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Introduction Management of traumatic brain injury (TBI) has to counterbalance prevention of secondary brain injury without systemic complications, namely lung injury. The potential risk of developing acute respiratory distress syndrome (ARDS) leads to therapeutic decisions such as fluid balance restriction, high PEEP and other lung protective measures, that may conflict with neurologic outcome. In fact, low cerebral perfusion pressure (CPP) may induce secondary ischemic injury and mortality, but disproportionate high CPP may also increase morbidity and worse lung compliance and hypoxia with the risk of developing ARDS and fatal outcome. The evaluation of cerebral autoregulation at bedside and individualized (optimal CPP) CPPopt-guided therapy, may not only be a relevant measure to protect the brain, but also a safe measure to avoid systemic complications. Aim of the study We aimed to study the safety of CPPopt-guided-therapy and the risk of secondary lung injury association with bad outcome. Methods and results Single-center retrospective analysis of 92 severe TBI patients admitted to the Neurocritical Care Unit managed with CPPopt-guided-therapy by PRx (pressure reactivity index). During the first 10 days, we collected data from blood gas, ventilation and brain variables. Evolution along time was analyzed using linear mixed-effects regression models. 86% were male with mean age 53±21 years. 49% presented multiple trauma and 21% thoracic trauma. At hospital admission, median GCS was 7 and after 3-months GOS was 3. Monitoring data was CPP 86±7mmHg, CPP-CPPopt -2.8±10.2mmHg and PRx 0.03±0.19. The average PFratio (PaO2/FiO2) was 305±88 and driving pressure 15.9±3.5cmH2O. PFratio exhibited a significant quadratic dependence across time and PRx and driving pressure presented significant negative association with PFRatio. CPP and CPPopt did not present significant effect on PFratio (p=0.533; p=0.556). A significant positive association between outcome and the difference CPP-CPPopt was found. Conclusion Management of TBI using CPPopt-guided-therapy was associated with better outcome and seems to be safe regarding the development of secondary lung injury.

Predictions of mortality may help in the selection of patients who benefit from intensive care. Endothelial dysfunction is partially responsible for many of the organic dysfunctions in critical illness. Reactive hyperaemia is a vascular response of the endothelium that can be measured by peripheral arterial tonometry (RH-PAT). We aimed to assess if reactive hyperaemia is affected by critical illness and if it correlates with outcomes. Prospective study with a cohort of consecutive patients admitted to an Intensive Care Unit. RH-PAT was accessed on admission and on the 7th day after admission. Early and late survivors were compared to non-survivors. The effect of RH-PAT variation on late mortality was studied by a logistic regression model. The association between RH-PAT and severity scores and biomarkers of organic dysfunction was investigated by multivariate analysis. 86 patients were enrolled. Mean ln(RHI) on admission was 0.580 and was significantly lower in patients with higher severity scores (p

The influence of the vehicle in topical treatment adherence remains to be elucidated. The aim of this study is to analyze the influence of the pharmaceutical dosage form on adherence to topical treatment in psoriasis patients, taking into consideration the mechanical features. The adherence was evaluated in a sample of 102 psoriasis patients, followed for approximately 45 days. Adherence was calculated with a new combined methodology using a log and medication weights. The effect of the group formulation was evaluated using logistic regression models. A complex effect of the vehicle on adherence was found, mediated by the affected area. The adherence was significantly higher for patients applying gels and creams than for those using ointments, whenever the body area affected was extensive. The opposite was found when the affected area was small. Mechanical properties can partially explain the findings since gels and creams may be easier to apply. Patient beliefs and preferences regarding vehicles and their sensory attributes might also explain the results. It is noteworthy that adherence was strikingly low, with more than 75% non-adherent patients. This real-world evidence provides an insight for pharmaceutical industries and guidance for treatment prescription by physicians aiming to address the public health emergency of treatment non-adherence.

Treatment of drug-resistant tuberculosis (TB), which is usually less successful than that of drug-susceptible TB, represents a challenge for TB control and elimination. We aimed to evaluate treatment outcomes and to identify the factors associated with death among patients with MDR and XDR-TB in Portugal. We assessed MDR-TB cases reported for the period 2000-2016, using the national TB Surveillance System. Treatment outcomes were defined according to WHO recommendations. We identified the factors associated with death using logistic regression. We evaluated treatment outcomes of 294 MDR- and 142 XDR-TB patients. The treatment success rate was 73.8% among MDR- and 62.7% among XDR-TB patients (p = 0.023). The case-fatality rate was 18.4% among MDR- and 23.9% among XDR-TB patients. HIV infection (OR 4.55; 95% CI 2.31-8.99; p < 0.001) and resistance to one or more second-line injectable drugs (OR 2.73; 95% CI 1.26-5.92; p = 0.011) were independently associated with death among MDR-TB patients. HIV infection, injectable drug use, past imprisonment, comorbidities, and alcohol abuse are conditions that were associated with death early on and during treatment. Early diagnosis of MDR-TB and further monitoring of these patients are necessary to improve treatment outcome. This work was developed under the scope of the project NORTE-01-0145-FEDER-000013 and NORTE-01-0145-FEDER-000023, supported by the Northern Portugal Regional Operational Programme (NORTE 2020), under the Portugal 2020 Partnership Agreement, through the European Regional Development Fund (FEDER) and projects PTDC/SAU-PUB/29521/2017. This work was partially supported by “Contratos-Programa” UIDB/50026/2020 and UIDB/04050/2020 funded by national funds through the FCT - Foundation for Science and Technology, I.P. OO is supported by the project NORTE-08-5369-FSE-000041, financed by the Operational Program NORTE 2020 and co-financed by the European Social Fund through a doctoral grant (UMINHO/BD/47/2016). This work was also supported by national funds through the FCT, I.P., under the project UIDB / 04750/2020.

RESUMO Objetivo: Investigar se a hiperemia reativa correlaciona-se com marcadores de disfunção endotelial e pode ser utilizada para identificar sepse na doença crítica. Métodos: Trata-se de estudo prospectivo em uma coorte de pacientes críticos. A disfunção endotelial foi avaliada quando da admissão, por meio da quantificação de hiperemia por tonometria arterial periférica e níveis plasmáticos de endotelina 1, E-selectina solúvel, endocana e sindecano 1. Os pacientes sépticos foram comparados com pacientes sem evidência de infecção. Resultados: Cinquenta e oito pacientes sépticos foram comparados com 28 controle. O logaritmo natural da tonometria arterial periférica teve correlação negativa com comorbidades cardiovasculares, severidade da doença e níveis plasmáticos de E-selectina solúvel (p = 0,024) e sindecano 1 (p < 0,001). O logaritmo natural da tonometria arterial periférica foi mais baixo nos pacientes sépticos quando comparado com os de pacientes controle (0,53 ± 0,48 versus 0,69 ± 0,42, respectivamente) e, quando ajustado à idade, o modelo multivariado predisse que cada 0,1 de diminuição em unidades de logaritmo natural da tonometria arterial periférica levou a aumento de 14,6% na probabilidade de infecção. Conclusão: A hiperemia reativa avaliada por tonometria arterial periférica tem estreita relação com E-selectina solúvel e sindecano 1, o que sugere associação entre ativação endotelial, degradação de glicocálix e reatividade vascular. A hiperemia reativa por tonometria arterial periférica parece estar comprometida em pacientes críticos, especialmente os com sepse. Abstract Objective: To investigate whether reactive hyperemia measured by peripheral arterial tonometry correlates with markers of endothelial dysfunction and may be used to identify sepsis in critical illness. Methods: A prospective study was performed using a cohort of critically ill patients. Endothelial dysfunction was assessed on admission by quantifying reactive hyperemia-peripheral arterial tonometry and plasma levels of endothelin-1, soluble E-selectin, endocan and syndecan-1. Septic patients were compared to patients without evidence of infection. Results: Fifty-eight septic patients were compared to 28 controls. The natural logarithm of reactive hyperemia-peripheral arterial tonometry was negatively correlated with cardiovascular comorbidities, disease severity and plasma levels of soluble E-selectin (p = 0.024) and syndecan-1 (p < 0.001). The natural logarithm of reactive hyperemia-peripheral arterial tonometry was lower in septic patients than in controls (0.53 ± 0.48 versus 0.69 ± 0.42, respectively). When adjusted for age, the multivariable model predicted that each 0.1-unit decrease in natural logarithm of reactive hyperemia-peripheral arterial tonometry increased the odds for infection by 14.6%. m. Conclusion: Reactive hyperemia-peripheral arterial tonometry is closely related to soluble E-selectin and syndecan-1, suggesting an association between endothelial activation, glycocalyx degradation and vascular reactivity. Reactive hyperemia-peripheral arterial tonometry appears to be compromised in critically ill patients, especially those with sepsis.

The psychosocial impact of psoriasis is well documented. However, the contributing role of clinical disease characteristics is not satisfactorily explored. This study aimed to validate the Self-administered Psoriasis Area and Severity Index (SAPASI) to a Portuguese population (SAPASI-PT) and to perform its cross-validation, assessing how the results will generalize to an independent data set, with the Psoriasis Area and Severity Index (PASI), in order to assess the influence of psoriasis' severity on psychosocial disability and psychopathology.A cross-sectional study with 228 patients with psoriasis was carried out. Data was collected through a sociodemographic and clinical questionnaire, SAPASI-PT, the Psoriasis Disability Index (PDI) and the Brief Symptoms Inventory (BSI). The cultural and linguistic adaptation of SAPASI to a Portuguese version and the cross validation with PASI was carried out. Multiple associations between psychosocial disability, psychopathology and severity, discomfort and location of lesions were investigated through logistic regression models.A good adjustment model for SAPASI-PT is found. Also, associations between psychosocial disability, psychopathology and the psoriasis severity and discomfort are found. The existence of lesions is positively associated with the severity of the disease. Patients with lesions in hands or genitals are those reporting a greater discomfort. The presence of lesions in hands is positively associated with PDI, i.e., with leisure and with treatment, marginally. Additionally, patients scoring higher in the personal dimension are found to have a significantly greater percentage of lesions in the genitals.The psoriasis severity and location of lesions are important determinants of patients´ quality of life. Lesions on face, hands and genitals are associated with a higher impact on psychosocial wellbeing of patients. Psychological counselling should be considered within psoriasis treatment context in patients with the described disease manifestations.

Background Knowledge of human immunodeficiency virus (HIV) status is essential to effectively manage both tuberculosis (TB) and HIV infection. This is why the World Health Organization (WHO) recommends routine HIV testing in all TB patients. Objective To determine the number of TB patients with unknown HIV status in Portugal and to identify the factors associated with unknown HIV status. Methods A retrospective study of all TB notifications from 2008 to 2014 in Portugal was conducted. A multiple logistic regression model was used to evaluate the association of sociodemographic and clinical factors with unknown HIV status. Results We examined the records of 18 445 patients with TB notification, 2402 of whom (13%) had unknown HIV status. Unknown HIV status was positively associated with age 65 years (adjusted odds ratio [aOR] 1.208, 95%CI 1.037-1.408) and extra-pulmonary TB (aOR 1.381, 95%CI 1.252-1.523), but negatively associated with unemployment (aOR 0.755, 95%CI 0.637-0.895), alcohol dependence (aOR 0.809, 95%CI 0.682-0.959) and drug dependence (aOR 0.566, 95%CI 0.449-0.713). Conclusion Risk perception is the most important barrier to complete knowledge of HIV status in TB patients in Portugal. Given the importance of HIV screening in TB patients, every effort should be made to ensure that all TB patients undergo HIV screening.

Background and Purpose— Aneurysmal subarachnoid hemorrhage (SAH) is characterized by important changes in the autonomic nervous system with potentially adverse consequences. The baroreflex has a key role in regulating the autonomic nervous system. Its role in SAH outcome is not known. The purpose of this study was to evaluate the association between the baroreflex and the functional 3-month outcome in SAH. Methods— The study used a prospective database of 101 patients hospitalized for SAH. We excluded patients receiving β-blockers or noradrenaline. Baroreflex sensitivity (BRS) was measured using the cross-correlation method. A good outcome was defined by a Glasgow Outcome Scale score at 4 or 5 at 3 months. Results— Forty-eight patients were included. Median age was 58 years old (36–76 years); women/men: 34/14. The World Federation of Neurosurgery clinical severity score on admission was 1 or 2 for 73% of patients. In the univariate analysis, BRS ( P =0.007), sedation ( P =0.001), World Federation of Neurosurgery score ( P =0.001), Glasgow score ( P =0.002), Fisher score ( P =0.022), and heart rate ( P =0.037) were associated with outcome. The area under the receiver operating characteristic curve for the model with BRS as a single predictor was estimated at 0.835. For each unit increase in BRS, the odds for a good outcome were predicted to increase by 31%. Area under the receiver operating characteristic curve for heart rate alone was 0.670. In the multivariate analysis, BRS (odds ratio, 1.312; 95% confidence interval, 1.048–1.818; P =0.018) and World Federation of Neurosurgery (odds ratio, 0.382; 95% confidence interval, 0.171–0.706; P =0.001) were significantly associated with outcome. Area under the receiver operating characteristic curve was estimated at 0.900. Conclusions— In SAH, early BRS was associated with 3-month outcome. This conclusion requires confirmation on a larger number of patients in a multicentre study.

Introduction Tuberculosis notification in Portugal has decreased in the last few years. As a consequence of the economic crisis, emigration has increased and immigration has decreased. Immigrants are a risk group for tuberculosis. Most emigrants are 20–44 years old and belong to the age group most affected by tuberculosis. Objective To describe the decrease in tuberculosis notification in Portugal over the last years from a demographical point of view. Methods Mathematical analysis was performed to quantify the effect of the migration movements (separately and simultaneously) on tuberculosis notification in Portugal from 2008 to 2014. We calculated the estimated tuberculosis notification for each year during the period of study: 1) fixing immigration rate and tuberculosis rate in immigrants at 2008 values; 2) fixing emigration rate and tuberculosis rate in emigrants at 2008 values; 3) fixing both phenomenons at 2008 values. Results The differences between the observed and the estimated numbers were small (≤0.5 cases/100 000 inhabitants). Discussion Impact of the migration movements on tuberculosis notification rate does not seem to be significant when analyzed for each phenomenon individually and simultaneously, by our model. This might mean that we have to concentrate our efforts in other risk factors for tuberculosis.

To investigate whether reactive hyperemia measured by peripheral arterial tonometry correlates with markers of endothelial dysfunction and may be used to identify sepsis in critical illness.A prospective study was performed using a cohort of critically ill patients. Endothelial dysfunction was assessed on admission by quantifying reactive hyperemia-peripheral arterial tonometry and plasma levels of endothelin-1, soluble E-selectin, endocan and syndecan-1. Septic patients were compared to patients without evidence of infection.Fifty-eight septic patients were compared to 28 controls. The natural logarithm of reactive hyperemia-peripheral arterial tonometry was negatively correlated with cardiovascular comorbidities, disease severity and plasma levels of soluble E-selectin (p = 0.024) and syndecan-1 (p0.001). The natural logarithm of reactive hyperemia-peripheral arterial tonometry was lower in septic patients than in controls (0.53 ± 0.48 versus 0.69 ± 0.42, respectively). When adjusted for age, the multivariable model predicted that each 0.1-unit decrease in natural logarithm of reactive hyperemia-peripheral arterial tonometry increased the odds for infection by 14.6%. m.Reactive hyperemia-peripheral arterial tonometry is closely related to soluble E-selectin and syndecan-1, suggesting an association between endothelial activation, glycocalyx degradation and vascular reactivity. Reactive hyperemia-peripheral arterial tonometry appears to be compromised in critically ill patients, especially those with sepsis.Investigar se a hiperemia reativa correlaciona-se com marcadores de disfunção endotelial e pode ser utilizada para identificar sepse na doença crítica.Trata-se de estudo prospectivo em uma coorte de pacientes críticos. A disfunção endotelial foi avaliada quando da admissão, por meio da quantificação de hiperemia por tonometria arterial periférica e níveis plasmáticos de endotelina 1, E-selectina solúvel, endocana e sindecano 1. Os pacientes sépticos foram comparados com pacientes sem evidência de infecção.Cinquenta e oito pacientes sépticos foram comparados com 28 controle. O logaritmo natural da tonometria arterial periférica teve correlação negativa com comorbidades cardiovasculares, severidade da doença e níveis plasmáticos de E-selectina solúvel (p = 0,024) e sindecano 1 (p0,001). O logaritmo natural da tonometria arterial periférica foi mais baixo nos pacientes sépticos quando comparado com os de pacientes controle (0,53 ± 0,48 versus 0,69 ± 0,42, respectivamente) e, quando ajustado à idade, o modelo multivariado predisse que cada 0,1 de diminuição em unidades de logaritmo natural da tonometria arterial periférica levou a aumento de 14,6% na probabilidade de infecção.A hiperemia reativa avaliada por tonometria arterial periférica tem estreita relação com E-selectina solúvel e sindecano 1, o que sugere associação entre ativação endotelial, degradação de glicocálix e reatividade vascular. A hiperemia reativa por tonometria arterial periférica parece estar comprometida em pacientes críticos, especialmente os com sepse.

Objective: To compare longitudinal trends of cardiotocographic (CTG) parameters between small-for-gestational-age (SGA) and normal fetuses, from 24 to 41 weeks of pregnancy. Methods: A prospective cohort study was carried out in singleton pregnancies without fetal malformations. At least one CTG was performed in each of the following intervals: 24–26 weeks+6 days, 27–29 weeks+6 days, 30–32 weeks+6 days, 33–35 weeks+6 days, 36–38 weeks+6 days and ≥39 weeks. Tracings were analyzed using the Omniview-SisPorto® 3.6 system. Cases with a normal pregnancy outcome, including a birthweight ≥10th percentile for gestational age, were compared with two groups of SGA fetuses: with birthweight th percentile (SGArd percentile (SGA Results: A total of 176 fetuses (31 SGA) and 1256 tracings (207 from SGA fetuses) were evaluated. All CTG parameters changed significantly throughout pregnancy in the three groups, with a decreasing baseline and probability of decelerations, and an increasing average long-term variability (LTV), average short-term variability (STV) and accelerations. Baseline showed a more pronounced decrease (steeper slope) in SGA fetuses, being higher in these cases at earlier gestational ages and lower later in pregnancy. Average LTV was significantly lower in SGA Conclusion: A unique characterization of CTG trends throughout gestation in SGA fetuses was provided. A steeper descent of the baseline was reported for the first time. The findings raise the possibility of clinical application of computerized CTG analysis in screening and management of fetal growth restriction.

The association between diabetes mellitus (DM) and tuberculosis (TB) has been a matter of study worldwide, since it is assumed that DM triples the risk of TB [1]. Recent studies have found discrepant prevalence of DM among TB patients, ranging from 5.3% in Denmark [2] to 44% in India [3]. There is an urgent need to control both epidemics in order to achieve the World Health Organization (WHO) TB elimination goal [4]. To reach this goal, an integrated approach between TB elimination strategies and control of noncommunicable diseases that perpetuate the risk for TB is fundamental [5]. In a Portuguese TB cohort, diabetes mellitus was associated with older age and no HIV infection or drug consumption

Introduction Tuberculosis notification in Portugal has decreased in the last few years. As a consequence of the economic crisis, emigration has increased and immigration has decreased. Immigrants are a risk group for tuberculosis. Most emigrants are 2044 years old and belong to the age group most affected by tuberculosis. Objective To describe the decrease in tuberculosis notification in Portugal over the last years from a demographical point of view. Methods Mathematical analysis was performed to quantify the effect of the migration movements (separately and simultaneously) on tuberculosis notification in Portugal from 2008 to 2014. We calculated the estimated tuberculosis notification for each year during the period of study: 1) fixing immigration rate and tuberculosis rate in immigrants at 2008 values; 2) fixing emigration rate and tuberculosis rate in emigrants at 2008 values; 3) fixing both phenomenons at 2008 values. Results The differences between the observed and the estimated numbers were small (0.5 cases/100 000 inhabitants). Discussion Impact of the migration movements on tuberculosis notification rate does not seem to be significant when analyzed for each phenomenon individually and simultaneously, by our model. This might mean that we have to concentrate our efforts in other risk factors for tuberculosis. (c) 2017 SEPAR

Introduction: Immigrants may utilize health care services differently than other residents and may also have a greater risk for tuberculosis (TB). Objective: Identify barriers to healthcare access by immigrants, factors associated with these barriers, and discuss strategies that may reduce these barriers. Material and methods: Anonymous questionnaires were given to immigrants at National Immigrant Support Centres between 2015 and 2016. Barriers to healthcare were identified using logistic regression. Results: One-hundred and nineteen questionnaires were administered to immigrants, 9 of whom (8%) presented with TB while in Portugal. Twenty-one percent of immigrants reported barriers to healthcare access, and 69% had general practitioners (GPs). The presence of barriers to healthcare access was negatively associated with having a GP and with being married or in a de facto union. Conclusions: A considerable proportion of immigrants reported having difficulties accessing healthcare services in Portugal where legally these barriers are nonexistent. Certain factors were associated with these difficulties. Keywords: Tuberculosis, Immigration, Health services, Barriers

The Human Immunodeficiency Virus (HIV) is an infectious agent that attacks the immune system cells. Without a strong immune system, the body becomes very susceptible to serious life threatening opportunistic diseases. In spite of the great progresses on medication and prevention over the last years, HIV infection continues to be a major global public health issue, having claimed more than 36 million lives over the last 35 years since the recognition of the disease. Monitoring, through registries, of HIV-AIDS cases is vital to assess general health care needs and to support long-term health-policy control planning. Surveillance systems are therefore established in almost all developed countries. Typically, this is a complex system depending on several stakeholders, such as health care providers, the general population and laboratories, which challenges an efficient and effective reporting of diagnosed cases. One issue that often arises is the administrative delay in reports of diagnosed cases. This paper aims to identify the main factors influencing reporting delays of HIV-AIDS cases within the portuguese surveillance system. The used methodologies included multilayer artificial neural networks (MLP), naive bayesian classifiers (NB), support vector machines (SVM) and the k-nearest neighbor algorithm (KNN). The highest classification accuracy, precision and recall were obtained for MLP and the results suggested homogeneous administrative and clinical practices within the reporting process. Guidelines for reductions of the delays should therefore be developed nationwise and transversally to all stakeholders., A. Rita Gaio was partially supported by CMUP (UID/MAT/00144/2013), which is funded by FCT (Portugal) with national (MEC) and European structural funds (FEDER), under the partnership agreement PT2020. Luis Paulo Reis was partially by the European Regional Development Fund through the programme COMPETE by FCT (Portugal) in the scope of the project PEst - UID/ CEC/00027/2015 Luis Paulo Reis and Brigida Monica Faria were partially funded by QVida+: Estimacao Continua de Qualidade de Vida para Auxilio Eficaz a Decisao Clinica, NORTE-01-0247-FEDER-003446, supported by Norte Portugal Regional Operational Programme (NORTE 2020), under the PORTUGAL 2020 Partnership Agreement.

Setting: Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat. Objective: Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation. Design: A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method. Results: We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations (“tree-in-bud” pattern and pleural effusion). Conclusion: TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children. Rita Gaio and Fábio Ferreira were partially supported by CMUP (UID/MAT/00144/2013), which is funded by FCT (Portugal) with national (MEC) and European structural funds (FEDER), under the partnership agreement PT2020.

Institutions should have more effective TB screening and HCWs should receive training to make informed decisions

BACKGROUND: Tuberculosis (TB) is a major concern among high-risk populations such as the homeless. OBJECTIVES: To evaluate TB incidence and treatment outcomes among homeless patients in Portugal and to identify predictors of unsuccessful TB treatment outcomes among the homeless. DESIGN: This was a retrospective cohort study of all TB patients notified in Portugal from 2008 to 2014. Characteristics of homeless TB patients were assessed and predictors of unsuccessful TB treatment were determined using logistic regression. RESULTS: TB incidence among the homeless was 122/100 000 homeless persons and was positively correlated with TB incidence among non-homeless persons. Homeless TB patients had a higher prevalence of alcohol and/or drug use, human immunodeficiency virus (HIV) co-infection, cavitary TB and smear positivity. The rate of unsuccessful treatment outcomes among the homeless was 28.6%, and was significantly associated with increased age, injection drug use (IDU) and HIV co-infection. CONCLUSION: TB incidence among homeless persons was five times that among the non-homeless, and higher in regions with greater TB incidence among non homeless persons. The successful treatment outcome rate was lower. Predictors of unsuccessful treatment were age, IDU and HIV co-infection. Integrated TB programmes targeting homeless and non-homeless patients, with measures targeting specific characteristics, may contribute to TB elimination in Portugal., CONTEXTE : La tuberculose (TB) est un souci majeur dans les populations à haut risque comme les personnes sans domicile fixe. OBJECTIFS : Evaluer le taux d’incidence de la TB et les resultats du traitement parmi des patients sans domicile fixe au Portugal et identifier les facteurs de préediction d’ échec du traitement de la TB parmi ces patients. SCHÉMA : Etude rétrospective de cohorte incluant tous les patients TB notifies au Portugal entre 2008 et 2014. Les caractéristiques des patients sans domicile fixe ont été ́évaluées et les facteurs de prédiction d’ échec du traitement de la TB ont été déterminés par ŕegression logistique. RESULTATS : Le taux d’incidence de la TB parmi les personnes sans domicile fixe a été de 122/100 000, et il a été positivement corrélé avec l’incidence de la TB parmi le reste de la population. Les patients tuberculeux sans domicile fixe avaient une prévalence plus élevée de consommation d’alcool et/ou de drogues, de co- infection au virus de l’immunodéficience humaine (VIH), de forme caverneuse et de frottis positif. Le taux d’ ́echec du traitement a ́et ́e de 28,6% ; l’ ́echec a ́ et ́esignificativement associé à un âge plus avancé, à la consommation de drogues injectables et à la co-infection par le VIH. CONCLUSION : L’incidence dela TB parmi les personnes sans domicile fixe a été cinq fois plus élevée que celle du reste de la population et plus haute dans les régions ou l’incidence dans le reste de la population est egalement plus élevée. Leur taux d’ échec du traitement à été plus faible. Les facteurs de prédiction d’ échec du traitement ont été l´âge, la consommation de drogues injectables et la co-infection `a VIH. Des programmes de TB intégrés ciblant les patients sans domicile fixe et les autres, avec des mesures spécifiques adaptées à leurs caractéristiques particulières, pourrait contribuer à l’ élimination de la TB au Portugal., MARCO DE REFERENCIA: La tuberculosis (TB) constituye una gran preocupación en las poblaciones muy vulnerables como las personas sin hogar. OBJETIVOS: Evaluar la tasa de incidencia de TB y los desenlaces terapéuticos en las personas sin domicilio en Portugal y definir los factores pronósticos de fracaso terapéutico en este grupo de la población. MÉTODO: Fue este un estudio retrospectivo de cohortes de todos los pacientes con diagnóstico de TB notificados del 2008 al 2014 en Portugal. Mediante un análisis de regresión logística se analizaron las características de los pacientes tuberculosos sin hogar y los factores pronósticos de fracaso terapéutico. RESULTADOS: La tasa de incidencia de TB en la población sin hogar fue 122 por 100 000 personas y exhibió una correlación positiva con la incidencia de TB en las personas con domicilio. Los pacientes con diagnóstico de TB y sin hogar presentaron una prevalencia más alta de consumo de alcohol y/o de drogas, de coinfección por el virus de la inmunodeficiencia humana (VIH), de lesiones cavernosas y de resultados positivos de la baciloscopia. La tasa de fracaso terapéutico en esta población fue 28,6% y se asoción de manera significativa con una mayor edad, el consumo de drogas intravenosas y la coinfección por el VIH. CONCLUSIÓN: La incidencia de TB en las personas sin hogar fue cinco veces mayor que en las personas con domicilio y fue más alta en las regiones con una mayor incidencia de TB en las personas con domicilio. La tasa de éxito terapéutico en las personas sin hogar fue más baja. Los factores pronósticos de fracaso terapéutico fueron la edad, el consumo de drogas intravenosas y la coinfecció non por el VIH. La ejecución de programas integrados de atención de la TB dirigidos a las personas sin hogar y con domicilio, que comporten medidas específicas que aborden sus características particulares, podrıa contribuir a la eliminación de la TB en Portugal, Study Group for Infectious Diseases of Instituto de Saúde Púublica da Universidade do Porto who collaborated on this project: B Miranda, C Carvalho, C Matos, C Carvalho, G Rodrigues, J Goncalves, L Maio and T Rito. This work was supported by contributions from Iceland, Liechtenstein and Norway through the European Economic Area Grants under the Public Health Initiatives Programme (PT 06, grant number 138DT1). RG was also partially supported by Centro de Matemática da Universidade do Porto (UID/MAT/00144/2013), which is funded by Fundação do Ministério de Ciência e Tecnologia(Portugal) with national (MEC) and European structural funds (Fonds europeen de d ́eveloppement economique et regional) under the PT2020 Partnership Agreement, info:eu-repo/semantics/publishedVersion

Setting: Portugal has the highest tuberculosis incidence in Western Europe and in two small northern regions it is more frequently associated with silicosis. Objective: The aim of the present study was to characterize the risk factors associated with silico-tuberculosis and non-silico-tuberculosis patients within the tuberculosis population between 1 January 1999 and 31 December 2012 in Portugal and to identify the possible differences in the diagnosis, treatment and outcome. Design: The study used the surveillance tuberculosis system database and a logistic regression analysis enhanced with boostrapping. Results: In the 13 years studied period, 16581 patients were diagnosed with TB - 205 with silicosis and 16376 without. Almost all (99%) of the silicotic population was male and lived in northern Portugal. When comparing both populations, the silicotuberculosis was more prone to being male (0 Conclusion: TB in silicotic patients is more difficult to diagnose and treat, emerging in older groups with no other risk factors for TB. TB awareness must be raised among medical doctors, especially among occupational health services.

P-glycoprotein (P-gp) is a transmembrane protein that mediates the efflux of innumerous structurally unrelated compounds. It was initially found over-expressed in tumor cells, associated to a multidrug resistance phenotype (MDR). Then, P-gp was found constitutively expressed in excretory cells/tissues and in circulating cells, such as lymphocytes. Considering the importance of this transporter in the establishment of therapeutic protocols and the existence of contradictory results, this study aimed at evaluating the influence of aging in the expression and function of P-gp in human lymphocytes, comparing two different methodologies to assess both parameters. P-gp activity and expression were evaluated in lymphocytes isolated from whole blood samples of 65 healthy caucasian male donors, divided into two groups according to age (group 1: under 30-years old; group 2: above 60-years old). P-gp expression was assessed using the anti-P-gp monoclonal antibody, UIC2, in the presence and in absence of vinblastine (Vbl). P-gp activity was evaluated measuring the efflux rate of the fluorescent P-gp substrate rhodamine 123 (Rho 123) and also using UIC2 shift assay. Flow cytometric analysis was performed to assess all the proceedings. Furthermore, P-gp expression and each of the P-gp activity determination methods were compared, through correlation analysis and linear regression models. We observed a significant age-dependent increase in mean P-gp expression (p = 0.029), which was not reflected in the transporter's activity (p > 0.050). Statistical analysis allowed selection of UIC2 shift assay over Rho 123 efflux assay as a more selective method to assess P-gp activity. Despite the significant correlation between P-gp expression and P-gp activity found in lymphocytes (Gp1(group 1)-r = 0.609, p < 0.001; Gp2-r = 0.461, p = 0.012), using UIC2 shift assay, these data reinforce the need for P-gp activity assessment, rather than P-gp expression determination alone, when starting new therapeutic regimens with P-gp substrates, especially in men older than 60 years of age.

Tuberculosis (TB) is a major global health problem. Over the last 20 years, although industrialized countries have shown changes in overall TB notifications with decreasing incidence in native population and increasing incidence in foreign-born populations. The objective was to characterize the risk factors associated with TB among native and foreign-born tuberculosis patients between 1 January 2008 and 31 December 2012 in Portugal. Retrospective case-control study was done to characterize the risk factors associated with tuberculosis among native and foreign-born population in Portugal. The medical records of all TB cases notified between the 1 january 2008 and 31 december 2012 were analysed. We analyzed 2092 foreign-born and 4294 native-born patients. 1362 (65%) of the foreign-borns were male with mean age 35.99 years (± 15.78). The native population had 2722 males (63%) with mean age 45.34 (± 20.86). HIV positivity [adjusted odds ratio (OR):2.143; 95% CI: 1.643-2.796], was the risk factor more frequently found in foreign-born cases; drug abuse was less frequently found in foreign-born cases (OR: 0.328; 95% CI: 0.229-0.470) and employment was more frequent among the foreign born group (OR: 1.458 95% CI: 1.204-1.764). The outcome of the disease and the time between the onset of symptoms and diagnosis were not statistically different between the 2 groups (p=1). The outcome and the period between symptom and diagnosis did not differ between the two studied groups. The risk factors associated with TB cases are different between the two populations. There is a need to define different strategies in these two populations.

BACKGROUND: Cyclic endometrial neoangiogenesis contributes to changes in local vascular patterns and is amenable to non-invasive assessment with Doppler sonography. We hypothesize that the uterine artery (UtA) impedance, measured by its pulsatility index (PI), exhibits a regular pattern during the normal menstrual cycle. Therefore, the main study objective was to derive normative new day-cycle-based reference ranges for the UtA-PI during the entire cycle from days 1 to 34 according to the isolated time effect and potential confounders such as age and parity. METHODS: From January 2009 to December 2012, a cross-sectional study of 1,821 healthy women undergoing routine gynaecological ultrasound was performed. The Doppler flow of the right and left UtA-PI was studied transvaginally by colour and pulsed Doppler imaging. The mean right and left values and the presence or absence of a bilateral protodiastolic notch were recorded. Reference intervals for the PI according to the cycle day were generated by classical linear regression. RESULTS: The majority of patients (97.5%) presented unilateral or bilateral UtA notches. The crude 5th, 50th, and 95th reference percentile curves of the UtA-PI at 1-34 days of the normal menstrual cycle were derived. In all curves, a progressive significant decrease occurred during the first 13 days, followed by an increase and recovery in the UtA-PI. The adjusted 5th, 50th, and 95th reference percentile curves for the effects of age and parity were also obtained. These two conditions generated an approximately identical UtA-PI pattern during the cycle, except with small but significant reductions at the temporal extremes. CONCLUSIONS: The median, 5th, and the 95th percentiles of the UtA-PI decrease during the first third of the menstrual cycle and recover to their initial values during the last two thirds of the cycle. The rates of decrease and recovery depend significantly on age and parity.

To the Editor: Despite progress in tuberculosis (TB) control, the response to the multidrug- resistant (MDR) TB and extensively drug-resistant (XDR) TB epidemic continues to be limited. The proportion of MDR-TB patients who successfully completed treatment varied from 44% (Eastern Mediterranean Region) to 58% (South-East Asia Region) [1]. Overall, treatment success was 48%, while 28% of cases were reported as lost to follow-up or had no outcome information [1]. The Global Plan's target for 2015 of achieving at least 75% treatment success in MDR-TB patients was only reached by 30 out of 107 countries [1]. In the present paper, we evaluated the treatment outcomes of M/XDR-TB patients in Portugal. Patients with pulmonary TB resistant to isoniazid and rifampin, who started treatment at some point between January 2000 and December 2008, were selected from the national database, which integrates the data from the mandatory registration of TB cases. The evaluation of treatment outcomes was conducted from February to April 2011. Patients were classified as having received no previous treatment for TB or as having received previous treatment(s) for TB. The World Health Organization (WHO) standard definitions were used to MDR-TB, XDR-TB and treatment outcome (treatment success, died, failure, default and transferred out) [1, 2]. Was analysed the relationship between treatment outcome and clinical and demographic factors. It were also identified the predictors of poor outcome in a population of M/XDR-TB patients. The association between explanatory variables and …

To the Editor: Contact screening, as a strategy to identify recently infected individuals, is part of the tuberculosis (TB) elimination strategy. It follows risk stratification concerning the infectiousness of the index patient, the duration and proximity of exposure, and the susceptibility of the contact [1, 2]. For its optimisation it is important to know which risk factors are associated with Mycobacterium tuberculosis transmission in order to not over screen or lose at-risk contacts. In view of that, this study aims to identify potential risk factors for M. tuberculosis transmission among contacts of pulmonary TB patients, in a Portuguese TB reference centre. From January to December of 2011, all contacts of confirmed pulmonary TB patients, screened in the TB centre, were questioned about their exposure to the index patient through a questionnaire completed during the medical appointment. Both household and casual contacts were screened, independent of their cumulative exposure. Contacts excluded: those with exposure outdoors ( e.g. in the street); those with incomplete characterisation of exposure ( e.g. index patients for whom we did not know the symptomatic period); those non-compliant with screening ( e.g. contacts who failed tuberculin skin test (TST) reading); and those with a past history of M. tuberculosis infection or TB disease ( e.g. contact´s verbal report of previous TB disease, contact with a pulmonary TB patient or treatment for latent tuberculosis infection (LTBI)). Contacts of patients with a diagnosis of pulmonary TB were identified for screening at the moment of the index patient diagnosis. The index patient was asked to identify contacts within the family, social and work spheres. Furthermore, some other …

Objective The aim of this study was to identify dietary patterns in 13-y-old adolescents and to evaluate their association with socioeconomic and behavioral factors. Methods Data from 1489 adolescents born in 1990 and enrolled in schools of Porto, Portugal, in 2003–2004 (EPITeen study) were analyzed, after excluding those without information on the food frequency questionnaire and the outliers. The questionnaire items were grouped into 14 food groups and dietary patterns were identified by cluster analysis (k-means). Their association with participants' characteristics was computed using multinomial logistic regression. Results Four dietary patterns were identified. The pattern healthier (16.1%) was characterized by the highest consumption of seafood, soup, vegetables/legumes, fruit, and added fats. The dairy products pattern (29.7%) showed the highest consumption of dairies. The pattern fast food and sweets (14.2%) presented the highest intake of fast food, sweets and pastry, soft drinks and coffee or tea. The lower intake pattern (40%) was characterized by a lower consumption of the majority of food groups. A higher odds of belonging to the fast food and sweets pattern, compared with the lower intake pattern was found among adolescents spending more time watching TV on the weekends (>360 min: odds ratio [OR], 2.09; 95% confidence interval [CI], 1.23–3.57) and among those consuming four to seven fried meals per week (OR, 3.96; 95% CI, 2.27–6.90). Adolescents with highly educated parents were less likely to belong to the fast food and sweets group. Conclusion Unhealthier behaviors and lower socioeconomic position were the main factors associated with the unhealthier dietary pattern (fast food and sweets). This information should be considered in the development of health-promotion interventions.

Purpose: Dietary pattern analysis may uncover the joint effects of multiple dietary components on bone health, but such research is scarce and targets mostly adults. Methods: We quantified prospective associations between dietary patterns and bone mineral density (BMD) in 1,007 adolescents of a cohort born in 1990 and recruited at schools in Porto during the 2003/2004 school year. Forearm BMD was measured using dual-energy X-ray absorptiometry. Participants’ dietary patterns were classified “Healthier”, “Dairy products”, “Fast food and sweets” and “Lower intake” according to previously identified patterns obtained in a larger sample of 1,489 participants using the K-means method. Using dietary patterns at 13 years old as the main exposure, associations were estimated cross-sectionally (with BMD at the age of 13) and prospectively (with annual BMD variation between 13 and 17 years), using linear regression coefficients adjusted for height, weight, energy intake and, in girls, for menarche age. Results: No significant associations between the a posteriori dietary patterns identified and mean BMD at 13 were found. However, among girls, adherence to a pattern characterized by low intake of energy and all food groups was negatively associated with annual BMD variation between 13 and 17 years [adjusted coefficient (95 % CI) −0.451 (−0.827; −0.074) mg·cm−2·year−1]. Conclusions: Although results showed that, in girls, adherence to a “Lower intake” dietary pattern is associated with lower annual BMD variation throughout adolescence, overall, there were no consistent associations between dietary patterns and forearm BMD in adolescents.

We correct an error in [1, Section 11] concerning the domain of definition for the local equivariant symplectic action. Let (M, ω) be a symplectic manifold equipped with a Hamiltonian action by a compact Lie group G. Identify the Lie algebra g = Lie(G) with its dual by an invariant inner product and let μ : M → g be a moment map for the action. We assume that μ is proper and G acts freely on μ(0). Identify S ∼= R/2πZ and let (x, η) : S → M × g be a smooth loop. The equivariant length of the loop (x, η) is defined by

Background: The foetal aortic Doppler frequency spectrum is influenced by cardiac output and contractility of the foetal heart as well as vascular compliance, blood viscosity and impedance of the arterial vascular system. The present study aimed at comparing Doppler flow pulsatility (PI) and resistance (RI) indexes of foetal proximal descending aorta (AoF) in the first, second and third trimesters of pregnancy, in low risk women and in those with chronic arterial hypertension, who had normal pregnancy outcomes. Methods: A longitudinal and prospective study was carried out in 101 singleton pregnancies (71 low-risk pregnancies and 30 with essential hypertension). Multivariate regression had to be considered due to the experiment’s nature: two different indexes were read on the same set of individuals, once at each trimester of the pregnancy [1st (11–14 weeks), 2nd (19–22 weeks) and 3rd (28–32 weeks) trimesters]. The response variable was denoted as index d, in a subject with hypertensive status h (hypertensive or normotensive), at continuous time t. Results: In both groups, AoF-PI and AoF-RI showed a small, but significant increase from the first to the second (1.850 ± 0.339 vs 2.110 ± 0.242 for PI, and 0.829 ± 0.068 vs 0.857 ± 0.038 for RI; p < 0.001) and the first to the third (1.850 ± 0.339 vs 2.163 ± 0.282 for PI, and 0.829 ± 0.068 vs 0.864 ± 0.037 for RI; p < 0.001) trimesters of pregnancy. The global model showed that while AoF-RI trends were converging as time progressed, the AoF-PI values exhibited a divergent trend (p < 0.05). Conclusions: Chronic stable hypertension in pregnancies with normal outcome, evidences an upward regular trend of foetal descending aorta pulsatility index that is similar to the normotensive condition.

The objective of this work was to compare Doppler flows pulsatility index (PI) and resistance indexes (RI) of uterine and internal iliac arteries during pregnancy in low risk women and in those with stage-1 essential hypertension. From January 2010 and December 2012, a longitudinal and prospective study was carried out in 103 singleton uneventful pregnancies (72 low-risk pregnancies and 31 with stage 1 essential hypertension)at the 1st, 2nd and 3rd trimesters. Multiple linear regression models, fitted using generalized least squares and whose errors were allowed to be correlated and/or have unequal variances, were employed; a model for the relative differences of both arteries impedance was utilized. In both groups, uterine artery PI and RI exhibited a gestational age related decreasing trend whereas internal iliac artery PI and RI increased. The model testing the hemodynamic adaptation in women with and without hypertension showed similar trend. Irrespective of blood pressure conditions, the internal iliac artery resistance pattern contrasts with the capacitance pattern of its immediate pelvic division, suggesting a pregnancy-related regulatory mechanism in the pelvic circulation.

About one-third of the population worldwide have Mycobacterium tuberculosis infections, although 90% of infected individuals never develop clinical disease [1, 2]. Heavy alcohol intake seems to increase risk of TB in males. New measures for alcohol abuse are needed The author's contributions are as follows. Conception and design: R. Duarte and O. Oliveira; analysis and interpretation: J. Francisco, O. Felgueiras, A.R. Gaio and R. Duarte; drafting the manuscript for important intellectual content: J. Francisco, O. Oliveira, A.R. Gaio and R. Duarte.

Background There is scarce evidence regarding the association between diet and metabolic syndrome (MetS) in Portuguese population. We aim to evaluate the association between a posteriori dietary patterns (DPs) and MetS and its features. Methods Using random digit dialing, a sample of 2167 adults was selected between 1999 and 2003, in Porto. During a face-to-face interview, a questionnaire was applied, anthropometric measures were taken, blood pressure measured and a fasting blood sample collected. Diet was assessed using a validated food frequency questionnaire, and four DPs were identified in each sex by multivariate finite mixture models. Results After adjustment for age and daily energy intake, comparing to the “healthy” DP, women with the “low fruit and vegetables” DP had a higher odds of high waist circumference (OR = 1.88 95% CI 1.17-3.01) and low HDL-cholesterol (OR = 1.78 95% IC 1.12-2.82) and women in the “red meat and alcohol” DP had higher odds of high waist circumference (OR = 1.45 95% CI 1.01-2.07) and of MetS (OR = 1.57 95% CI 1.07-2.29); men with the “fish” DP had a higher odds of high triglycerides (OR = 1.57 95% CI 1.05-2.35). After further adjustments (education, physical activity, smoking, alcohol drinking, BMI, and menopausal status) no significant associations remained. Conclusions Four distinct DPs were identified in a community sample of Portuguese adults and there was no association with the prevalence of MetS.

Establishing credible cut scores for performance-type examinations in health professions education can be challenging. The authors aimed to compare the pass-fail cut-score reliability with the maximum reliability cut-score from multiple-choice tests (MCTs) designed on different undergraduate disciplines. Using the cross-sectional evaluation of 1370 tests from six disciplines from Porto medical school, Portugal, in 2010, the pass-fail cut-score reliability was obtained from the one-parameter logistic model of item response theory model. The test information curve achieved maximum reliability for ability levels ranging from -1.40 to -0.01 standard deviations below the average. The pass-fail cut score for estimated ability ranged from -1.36 to 0.25. These results showed that all MCTs had a pass and fail threshold of competence, and that was appropriate for the maximum information obtainable from the examination to occur at the pass and fail level; nevertheless, the maximum information was not achieved in the pass and fail level.

Background Previous studies showed an inter-observer agreement for the NYHA classification of approximately 55%. The aim of this study was to calibrate the New York Heart Association (NYHA) classification system between observers, increasing its reliability. Results Among 1136 community-dwellers in Porto, Portugal, aged ≥ 45 years, 265 reporting breathlessness answered a 4-item questionnaire to characterize symptom severity. The questionnaire was administered by 7 physicians who also classified the subject's functional capacity according to NYHA. Each subject was assessed by one physician. We calibrated NYHA classifications by the concurrent method, using 1-parameter logistic graded response model. Discrepancies between observers were assessed by differences in ability thresholds between NYHA classes I-II and II-III. The ability estimated by the model was used to predict the NYHA classification for each observer. Estimates of the first and second thresholds for each observer ranged from -1.92 to 0.46 and from 1.42 to 2.30, respectively. The agreement between estimated ability and the observers' NYHA classification was 88% (kappa = 0.61). Conclusions The study objectively indicates the main reason why several studies have reported low inter-observer is the existence of discrepant thresholds between observers in the definition of NYHA classes. The concurrent method can be used to minimize the reliability problem of NYHA classification.