenocarcinoma

SUMMARY

Pituitary metastasis (PM) can be the initial presentation of an otherwise unknown malignancy. As PM has no clinical or radiological pathognomonic features, diagnosis is challenging. The authors describe the case of a symptomatic PM that revealed a primary lung adenocarcinoma. A 62-year-old woman with multiple sclerosis and no history of malignancy, incidentally presented with a diffusely enlarged and homogeneously enhancing pituitary gland associated with stalk enlargement. Clinical and biochemical evaluation revealed anterior hypopituitarism and diabetes insipidus. Hypophysitis was considered the most likely diagnosis. However, rapid visual deterioration and pituitary growth raised the suspicion of metastatic involvement. A search for systemic malignancy was performed, and CT revealed a lung mass, which proved to be a lung adenocarcinoma. Accordingly, the patient was started on immunotherapy. Resection of the pituitary lesion was performed, and histopathology analysis revealed metastatic lung adenocarcinoma. Following surgery, the patient underwent radiotherapy. More than 2 years after PM detection, the patient shows a clinically relevant response to antineoplastic therapy and no evidence of PM recurrence.

LEARNING POINTS

Although rare, metastatic involvement of the pituitary gland has been reported with increasing frequency during the last decades. Pituitary metastasis can be the initial presentation of an otherwise unknown malignancy and should be considered in the differential diagnosis of pituitary lesions, irrespective of a history of malignancy. The sudden onset and rapid progression of visual or endocrine dysfunction from a pituitary lesion should strongly raise the suspicion of metastatic disease. MRI features of pituitary metastasis can overlap with those of other pituitary lesions, including hypophysitis; however, rapid pituitary growth is highly suggestive of metastatic disease. Survival after pituitary metastasis detection has improved over time, encouraging individualized interventions directed to metastasis to improve quality of life and increase survival.

A benign cause of hyperandrogenism in a postmenopausal woman

SUMMARY

Menopause is a relative hyperandrogenic state but the development of hirsutism or virilizing features should not be regarded as normal. We report the case of a 62-year-old woman with a 9-month history of progressive frontotemporal hair loss and hirsutism, particularly on her back, arms and forearms. Blood tests showed increased total testosterone of 5.20 nmol/L that remained elevated after an overnight dexamethasone suppression test. Free Androgen Index was 13.1 and DHEAS was repeatedly normal. Imaging examinations to study adrenals and ovaries were negative. The biochemical profile and the absence of imaging in favor of an adrenal tumor made us consider the ovarian origin as the most likely hypothesis. After informed consent, bilateral salpingectomy-oophorectomy and total hysterectomy were performed. Gross pathology revealed ovaries of increased volume and histology showed bilateral ovarian stromal hyperplasia. Testosterone levels normalized after surgery and hirsutism had completely subsided 8 months later.

LEARNING POINTS

Menopause is a relative hyperandrogenic state Hirsutism and/or virilizing features, in a postmenopausal woman, should raise the hypothesis of a malignant cause In the absence of an identifiable ovarian or adrenal tumor, the ovarian origin remains the most likely Peripheral aromatization of excess androgen may conduct to high levels of estrogen increasing the risk of endometrial cancer Bilateral oophorectomy results in significant clinical improvement.

New-onset diabetes after kidney transplantation revealing HNF1B-associated disease

SUMMARY

Molecular alterations of the transcription factor hepatocyte nuclear factor 1B (HNF1B) are associated with systemic disease, with kidney disease and maturity-onset diabetes of the young (MODY) as the most characteristic manifestations. Other features comprise pancreatic exocrine insufficiency, liver and biliary anomalies, and genital tract malformations. HNF1B-associated disease is clinically heterogeneous, and therefore the diagnosis is challenging. The authors describe the case of a 19-year-old man with new-onset diabetes after kidney transplantation (NODAT). The kidney disease presented during fetal life as bilateral hyperechogenic kidneys. Renal function progressively deteriorated during childhood, and at the age of 19, the patient was submitted to a living-kidney transplant. Two weeks after transplant, NODAT developed. Given the young age and normal body weight, NODAT was unexpected, and the possibility of HNF1B-associated disease was considered. Screening for mutations in HNF1B was undertaken, and a known mutation was found. As this case highlights, HNF1B-associated disease should be considered when NODAT unexpectedly develops in young kidney transplant recipients with a suggestive renal disease.

LEARNING POINTS

HNF1B anomalies are associated with systemic disease, including kidney disease, diabetes mellitus, pancreatic exocrine insufficiency, liver test abnormalities and genital tract malformations. Phenotype is variable and there are no pathognomonic manifestations, but kidney disease appears to be the most common feature and diabetes the most frequent extra-renal phenotype. Spontaneous gene alterations are common, and the lack of family history should not exclude the diagnosis. HNF1B defects should be considered when NODAT develops in a young adult kidney transplant recipient with a suggestive kidney disease and without extensive risk factors for diabetes. The most appropriate treatment for HNF1B-associated diabetes is not established, but immunosuppressive therapy superimposed on a beta-cell dysfunction seems to determine the need for insulin therapy after a variable period. Immunosupressive regimens free of calcineurin inhibitors should be considered in patients with HNF1B-associated disease to minimize the risk of developing NODAT.

Hypoparathyroidism as the single major component for decades of autoimmune polyglandular syndrome type 1

SUMMARY

Autoimmune polyglandular syndrome type 1 (APS-1) is a very rare autoimmune entity, accounting for about 400 cases reported worldwide. It is characterized by the presence of at least two of three cardinal components: chronic mucocutaneous candidiasis (CMC), hypoparathyroidism and Addison's disease. It typically manifests in childhood with CMC and years later with hypoparathyroidism. A 50-year-old man was referred to the Endocrinology outpatient clinic due to irregular follow-up of primary hypoparathyroidism diagnosed at age 7. Previous analysis reported frequent fluctuations of calcium and phosphate levels and persistent hypercalciuria. He presented several comorbidities, including bilateral cataracts, other ocular disorders, transient alopecia and chronic gastritis. Due to weight loss, fatigue, gastrointestinal complaints and the findings at objective examination, Addison's disease and CMC were investigated and confirmed. Antifungal therapy and hormonal replacement were started with evident clinical improvement. Regarding hypoparathyroidism, calcium-phosphate product decreased and other extraskeletal calcifications were diagnosed, such as nephrolithiasis and in basal ganglia. Further evaluation by genetic analysis revealed homozygosity for a frameshift mutation considered to be a pathogenic variant. It was reported only in two Asian siblings in compound heterozygosity. This case highlights the broad phenotypic spectrum of APS-1 and the significative intra-familial phenotype variability. A complete clinical history taking and high index of suspicion allowed the diagnosis of this rare entity. This case clarifies the need for regular long-term follow-up. In the specific case of hypoparathyroidism and Addison's disease in combination, the management of APS-1 can be complex.

LEARNING POINTS

Autoimmune polyglandular syndrome type 1 (APS-1) is a deeply heterogeneous genetic entity with a broad spectrum of clinical manifestations and a significant intra-family phenotypic variability. Early diagnosis of APS-1 is challenging but clinically relevant, as endocrine and non-endocrine manifestations may occur during its natural history. APS-1 should be considered in cases of acquired hypoparathyroidism, and even more so with manifestations with early onset, family history and consanguinity. APS-1 diagnosis needs a high index of suspicion. Key information such as all the comorbidities and family aspects would never be valued in the absence of a complete clinical history taking. Especially in hypoparathyroidism and Addison's disease in combination, the management of APS-1 can be complex and is not a matter of simply approaching individually each condition. Regular long-term monitoring of APS-1 is essential. Intercalary contact by phone calls benefits the control of the disease and the management of complications.

Referral to the national network of integrated care: the nurses' perception

OBJECTIVE

to understand the referral to the National Network of Integrated Continuous Care, from the perspective of nurses who work in this care context.

METHOD

an exploratory and descriptive study with a qualitative approach, with data collection between July and September 2019 through interviews with 12 nurses who work in Integrated Continuous Care Teams, in Northern Portugal. The content analysis technique was used to analyze the statements.

RESULTS

the professionals revealed that there are difficulties and constraints in the process of referring users to the National Network of Integrated Continuous Care. The process is bureaucratic, complex, and time-consuming, conditioning user accessibility to timely care.

CONCLUSION

the referral process is a very bureaucratic and time-consuming procedure, which not only conditions and delays users' access to the National Network of Integrated Continuous Care network, contributing to the worsening of the clinical status of some patients. The number of professionals is insufficient, inducing the demand for services through urgency. The focus on primary care should seek to improve inequalities in access, compete for more equitable and accessible care, generating more quality in health care.

Key Factors to Consider in Team Meetings when Dealing with Multimorbidity in Primary Care: Results from a Delphi Panel

BACKGROUND

Multimorbidity brings several difficulties and challenges to the daily work of primary care teams. Team meetings are opportunities to discuss approaches and solutions on how to best manage multimorbid patients.

OBJECTIVE

This qualitative study aimed to collect a consensus, from general practitioners that deal with multimorbid patients, about their perspectives regarding multimorbidity team meetings in primary care.

METHODS

The study followed a modified Delphi method with 15 Portuguese general practitioners. After every round of responses, results were analyzed, and justifications for non-consensual items were aggregated by the investigators, and then a new Delphi round with the revised questionnaire was again initiated. This process was repeated until consensus has been reached.

RESULTS

Overall, a list of 10 key themes associated with the ideal meeting was agreed: (a) definition; (b) setting; (c) duration; (d) frequency; (e) number of participants; (f) attendance; (g) requirement of patient's presence; (h) number of patients/clinical cases; (i) structure of the meeting; and (j) sharing meeting results. The consensus was achieved after two Delphi rounds with a mean score between 7.9 and 8.7 (maximum score of 9.0 per key theme).

CONCLUSION

The complexity of multimorbidity affects meetings' periodicity, duration, and participants. Ideally, it should be an interprofessional primary care team meeting. Further research exploring meeting outcomes (organizational effectiveness and healthcare quality) of the proposed factors is needed before they can be recommended for general use.

Metabolic Syndrome, Thyroid Function and Autoimmunity - The PORMETS Study

BACKGROUND

The prevalence of thyroid dysfunction and autoimmunity in the Portuguese population has not yet been estimated. However, the national prevalence of the metabolic syndrome remains high. The association of thyroid pathology with cardiovascular risk has been addressed but is still unclear. Our study aimed to evaluate the prevalence of thyroid dysfunction and autoimmunity and to assess the associations of thyroid-stimulating hormone and thyroid hormones and antibodies with metabolic syndrome, its components, and other possible determinants in a national sample.

MATERIAL AND METHODS

The present study included a subsample of 486 randomly selected participants from a nationwide cross-sectional study sample of 4095 adults. A structured questionnaire was administered on past medical history and socio-demographic and behavioural characteristics. Blood pressure and anthropometric measurements were collected, and the serum lipid profile, glucose, insulin, hs- CRP, TSH, FT4, FT3 and thyroid antibodies were measured.

RESULTS

In our sample, the prevalence of hypothyroidism, hyperthyroidism and undiagnosed dysfunction was 4.9%, 2.5% and 72.2%, respectively. Overall, the prevalence of positivity for the thyroid peroxidase and thyroglobulin antibodies was 11.9% and 15.0%, respectively. A positive association was found between free triiodothyronine and metabolic syndrome (OR: 2.019; 95% CI: 1.196, 3.410). Additionally, thyroid peroxidase antibodies had a negative association with metabolic syndrome (OR: 0.465; 95% CI: 0.236, 0.917) and its triglyceride component (OR: 0.321; 95% CI: 0.124, 0.836).

CONCLUSION

The prevalence of undiagnosed thyroid dysfunction and autoimmunity was high. Thyroid peroxidase antibodies were negatively associated with metabolic syndrome and its triglyceride component, whereas the free triiodothyronine level was positively associated with metabolic syndrome.

Assessment of depression and suicidal behaviour among medical students in Portugal

OBJECTIVES

To examine depression and suicidal behaviour and associated factors in a sample of medical students in Portugal.

METHODS

We conducted a cross-sectional study design of 456 native Portuguese medical students from the 4^th and 5^th year at the University of Lisbon. Participants answered a self-report survey including questions on demographic and clinical variables. Statistical analyses were conducted using the chi-square test, with a Monte Carlo simulation when appropriate.

RESULTS

Depression among medical students was 6.1% (n=28) and suicidal behaviour 3.9% (n=18). Higher depression scores were noted in female medical students (χ²=4.870,df=2,p=0.027), students who lived alone (χ²=8.491,df=3,p=0.037), those with poor physical health (χ²=48.269,df=2,p<0.001), with poor economic status (χ²=8.579,df=2,p=0.014), students with a psychiatric diagnosis (χ²=44.846,df=1,p=0.009), students with a family history of psychiatric disorders (χ²=5.284,df=1,p=0.022) and students with high levels of anxiety (χ²=104.8, df=3, p<0.001).  Depression scores were also higher in students with suicidal ideation (χ²=85.0,df=1,p<0.001), suicidal plan (χ²=47.9,df=1,p<0.001) and suicidal attempt (χ²=19.2,df=1,p<0.001). Suicidal behaviour was higher in medical students who lived alone (χ²=16.936,df=3,p=0.001), who had poor physical health (χ²=18,929,df=2,p=0.001), poor economic status (χ²=9.181,df=2,p=0.01), who are/were in psychopharmacology treatment (χ²=30.108,df =1,p<0.001), and who had high alcohol use (χ²=7.547,df=2,p=0.023), severe depression (χ²=88.875,df=3,p<0.001) and high anxiety levels (χ²=50.343,df=3,p<0.001). The results also revealed that there were no differences between students in the 4^th and 5^th years of medical school regarding rate of depression and suicidal behaviour.

CONCLUSIONS

Since depression and suicidal behaviour are mental health problems affecting a significant proportion of medical students, medical schools should implement programs that promote mental health wellness, physical health and economic status between other factors.

Connecting the dots on health inequalities--a systematic review on the social determinants of health in Portugal

INTRODUCTION

Health inequalities are recognised as a public health issue worldwide, but only a few countries have developed national strategies to monitor and reduce them. Despite its considerable health inequalities, Portugal seems to lack a systematic strategy to tackle them, possibly due to the absence of organised evidence on the issue. We performed a systematic review that aimed to describe the available evidence on social inequalities in health in Portugal, in order to contribute towards a comprehensive and focused strategy to tackle them.

METHODS

We followed the PRISMA guidelines and searched Scopus, Web of Science and PubMed for studies that looked at the association between a measure of socioeconomic status and a health outcome in the Portuguese resident population since the year 2000. We excluded health behaviours and healthcare use from our search. We performed a qualitative description of the results.

RESULTS

Seventy-one publications were selected, all reporting observational analyses, most of them using cross-sectional data. These publications showed strong evidence for health inequalities related to education and gender, chiefly for obesity, self-rated health and mental health.

CONCLUSIONS

Analysis of the eligible publications showed that current research does not seem to have consistently covered the link between health and key Portuguese social problems. A strategy focusing on the monitoring of most prevalent diseases, most determining socioeconomic factors and vulnerable populations would be crucial to guide academic research in a country in which health inequalities are so ubiquitous and deeply rooted.

REGISTRATION

This systematic review is not registered.

Mosquito surveillance for prevention and control of emerging mosquito-borne diseases in Portugal - 2008-2014

Mosquito surveillance in Europe is essential for early detection of invasive species with public health importance and prevention and control of emerging pathogens. In Portugal, a vector surveillance national program-REVIVE (REde de VIgilância de VEctores)-has been operating since 2008 under the custody of Portuguese Ministry of Health. The REVIVE is responsible for the nationwide surveillance of hematophagous arthropods. Surveillance for West Nile virus (WNV) and other flaviviruses in adult mosquitoes is continuously performed. Adult mosquitoes-collected mainly with Centre for Disease Control light traps baited with CO2-and larvae were systematically collected from a wide range of habitats in 20 subregions (NUTS III). Around 500,000 mosquitoes were trapped in more than 3,000 trap nights and 3,500 positive larvae surveys, in which 24 species were recorded. The viral activity detected in mosquito populations in these years has been limited to insect specific flaviviruses (ISFs) non-pathogenic to humans. Rather than emergency response, REVIVE allows timely detection of changes in abundance and species diversity providing valuable knowledge to health authorities, which may take control measures of vector populations reducing its impact on public health. This work aims to present the REVIVE operation and to expose data regarding mosquito species composition and detected ISFs.

A scenario-planning approach to human resources for health: the case of community pharmacists in Portugal

BACKGROUND

Health workforce planning is especially important in a setting of political, social, and economic uncertainty. Portuguese community pharmacists are experiencing such conditions as well as increasing patient empowerment, shortage of primary care physicians, and primary health care reforms. This study aims to design three future scenarios for Portuguese community pharmacists, recognizing the changing environment as an opportunity to develop the role that community pharmacists may play in the Portuguese health system.

METHODS

The community pharmacist scenario design followed a three-stage approach. The first stage comprised thinking of relevant questions to be addressed and definition of the scenarios horizon. The second stage comprised two face-to-face, scenario-building workshops, for which 10 experts from practice and academic settings were invited. Academic and professional experience was the main selection criteria. The first workshop was meant for context analysis and design of draft scenarios, while the second was aimed at scenario analysis and validation. The final scenarios were built merging workshops' information with data collected from scientific literature followed by team consensus. The final stage involved scenario development carried by the authors alone, developing the narratives behind each scenario.

RESULTS

Analysis allowed the identification of critical factors expected to have particular influence in 2020 for Portuguese community pharmacists, leading to two critical uncertainties: the "Legislative environment" and "Ability to innovate and develop services". Three final scenarios were built, namely "Pharmacy-Mall", "e-Pharmacist", and "Reorganize or Die". These scenarios provide possible trends for market needs, pharmacist workforce numbers, and expected qualifications to be developed by future professionals.

CONCLUSIONS

In all scenarios it is clear that the future advance of Portuguese community pharmacists will depend on pharmaceutical services provision beyond medicine dispensing. This innovative professional role will require the acquisition or development of competencies in the fields of management, leadership, marketing, information technologies, teamwork abilities, and behavioural and communication skills. To accomplish a sustainable evolution, legislative changes and adequate financial incentives will be beneficial. The scenario development proves to be valuable as a strategic planning tool, not only for understanding future community pharmacist needs in a complex and uncertain environment, but also for other health care professionals.

Prevalence of canine heartworm (Dirofilaria immitis) disease in dogs of central Portugal

The aim of the present study was to determine the prevalence and risk factors concerning Dirofilaria immitis infection in dogs from Figueira da Foz, located in the central region of Portugal. In the period between November 2009 and January 2011, 304 blood samples were obtained from dogs over 1 year of age, with no previous history of heartworm prevention or diagnosis. Every blood sample was analyzed using varied laboratory techniques (direct microscopic evaluation of a fresh blood sample, the modified Knott technique, and the ELISA antigen detection test - IDEXX Snapp®). In the samples in which microfilaremia was detected, a histochemical technique using acid phosphatase staining was applied to identify the species of microfilariae. A total prevalence of 27.3% (83 out of 304) was found. We also found that 73.5% of all positive cases (61 out of 83) were microfilaremic, and 26.5% were occult infections (22 out of 83). By means of a histochemical technique Dirofilaria immitis was identified in 96.7% of microfilaremic samples. A multivariate model allowed us to identify the following risk factors for the presence of heartworm disease: age between 4 and 9 years, dogs living in a rural environment, large breed dogs, and living outdoors. This study shows for the first time the high prevalence of heartworm disease in a central area of Portugal and emphasizes the importance of systematic screening for this disease, as well as the need to prevent it in dogs in this area.

Trends of cross-border mobility of physicians and nurses between Portugal and Spain

CONTEXT

Health workforce cross-border mobility has an impact not only on individual health workers, but also on how health services are organized, planned, and delivered. This paper presents the results of a study of current mobility trends of health professionals along the borders between Portugal and Spain. The objective was to describe the profile of mobile physicians and nurses; to elicit the opinions of employers on mobility factors; to describe incentive policies to retain or attract health professionals; and to collect and analyse employers' opinions on the impact of this mobility on their health services.

METHODS

Phone interviews of key informants were used to collect relevant data. The interviews were conducted during December 2010 and January 2011 in health organizations along the border of the two countries. In Portugal and Spain, four and 13 organizations were selected, respectively. Interviews were obtained in all the Portuguese organizations and in four of the Spanish organizations.

RESULTS

Findings suggest that cross-border mobility between the two countries has decreased. From Spain to Portugal, mobility trends are mainly of physicians who seek professional development in the form of specialization, the availability of positions, better salaries, and the perceived good living conditions. The mobility of nurses lasted until 2008, when reforms improved working conditions in Spain and contributed to reversing the flow. Since then, there has been an increase of Portuguese nurses going to Spain seeking better working conditions or simply a job. Portuguese nurses as well as Spanish physicians are well considered in terms of professionalism and qualifications by their Spanish and Portuguese hosts, respectively.

CONCLUSIONS

There is a deficit of valid data on the health workforce in general. The present study allowed further exploration of the reality of the mobility trends between Portugal and Spain. At present, the mobility trends are mainly of Spanish physicians to Portugal and Portuguese nurses to Spain. There is a consensus on both sides of the border that the benefits of migratory flows are much greater than the limited problems (for example, language and salary differences) that they may bring.

Leishmania infection and host-blood feeding preferences of phlebotomine sandflies and canine leishmaniasis in an endemic European area, the Algarve Region in Portugal

The Algarve Region (AR) in southern Portugal, which is an international tourist destination, has been considered an endemic region of zoonotic leishmaniasis caused by Leishmania infantum since the 1980s. In the present study, phlebotomine and canine surveys were conducted to identify sandfly blood meal sources and to update the occurrence of Leishmania infection in vectors and dogs. Four sandfly species were captured: Phlebotomus perniciosus, Phlebotomus ariasi, Phlebotomus sergenti and Sergentomyia minuta. In one P. perniciosus female, L. infantum DNA was detected. Blood meal tests showed that this species had no host preferences and was an opportunistic feeder. An overall canine leishmaniasis (CanL) seroprevalence of 16.06% was found; the seroprevalence was 3.88% in dogs housed in kennels and 40.63% in dogs that attended veterinary clinics. The simultaneous occurrence of dogs and P. perniciosus infected with L. infantum in the AR indicates that the region continues to be an endemic area for CanL. Our results reinforce the need for the systematic spatial distribution of phlebotomine populations and their Leishmania infection rates and the need to simultaneously perform pathogen monitoring in both invertebrate and vertebrate hosts to investigate the transmission, distribution and spreading of Leishmania infection.

Cross-cultural adaptation of The Beliefs about Medicines Questionnaire into Portuguese

CONTEXT AND OBJECTIVES

The Beliefs about Medicines Questionnaire (BMQ-Specific) has proven useful for measuring patients' beliefs and associating them with non-adherence to treatment in several illness groups. The aim was to cross-culturally adapt the BMQ-Specific into Portuguese for the general population of medicine users.

DESIGN AND SETTING

Cross-sectional study conducted among users of public hospitals and outpatient clinics in Guarda and Covilhã, Portugal.

METHODS

The BMQ-Specific was translated using international recommendations for performing cross-cultural adaptation and was administered to 300 patients. An initial principal component analysis (PCA) was conducted with the extraction criterion of eigenvalue > 1.0, followed by a second PCA with restriction to two components. Reliability was assessed by calculating Cronbach's alpha coefficient.

RESULTS

The mean scores obtained for the Necessity and Concerns subscales of the Portuguese BMQ-Specific were 19.9 (standard deviation, SD = 2.8) (range 10 to 25) and 17.7 (SD = 3.9) (range 6 to 30), respectively. The first PCA produced an unstable three-component structure for the Portuguese BMQ-Specific. The final PCA solution yielded a two-component structure identical to the original English version (a five-item Necessity and a six-item Concerns subscale), and explained 44% of the variance. Cronbach's alpha for the complete Portuguese BMQ-Specific was 0.70, and 0.76 and 0.67 for the Necessity and Concerns subscales, respectively.

CONCLUSION

A cross-culturally adapted Portuguese version of the BMQ-Specific questionnaire for use among the general population of medicine users was obtained, presenting good internal consistency and component structure identical to the original English version.

Changing patterns of cardiovascular diseases and cancer mortality in Portugal, 1980-2010

BACKGROUND

Cardiovascular diseases and cancer are jointly responsible for more than half all deaths in Portugal. They also share some important risk factors and act as mutual competing risks. We aimed firstly to describe time trends in death rates and years of life lost due to cardiovascular diseases and cancer in the Portuguese population from 1980 to 2010; and secondly to quantify the contribution of the variation in population and age structure, and age-independent "risk" by cardiovascular or oncological causes to the change in the corresponding number of deaths.

METHODS

We estimated the annual percent change in age-standardized mortality rates from cardiovascular diseases and cancer, in each sex. The specific contribution of demographic changes (due to changes in population size and in population age structure) and the variation in the age-independent "risk" of dying from the disease to the observed trends in the number of deaths was quantified using the tool RiskDiff. Years of life lost were computed using the Global Burden of Disease method.

RESULTS

Among men, the mortality rate from all cardiovascular diseases was more than two-fold higher than cancer mortality in 1980. However, three decades later mortality from cancer surpassed cardiovascular diseases. After 2005, the years of life lost from cancer were also higher than from cardiovascular diseases. Among women, despite the decrease in death rates, cardiovascular diseases remained the leading cause of death in 2010 and their absolute burden was higher than that of cancers across the whole period, mainly due to more events in older women.

CONCLUSIONS

In Portugal, the 20th century witnessed a dramatic decrease in the cardiovascular disease mortality and YLL, and the transition towards cancer. In more recent years, the highest burdens of disease came from cancers in men and from cardiovascular diseases in women.

Experience and satisfaction of stroke patients with institutions in the network of care: the Portuguese insight

Purpose

Theory

Methods

Results and conclusions

Discussion

Care transition and network activation in Portugal

Purpose

Theory

Methods

Results and conclusions

Multidisciplinary home training for stroke patients in Portugal: the perspective of care professionals

Purpose

To systematize the content of home-care interventions for stroke patients in Portugal and assess their relevance, feasibility and acceptability from the perspective of care professionals.

Theory

Research seems to show that Integrated Home Care (IHC) is an excellent form of rehabilitation as the domicile is the place where the patient feels safe, participate most and have direct feedback from ADL training [1]. Moreover, recent results show that IHC has the potential to lower the costs of post-stroke rehabilitation [2]. Cost-effectiveness analysis would then be an important tool for decision-makers regarding alternative IHC interventions. However, in practice the realization of the potential benefits of IHC has to overcome serious barriers and the dissemination of IHC in the European Union will depend “on the upgrade of health professionals from a defensive kind of monodisciplinary professionalism towards an open-ended multidisciplinary professionalism” [1]. Therefore, it is fundamental to assess health professionals’ perceptions and experiences regarding the relevance, feasibility and acceptability of home-based rehabilitation and their willingness to participate.

Methods

In Portugal, the home rehabilitation teams include a gerontologist which is the case manager, a physiotherapist, an occupational therapist and a psychologist. A mixed method was used to analyse the teams’ interventions at home. Information about each session was recorded by all professionals in a standardized form. Additionally, case managers have written qualitative reports, according to a pre-defined minimum structure and the psychologist has written patient specific psychology reports. We analysed the sessions’ reports of 80 patients who have received rehabilitation services at home. This information was coded, keyed into a database and analyzed with PASW Statistics 18. In the qualitative phase, we have explored health professional’s perceptions on experiences with home-care rehabilitation process. Data were collected within a focus group composed by two physiotherapists, two occupational therapists, a psychologist and two gerontologists. A group of three researchers with specific roles joined the focus group, namely a moderator, a recorder and a coordinator. The session’s content was recorded, transcript and analyzed with NVivo 9.

Results and conclusions

Quantitative results consist on the average number of sessions at home per specialty, the duration of sessions, the reasons for therapeutic rehabilitation, the type of intervention executed by the professionals, the specific content of treatments in home care and strategies used by professionals in this type of rehabilitation. Qualitative results include health professionals individual and collective understanding of patients’ achievements and effort required from the professionals and their assessment of the measures used to evaluate the results.

Tongue nodules in canine leishmaniosis--a case report

BACKGROUND

Canine leishmaniosis (CanL) caused by Leishmania infantum is an endemic zoonosis in southern European countries. Infected dogs can present rare or atypical forms of the disease and diagnosis can be challenging. The present report describes a case of tongue nodules in a 3-year-old neutered female Labrador Retriever dog with leishmaniosis.

FINDINGS

A fine needle aspiration of the lingual nodules revealed amastigote forms of Leishmania inside macrophages. Differential diagnosis ruled out neoplasia, calcinosis circumscripta, solar glossitis, vasculitis, amyloidosis, eosinophilic granulomas, chemical and electrical burns, uremic glossitis and autoimmune diseases. Combined therapy with antimoniate meglumine and allopurinol for 30 days resulted in the normalization of hematological and biochemical parameters. Two months after diagnosis and the beginning of treatment, a mild inflammatory infiltrate was observed by histopathology, but an anti-Leishmania immunofluorescence antibody test (IFAT) was negative as well as a PCR on both tongue lesions and a bone marrow aspirate. Seven months after diagnosis, the dog's general condition appeared good, there were no tongue lesions and a new IFAT was negative. Fifteen months after diagnosis this clinically favourable outcome continued.

CONCLUSIONS

The dog could have suffered a relapsing episode of CanL, but a new systemic or local infection cannot be excluded. Regular clinical re-evaluation should be maintained, as a future relapse can potentially occur. In conclusion, CanL should be considered in the differential diagnosis of nodular glossitis in dogs.

Importance of local knowledge in plant resources management and conservation in two protected areas from Trás-os-Montes, Portugal

Many European protected areas were legally created to preserve and maintain biological diversity, unique natural features and associated cultural heritage. Built over centuries as a result of geographical and historical factors interacting with human activity, these territories are reservoirs of resources, practices and knowledge that have been the essential basis of their creation. Under social and economical transformations several components of such areas tend to be affected and their protection status endangered.Carrying out ethnobotanical surveys and extensive field work using anthropological methodologies, particularly with key-informants, we report changes observed and perceived in two natural parks in Trás-os-Montes, Portugal, that affect local plant-use systems and consequently local knowledge. By means of informants' testimonies and of our own observation and experience we discuss the importance of local knowledge and of local communities' participation to protected areas design, management and maintenance. We confirm that local knowledge provides new insights and opportunities for sustainable and multipurpose use of resources and offers contemporary strategies for preserving cultural and ecological diversity, which are the main purposes and challenges of protected areas. To be successful it is absolutely necessary to make people active participants, not simply integrate and validate their knowledge and expertise. Local knowledge is also an interesting tool for educational and promotional programs.

Using discrete event simulation to compare the performance of family health unit and primary health care centre organizational models in Portugal

BACKGROUND

Recent reforms in Portugal aimed at strengthening the role of the primary care system, in order to improve the quality of the health care system. Since 2006 new policies aiming to change the organization, incentive structures and funding of the primary health care sector were designed, promoting the evolution of traditional primary health care centres (PHCCs) into a new type of organizational unit--family health units (FHUs). This study aimed to compare performances of PHCC and FHU organizational models and to assess the potential gains from converting PHCCs into FHUs.

METHODS

Stochastic discrete event simulation models for the two types of organizational models were designed and implemented using Simul8 software. These models were applied to data from nineteen primary care units in three municipalities of the Greater Lisbon area.

RESULTS

The conversion of PHCCs into FHUs seems to have the potential to generate substantial improvements in productivity and accessibility, while not having a significant impact on costs. This conversion might entail a 45% reduction in the average number of days required to obtain a medical appointment and a 7% and 9% increase in the average number of medical and nursing consultations, respectively.

CONCLUSIONS

Reorganization of PHCC into FHUs might increase accessibility of patients to services and efficiency in the provision of primary care services.

Folklore and traditional ecological knowledge of geckos in Southern Portugal: implications for conservation and science

Traditional Ecological Knowledge (TEK) and folklore are repositories of large amounts of information about the natural world. Ideas, perceptions and empirical data held by human communities regarding local species are important sources which enable new scientific discoveries to be made, as well as offering the potential to solve a number of conservation problems. We documented the gecko-related folklore and TEK of the people of southern Portugal, with the particular aim of understanding the main ideas relating to gecko biology and ecology. Our results suggest that local knowledge of gecko ecology and biology is both accurate and relevant. As a result of information provided by local inhabitants, knowledge of the current geographic distribution of Hemidactylus turcicus was expanded, with its presence reported in nine new locations. It was also discovered that locals still have some misconceptions of geckos as poisonous and carriers of dermatological diseases. The presence of these ideas has led the population to a fear of and aversion to geckos, resulting in direct persecution being one of the major conservation problems facing these animals. It is essential, from both a scientific and conservationist perspective, to understand the knowledge and perceptions that people have towards the animals, since, only then, may hitherto unrecognized pertinent information and conservation problems be detected and resolved.

Process mapping and the integration of care

Introduction

The main objective of this work is to show how process mapping may contribute to the improvement of intra- and inter-organizational integration of care.

Theory and methods

Under logic of service integration, quality of care depends not only on how the internal processes are implemented, but also on the quality of the transitions of care with external entities. We conducted a case study on a health centre located in the Centre Region of Portugal. Data was collected during the first semester of 2009. Petri nets were used as a modeling tool.

Results

We mapped eleven processes involving a patient directly. The informality of many of the processes became evident. Activities are guided by formalisms imposed by law and by the good practices of professionals. Some processes are not normalized and represented in the computerized information system. The media most used to communicate with other entities are the phone and paper. Under the RNCCI (Rede Nacional de Cuidados Integrados e Continuados—National Network for Integrated Care), the information is all organized in an integrated manner, and the processes are support by a customized, nation-wide, web-based information system. However, this platform is not integrated with the other applications in use.

Conclusions and discussion

We have demonstrated the viability and the benefits of process mapping techniques in the context of a Health Centre. It allowed to identify and understand the ‘what’, ‘why’, ‘when’, ‘where’, ‘who’ of each process, sub-process, task and activity and to develop graphical views of the processes.

Current status and developments in the care of stroke patients in Portugal

Introduction

We discuss current status and developments in the care of stroke patients in Portugal.

Theory and methods

Stroke is the main cause of death in Portugal and the main cause of disability on elderly people. This situation has raised great concern and several initiatives have been put in place to deal with the problem. The Unidades de Acidentes Vasculares Cerebrais – (UAVC) (Stroke Unit) were launched in 2001, aiming at reducing length of stay in acute care hospitals, functional incapacity and post-stroke complications, the number of patients in need of home nursing or specialized inpatient long-term care, as well as facilitating reintegration in family and society, namely return to workplace. The study is based on deep literature review and clinical experience in specialized care for stroke patients in Portugal.

Results

Until the launch of UAVCs, a patient suffering from stroke would be admitted to a Serviço de Neurologia (Neurology Service) or to a Serviço de Medicina Interna (Internal Medicine Service), probably in the hospital closest to the occurrence and care would be oriented to the acute phase. Nowadays, patients with a diagnosis of stroke are preferably directed to a UAVC. These units integrate health professionals especially trained for these situations and apply diagnostic and therapeutic procedures according to protocols that follow the most recent international recommendations. The multidisciplinary teams execute integrated care and rehabilitation plans based on the individual needs. Complementary exams are done systematically aiming at more complete understanding. After discharge, patients are followed up in outpatient specific consultation. One of the most relevant practices adopted is physiotherapy care that promotes early mobilization and get up.

Conclusions and discussion

There are about 30 UAVCS in Portugal, some of them still working under technical and human limitations. However, these units are but one of the links in the chain of care. Many attempts have been made to integrate care in Portugal. At least in some areas, much is still to be done in this regard.