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Background: The evaluation of perceptions of patients with rheumatoid arthritis (RA) has a positive influence in their health outcomes and overall experience of care. The Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure (CQRA-PREM) was developed to provide the perceptions and the feedback of the patients with RA to the health professionals team. This PREM is already validated and in use in the United Kingdom (UK) and Netherlands. In Portugal, there is no validated PREM to evaluate the experience of patients with RA. Objective: To translate, cultural adapt and validate the content of the CQRA-PREM for the Portuguese population. Methods: A qualitative study using focus groups was conducted to evaluate CQRA-PREM content validity. The CQRA-PREM was first translated and cultural adapted to Portuguese by two researchers, and after back translation, a panel of experts agreed on the preliminary Portuguese version of CQRA-PREM. Patients with RA were recruited from a rheumatology center at a tertiary university hospital center to participate in focus group meetings. Before the focus group they filled in the preliminary version of CQRA-PREM, with its 7 domains and 24 items (Likert scale 1-5). Results: Twelve participants (median 54 (45-58) years old; 92% female) were included in two focus groups. All domains of the questionnaire had medians of 3 or above. Seven major themes and six subthemes emerged. Participants considered the questionnaire as very clear and simple and with adequate questions. Patients pointed as extremely important being treated with dignity and respect and considered the awareness of the multidisciplinary team and the presentation of support programs and organizations as areas for improvement. Conclusion: The Portuguese version of the CQRA-PREM is acceptable and its content is valid in the perspective of patients with RA to assess the quality of care provided by the healthcare services. [ABSTRACT FROM AUTHOR]

Aims: to test the measurement properties of the Portuguese version of the Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure (CQRA-PREM) for patients with rheumatoid arthritis (RA)., Methods: This cross-sectional clinical field study recruited adult patients with RA during rheumatology appointments of a Portuguese rheumatology center. Patients completed the Portuguese version of CQRA-PREM, composed of 7 domains and 24 questions. Sociodemographic characteristics, symptoms/disease duration, current treatment, Pain-Visual Analog Scale (VAS), Patient Global Assessment (PGA)-VAS and Health Assessment Questionnaire (HAQ) were also collected from the patient. Disease Activity Score for 28 joints with C-reactive Protein (DAS28-CRP) was recorded by the rheumatologist. The assessment of CQRA-PREM measurement properties followed the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations., Results: A total of 61 patients with RA were included. The domains in which patients showed better experience were the "Needs and preferences", followed by "Coordination and Communication". The domain "Information, education and self-care" was an identified area of improvement for providing patient-centered care. Ceiling effects were found in four domains of the CQRA-PREM. Internal consistency of all domains was considered good (α>0.7). Homogeneity was considered good for each question in all domains analyzed (0.30≤rp≤0.70). The divergent validity of the PREM was good, revealing that the domains were not correlated (Pain-VAS, HAQ, DAS28-CRP) or only weakly (PGA-VAS) correlated with clinical outcomes., Conclusions: The CQRA-PREM showed acceptable measurement properties and is a useful tool for evaluating quality of healthcare provided in daily practice, as perceived by RA patients in Portugal.

Background: The increased focus on quality indicators (QIs) and the use of clinical registries in real-world cancer studies have increased compliance with therapeutic standards and patient survival. The European Society of Breast Cancer Specialists (EUSOMA) established QIs to assess compliance with current standards in breast cancer care., Methods: This retrospective study is part of H360 Health Analysis and aims to describe compliance with EUSOMA QIs in breast cancer management in different hospital settings (public vs. private; general hospitals vs. oncology centers). A set of key performance indicators (KPIs) was selected based on EUSOMA and previously identified QIs. Secondary data were retrieved from patients' clinical records. Compliance with target KPIs in different disease stages was compared with minimum and target EUSOMA standards., Results: A total of 259 patient records were assessed. In stages I, II, and III, 18 KPIs met target EUSOMA standards, 5 met minimum standards, and 8 failed to meet minimum standards. Compliance with KPIs varied according to the type of hospital (particularly regarding diagnosis) and disease stage. Although small differences were found in KPI compliance among institutions, several statistical differences were found among treatment KPIs according to disease stage, particularly in stage III., Conclusions: This study represents the first assessment of the quality of breast cancer care in different hospital settings in Portugal and shows that, although most QIs meet EUSOMA standards, there is room for improvement. Differences have been found across institutions, particularly between oncology centers and general hospitals, in diagnosis and compliance with KPIs among disease stages. Stage III showed the greatest variability in compliance with treatment KPIs, probably related to the lower specificity of the guidelines in this disease stage.

Introduction: PD-[L]1 inhibitors revolutionized cancer treatment but challenge the affordability of health systems. This policy-focused model aimed to estimate the health and budget impact of anti-PD-(L)1s in Portugal and inform current discussions., Materials and Methods: The Health Impact Projection (HIP) model estimates clinical (life years, progression-free survival [PFS] years, and quality-adjusted life years [QALY] gained and adverse events [AEs] incurred) and economic (direct and indirect costs) outcomes in a world where cancer patients are initiating treatment with standard-of-care (SOC) versus SOC plus anti-PD-(L)1s over a 3-year time horizon. Indications included adjuvant and metastatic melanoma, non-small cell lung cancer (first and second line), metastatic triple-negative breast cancer, head and neck cancer, urothelial carcinoma, and renal cell carcinoma. Model inputs were based on publicly available literature data and expert opinion., Results: The model estimated that, over 3 years, 7,773 patients would be treated with anti-PD-(L)1s, realizing a gain of 4,787 life years, 6,901 PFS years, and 4,214 QALYs and avoiding 399 AEs. The introduction of anti-PD-(L)1s had a projected average annual impact of ≈ €108 million and a share of 20% of total cancer medicines expenditure and 0.6% of total healthcare expenditure in 2021. Although higher disease management costs are expected for patients living longer with anti-PD-(L)1s and drug acquisition costs are considerable, that is partially offset by a reduction in end-of-life costs (€611,092/year) and costs associated with patient productivity lost to cancer (€9,128,142/year)., Discussion: This model highlights the significant survival and QoL benefit of anti-PD-(L)1s for cancer patients in Portugal, with a relatively low increased cost in total healthcare expenditure., Competing Interests: LC participated in advisory boards sponsored by MSD. AM received honoraria as consultant/speaker from Amgen, Astellas, Bayer, B. Braun, Bristol Myers-Squibb, Janssen, Merck-Serono, Merck Sharp & Dohme, Novartis, OM Pharma, Pfizer, Pierre Fabre, Roche, and Servier; travel/logistics support from Amgen, Astellas, Bayer, Bristol Myers-Squibb, Janssen, Merck-Serono, Merck Sharp & Dohme, Novartis, OM Pharma, Pfizer, Pierre Fabre, Roche, and Servier; and research funding from Bayer. RS received honoraria as consultant/speaker from Roche, Merck Sharp & Dohme, Novartis, Pierre-Fabre, Bristol-Myers Squibb, Astrazeneca, Glaxosmith, Lilly, Pfizer, and Tesaro. CV performed consulting or advisory activities for MSD, Bristol-Myers Squibb, Merck Serono, Novartis, F. Hoffmann-La Roche Ltd., Lilly and Grünenthal and received reimbursement for travel expenses from F. Hoffmann-La Roche Ltd., MSD, BMS, Pfizer, and Novartis. RH is an employee of Adelphi Values Ltd. Adelphi Values Ltd. received reimbursement from MSD for the conduct of this study. AR and SP are employees of MSD and may own stock and/or hold stock options in Merck & Co., Inc., Kenilworth, NJ, USA. AA performed consulting/advisory activities for Merck Sharp & Dohme, Bristol Myers Squibb, AstraZeneca, Janssen, Pfizer, IPSEN, Takeda, Boehringer Ingelheim; research funding for Astellas, Janssen; and expert testimony for Merck Sharp & Dohme, Bristol Myers Squibb, AstraZeneca, Janssen, Pfizer, IPSEN, Takeda, and Boehringer Ingelheim. The authors declare that this study received funding from MSD Portugal and MSD International Business GmbH. The funder had the following involvement in the study: funding in model development, contributing with local data and expertise, and commenting on the paper. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Costa, Alexandre, Mansinho, Sousa, Vieira, Hughes, Roediger, Pereira and Araújo.)

Introduction: Despite years of experience with biological disease modifying anti-rheumatic drugs (bDMARD) in rheumatoid arthritis (RA), little is known about differences in infectious risk among bDMARDs. The aim of this study was to assess the incidence and type of infections in RA patients on bDMARDs and to determine possible predictors., Methods: A retrospective multicenter cohort study that included patients registered in the Rheumatic Diseases Portuguese Registry (Reuma.pt) with RA, and exposed to at least one bDMARD until April 2021. RA patients under bDMARD and with at least one episode of severe infection (SI), defined as infection that requires hospitalization, use of parenteral antibiotics or that resulted in death, were compared to patients with no report of SI. Demographic and clinical data at baseline and at the time of each SI were collected to establish comparisons between different groups of bDMARDs. Comparisons between different bDMARDs were assessed and logistic regression was performed to identify predictors of SI., Results: We included 3394 patients, 2833 (83.5%) female, with a mean age at RA diagnosis of 45.5±13.7 years. SI was diagnosed in 142 of the 3394 patients evaluated (4.2%), totaling 151 episodes of SI. At baseline, patients with SI had a significantly higher proportion of prior orthopedic surgery, asthma, interstitial lung disease, chronic kidney disease and corticosteroid use, higher mean age and longer median disease duration at first bDMARD. Nine patients died (6.0%). Ninety-two SI (60.9%) occurred with the first bDMARD, the majority leading to discontinuation of the bDMARD within 6 months (n=75, 49.7%), while 65 (43.0%) restarted the same bDMARD and 11 (7.3%) switched to another bDMARD (6 of them to a different mechanism of action). In the multivariate analysis, we found that chronic kidney disease, asthma, infliximab, corticosteroid use, interstitial lung disease, previous orthopedic surgery, higher Health Assessment Questionnaire and DAS284V-ESR are independent predictors of SI., Conclusion: This study described the incidence and types of SI among Portuguese RA patients on biologics, identifying several predictors of SI, both globally and with different bDMARDs. Physicians should be aware of the real-word infectious risk in RA patients on bDMARDs when making treatment decisions.

Background: Musculoskeletal symptoms represent the most common extraintestinal manifestations of inflammatory bowel disease (IBD) and a major cause of impaired quality of life in these patients. Spondyloarthritis (SpA) is classically associated with IBD, but other rheumatic manifestations may occur., Objective: To characterize musculoskeletal symptoms and rheumatic diseases in an IBD cohort., Methods: Retrospective monocentric descriptive study including all the patients with IBD consecutively referred from Gastroenterology to the Reumatology Department (from January of 2013 to April of 2021) in a Portuguese tertiary university hospital. Demographic and clinical data were collected and musculoskeletal symptoms and rheumatic diseases diagnosed in the Rheumatology outpatient center were registered., Results: A total of 235 patients were included: 177 (75.3%) with Crohn´s disease (CD) and 58 (24.7%) with ulcerative colitis. Musculoskeletal symptoms were observed in 142 (60.4%) patients and 105 (44.7%) had some rheumatic condition. Regarding spondyloarthritis, 46 (19.6%) patients fulfilled ASAS (Assessment of SpondyloArthritis international Society) criteria for axial SpA and 5 (2.1%) for peripheral SpA. Osteoarthritis (n=70, 29.8%) and osteoporosis (n=33, 14%) were the most frequent non-inflammatory rheumatic conditions observed, mostly previously undiagnosed. No significant differences were observed between CD and UC., Conclusion: Rheumatic conditions are frequent in IBD patients and are not limited to SpA features. They remain mostly undiagnosed and the collaboration between gastroenterologists and rheumatologists is important for their best management.

This is the first detailed description of an erosive seronegative polyarthritis in the Vogt-Koyanagi-Harada Syndrome in Portugal.

Introduction: Long-term survivors of cystic fibrosis (CF) have a dramatic increase in the risk of osteoporosis and incident fracture. The objective of this work is to characterize a CF related bone disease in a Portuguese cohort of CF patients., Methods: We performed a cross-sectional, observational study on a cohort of CF adult patients. Clinical status, laboratory parametres, nutrition, lung function tests, genetics and bone mineral density (BMD) data were collected from a CF reference centre., Results: Of 30 patients, 53.3% were males (n=16). Median age was 32.5 (27.0; 32,5) and median body mass index (BMI) was 22,04 (19,85; 24,55), with 4 patients (13.3%) being underweight (BMI<18.5 kg/m²). Four patients (13.3 %) were diagnosed with osteoporosis and 15 patients (50%) has low BMD. Among them, 2 (6.7%) had fragility fractures. A moderate correlation was found between the lumbar spine (LS) BMD and BMI and, as expected, femural neck BMD and LS BMD has moderate to strong correlations with BMD Z scores., Conclusion: Despite the young middle age we found a high prevalence of low BMD and osteoporosis in patients with CF. Early recognition and treatment are the most effective strategies for reducing the morbidity due to osteoporosis in these patients.

The actual prevalence of CLA (caseous lymphadenitis) in small ruminant flocks is underestimated in many countries, and because it is not a notifiable disease, it will continue to spread without data and information about its real economic impact. The difficulty in the accurate identification of the causative agent in internal subclinical cases allows the disease to spread within and between flocks. This research intends to assess the utility of an ELISA (enzyme-linked immunosorbent assay) test in the detection of internal subclinical cases of CLA in farms and to simultaneously add data on the seroprevalence of the disease in Portugal. Sera from 756 small ruminants, 70% sheep (528/756) and 30% goats (228/756) were screened for antibodies against Corynebacterium pseudotuberculosis using the ELISA technique based on a recombinant phospholipase D (ELITEST CLA # CK105A ® ). The animals showing internal lesions (n ꞊ 58) were sampled for the identification of the aetiological agent. In this investigation, the prevalence of CLA was 34% (258/756), with the ELISA test showing a low specificity (78%) and high sensitivity (100%). The proof was able to detect 57% (13/23) of subclinical cases of CLA confirmed by postmortem examination and conventional PCR (polymerase chain reaction). The results also reveal that goats have a higher propensity for the disease, and dairy farms and non-extensive production units appear to be more susceptible to CLA. This research clarifies an actual problem and pointed out the importance of CLA in small ruminant herds in Portugal. Finally seems to demonstrate that the ELISA test is a good diagnostic tool for use in CLA eradication programmes., (© 2020 The Authors. Veterinary Medicine and Science Published by John Wiley & Sons Ltd.)

Background: Hypersensitivity reactions to antineoplastic agents may lead to discontinuation of first-line treatments. Rapid drug desensitization (RDD) allows for a safe reintroduction in patients who are allergic to them., Objective: To evaluate the safety and efficacy of the Brigham and Women's Hospital's 12-step RDD in a Portuguese patient population with cancer and to identify markers associated with breakthrough reactions (BTRs) to platins., Methods: We conducted a retrospective review of desensitizations undertaken at the Immunoallergology Day-Care Unit of the Santa Maria Hospital in Lisbon, Portugal, from July 2008 to July 2019. Adult patients with cancer and with immediate hypersensitivity reactions were included. Skin testing was performed to platins, trastuzumab, and cetuximab. The 12-step protocol was used for most patients, and a shorter protocol was used in 9 patients who were taxane-reactive to resume regular infusions., Results: A total of 1471 RDDs were performed in 272 patients to 136 platins, 124 taxanes, 13 monoclonal antibodies, and 10 other drugs. Skin test results were positive in 127 of patients who were platin-reactive (95.3%) and negative in patients who were cetuximab- and trastuzumab-reactive. There were 141 BTRs during RDD (9.6% of infusions), 79.4% induced by platins with the majority having mild reactions (68.8%). There were 8 patients who were paclitaxel-reactive, and who completed a shorter protocol and resumed regular infusions successfully. Multiple platin infusions (cutoff: ≥10) and total immunoglobulin E greater than or equal to 100 U/mL were identified as independent risk factors for BTRs in patients who were platin-reactive., Conclusion: This large single-center study confirmed the safety and efficacy of the 12-step RDD protocol in a diverse cancer population, providing evidence of its universal applications. Total immunoglobulin E is a potentially useful biomarker to identify high-risk patients who are platin-reactive., (Copyright © 2020 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate belimumab effectiveness and safety in real-life Portuguese patients with Systemic Lupus Erythematosus (SLE)., Materials and Methods: Multicenter cohort study including all SLE patients treated with belimumab in seven Portuguese rheumatology centers. Demographic, clinical and serological data were collected at baseline, 6, 12 and 24 months of treatment with belimumab. To evaluate effectiveness we used SLE Responder Index (SRI) rates and changes in SELENA-SLEDAI. Safety was evaluated by the number of adverse events., Results: Thirty-eight patients were included: 37 (97.4%) female, with a mean age of 46.2±13.9 years. Mean SELENA-SLEDAI was 8.2±3.9, 78.8% had elevated anti-double-stranded DNA (anti-dsDNA) antibodies and 72.7% had complement consumption at baseline. Multiorgan involvement was the leading cause for the use of belimumab. SRI response was achieved in 51.9%, 60% and 91.7% at 6, 12 and 24 months of belimumab treatment, respectively. LUNDEX adjusted SRI response rates were 45.4%, 45.0% and 45.8% at 6, 12 and 24 months of belimumab, respectively. Mean SELENA-SLEDAI, anti-dsDNA antibodies and daily prednisolone dosage decreased significantly from baseline to 6, 12 and 24 months and C3 levels increased significantly at 12 months of belimumab treatment. Five patients presented adverse events (infections in three cases) and eleven patients discontinued belimumab (four due to inefficacy, three due to adverse events and four were lost to follow-up)., Conclusions: Our study confirmed, in real-life Portuguese patients with active SLE, the effectiveness of belimumab in reduction of disease activity, immunological response and steroid-sparing, with a good safety profile.

Background: The vasculitides are a group of rare diseases with different manifestations and outcomes. New therapeutic options have led to the need for long-term registries. The Rheumatic Diseases Portuguese Register, Reuma.pt, is a web-based electronic clinical record, created in 2008, which currently includes specific modules for 12 diseases and > 20,000 patients registered from 79 rheumatology centres. On October 2014, a dedicated module for vasculitis was created as part of the European Vasculitis Society collaborative network, enabling prospective collection and central storage of encrypted data from patients with this condition. All Portuguese rheumatology centres were invited to participate. Data regarding demographics, diagnosis, classification criteria, assessment tools, and treatment were collected. We aim to describe the structure of Reuma.pt/vasculitis and characterize the patients registered since its development., Results: A total of 687 patients, with 1945 visits, from 13 centres were registered; mean age was 53.4 ± 19.3 years at last visit and 68.7% were females. The most common diagnoses were Behçet's disease (BD) (42.5%) and giant cell arteritis (GCA) (17.8%). Patients with BD met the International Study Group criteria and the International Criteria for BD in 85.3 and 97.2% of cases, respectively. Within the most common small- and medium-vessel vasculitides registered, median [interquartile range] Birmingham Vasculitis Activity Score (BVAS) at first visit was highest in patients with ANCA-associated vasculitis (AAV) (17.0 [12.0]); there were no differences in the proportion of patients with AAV or polyarteritis nodosa who relapsed (BVAS≥1) or had a major relapse (≥1 major BVAS item) during prospective assessment (p = 1.00, p = 0.479). Biologic treatment was prescribed in 0.8% of patients with GCA, 26.7% of patients with AAV, and 7.6% of patients with BD. There were 34 (4.9%) deaths reported., Conclusions: Reuma.pt/vasculitis is a bespoke web-based registry adapted for routine care of patients with this form of rare and complex diseases, allowing an efficient data-repository at a national level with the potential to link with other international databases. It facilitates research, trials recruitment, service planning and benchmarking.

Introduction: Diabetic Foot infections (DFI) are a major cause of hospitalization in patients with diabetes. The microbiological study of diabetic ulcers is essential to adequate antibiotic therapy and to minimize the selection of resistant microorganisms. The aim of this study was to characterize and to compare the evolution of isolated microorganisms between the biennium 2010-2011 and 2016-2017, in hospitalized patients with DFI., Material and Methods: Retrospective evaluation of the clinical and analytical data of patients who were admitted due to DFI in 2010-2011 (group 2010/11) and 2016-2017 (group 2016/17). Only the first hospitalization for each patient was included. An adequate descriptive and comparative statistical analysis was performed., Results: There were 274 admissions due to DFI, 151 in 2010/11 and 123 in 2016/17. There was an increase in admissions due to neuroischemic DFI (51.0% in 2010/11 to 61.8% in 2016/17, p = 0.048). Staphylococcus aureus (SA) was the most common isolate in 2010/11 (26.7%). In 2016/17 most cultures were mixed polymicrobial and isolation of Enterobacteriaceae and Pseudomonas aeruginosa increased from 2010/11 to 2016/17 (15.9% to 30.6%, p = 0.001, and 9.1% to 13.7%, p = 0.048, respectively)., Conclusion: There was an increase in the prevalence of neuroischemic DFU. The Enterobacteriaceae family replaced SA as the most prevalent pathogen in DFI, with an increase in the isolation of gram-negative microorganisms and mixed polymicrobial cultures. Chronic neuroischemic infected ulcers usually present distinct bacterial isolates; knowledge about the most common agents is warranted in order to better select empiric antibiotic therapy., Competing Interests: Declaration of competing interest The authors of this manuscript certify that they have NO affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. There was no funding for the manuscript., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: The main aim of the study was to evaluate the efficacy and safety profile of Nivolumab, an immune-checkpoint-inhibitor antibody, in advanced, previously treated, Non-Small Cell Lung Cancer (NSCLC) patients, in a real world setting., Methods: We performed a retrospective, multicentre data analysis of patients who were included in the Portuguese Nivolumab Expanded Access Program (EAP). Eligibility criteria included histologically or citologically confirmed NSCLC, stage IIIB and IV, evaluable disease, sufficient organ function and at least one prior line of chemotherapy. The endpoints included Overall Response Rate (ORR), Disease Control Rate (DCR), Progression Free Survival (PFS) and Overall Survival (OS). Safety analysis was performed with the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 4.0, and immune-related Adverse Events (irAEs) were treated according to protocol treatment guidelines. Tumour response was assessed using the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.1. Data was analysed using SPSS, version 21.0 (IBM Statistics)., Results: From June 2015 to December 2016, a total of 229 patients with advanced NSCLC were enrolled at 30 Portuguese centres. Clinical data were collected up to the end of July 2018. The baseline median age was 64 years (range 37-83) and the majority of patients were males (70.3%) and former/current smokers (69.4%). Patients with non-squamous histology predominated (88.1%), and 67.6% of the patients had received 2 or more prior lines of chemotherapy. Out of 229 patients, data was available for 219 patients (3 patients did not start treatment, while data was unavailable in 7 patients); of the 219 patients, 15.5% were not evaluated for radiological tumour assessment, 1.4% had complete response (CR), 21% partial response (PR), 31% stable disease (SD) and 31.1% progressive disease (PD). Thus, the ORR was 22.4% and DCR was 53.4% in this population. At the time of survival analysis the median PFS was 4.91 months (95% CI, 3.89-6.11) and median OS was 13.21 months (95% CI, 9.89-16.53). The safety profile was in line with clinical trial data., Conclusions: Efficacy and safety results observed in this retrospective analysis were consistent with observations reported in clinical trials and from other centres., (Copyright © 2019 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.)

Aims and Methods: In rheumatoid arthritis (RA), cardiovascular (CV) comorbidities are a major cause of mortality. Coronary Calcium Score (CCS) assessed by computed tomography has been associated with RA prognosis. In this work, we aimed to assess CCS in female RA patients and determine CCS association with different clinical, laboratory and imaging disease parameters., Results: We evaluated 60 female patients, with a mean age of 53.6 ± 10.4 years, a mean Disease Activity Score of 28 joints (DAS28) (4v) and Health Assessment Questionnaire (HAQ) of 4.542 ± 1.317 and 1.488 ± 0.631, respectively, and a disease duration of 14.7 ± 10.3 years. Mean CCS value was 35.192 ± 117.786. CCS > 10 was significantly associated with CV risk factors (age: odds ratio [OR] = 1.120; P = .002, body mass index [BMI] ≥ 25 kg/m 2 : OR = 0.271; P = .025, high-density lipoprotein [HDL]: OR = 0.011; P = .025, low-density lipoprotein/ HDL ratio: OR = 2.084; P = .030, apolipoprotein A1 [ApoA1]: OR = 0.965; P = .014, apolipoprotein B/ApoA1 [ApoB/ApoA1] ratio: OR = 59.834; P = .011, homocysteine: OR = 1.287; P = .045, diabetes: OR = 10.400; P = .043, and anti-diabetic therapy: OR = 10.667, P = .041), disease parameters (C-reactive protein [CRP]: OR = 1.038; P = .046, DAS[4v]: OR = 1.900; P = .009, DAS28[4v; CRP]: OR = 1.700; P = .019, DAS[3v]: OR = 1.947; P = .010, DAS28[3v; CRP]: OR = 1.696; P = .022, HAQ: OR = 3.299; P = .023, erosion score: OR = 1.015; P = .012, and total modified Sharp/van der Heijde Score: OR = 1.008; P = .035), biomarkers (osteoprotegerin: OR = 1.505; P = .022), and bone mineral density (femoral: OR = 0.005; P = .018, lumbar spine: OR = 0.001; P = .002, left hand: OR = 7.9 × 10 -9 ; P = .005, and osteoporosis: OR = 6.628; P = .007). After adjustment for age and BMI, significant associations were maintained with ApoA1, ApoB/ApoA1 ratio, homocysteine, CRP, DAS(4v), DAS(4v; CRP), DAS(3v) and DAS(3v; CRP). A sensitivity analysis undertaken after excluding the 6 diabetics yielded similar results., Conclusions: Our work reinforces the hypothesis that in RA, CCS may be a useful tool in CV risk assessment, particularly valuable in poorer controlled patients with certain lipoprotein profiles., (© 2019 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Study Objective: To determine the incidence, risk factors, and predictors of survival of perioperative cardiac arrests (PCAs) occurring in patients who underwent non-cardiac and non-obstetric surgery from January 2008 to May 2015 at a tertiary hospital; determine the incidence and risk factors of anesthesia-related PCA., Design: Retrospective observational study., Setting: Operating room and postoperative recovery area., Patients: Sixty-two PCA cases from an anesthesia database of 122,289 anesthetics., Interventions: Each PCA was classified as anesthesia-related, partially anesthesia-related, or anesthesia unrelated. The main outcome variables were occurrence of PCA, survival at least 1 h after initial resuscitation and survival to hospital discharge. To determine the risk factors for PCA, for each patient who suffered a PCA, two other patients that underwent anesthesia on the same day and in the same operating suite were selected., Measurements: Three sets of variables were collected; patient-related, surgical procedure-related, and PCA-related., Main Results: The incidence of PCAs of all causes was 5.07 per 10,000 anesthetics, and the associated mortality was 2.9 per 10,000 anesthetics. The independent risk factors for occurrence were: ASA PS score higher than 3, diagnosed cardiac disease, and the use of vasopressors. Decreased survival was associated with: higher ASA PS score, urgent surgical procedures of a higher complexity, use of vasopressors, documented hypotension prior to PCA, and arrests due to bleeding. The incidence of anesthesia-related PCAs was 0.74 per 10,000 anesthetics, and the associated mortality was 0.08 per 10,000 anesthetics. The main causes of anesthesia-related PCAs were associated with medication and airway/ventilation, and the independent risk factors for occurrence were: ASA PS score higher than 3 and diagnosed cardiac disease., Conclusions: Most PCAs were not due to anesthesia-related causes, and anesthesia-related PCAs were associated with improved survival. Improvements in the management of high-risk patients, medication administration, and airway/ventilation management may result in better outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To analyze the Health related Quality of Life (HRQoL) and physical function in rheumatoid arthritis (RA) patients and compare it with the general population. We also intended to analyze about disease activity influence in HRQoL and functional capacity, as well as determine potential determinants for these outcomes., Material and Methods: A cross-sectional study was conducted in RA patients from a university hospital of Portugal. We obtained Short Form 36, EuroQoL 5D, health assessment questionnaire, visual analog scale for pain and patient's assessment of disease activity. Comparisons between SF-36 and EQ-5D values with our population reference values were conducted using the Mann-Whitney test. Data were compared in different levels of disease activity, using Kruskal Wallis test and Fisher's exact test. A multiple regression analysis was conducted to identify the potential determinants of outcomes., Results: RA sample showed significantly lower values than the portuguese general population on physical summary measure of SF-36 (median=32 vs. 50, p<0.001) and EQ-5D (median=0.620 vs. 0.758 respectively; p<0.001). Lower disease activity levels had better PROs and this was true even when compared patients achieving remission with those in low disease activity. The HAQ (r 2 =67%), VAS-P (r 2 =62%) and VAS-DA (r 2 =58%) were the variables that strongly related to SF-36. Considering HAQ, the strongest relation was found with VAS-P, VAS-DA and age (r 2 =60%, 61% and 33%, respectively). Multiple regression analysis identified HAQ, VAS-P and educational status as determinants of the HRQoL; age, female gender, employment, VAS-P and VAS-DA as determinants of physical function., Conclusion: Impairment of HRQoL in RA patients is enormous. We found significant differences between different levels of disease activity, showing higher HRQoL and functional capacity at lower disease activity levels., (Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.)

This study aims to compare adequate fruit and vegetable (F&V) intake between immigrants and natives in Portugal, and to analyse factors associated with consumption of F&V among immigrants. Data from a population based cross-sectional study (2014) was used. The final sample comprised 17,410 participants (≥20 years old), of whom 7.4% were immigrants. Chi-squared tests and logistic regression models were conducted to investigate the association between adequate F&V intake, sociodemographic, anthropometric, and lifestyle characteristics. Adequate F&V intake was more prevalent among immigrants (21.1% (95% CI: 19.0⁻23.4)) than natives (18.5% (95% CI: 17.9⁻19.1)), ( p = 0.000). Association between migrant status and adequate F&V intake was only evident for men: immigrants were less likely to achieve an adequate F&V intake (OR = 0.67, 95% CI = 0.66⁻0.68) when compared to Portuguese. Among immigrants, being female, older, with a higher education, and living in a low urbanisation area increased the odds of having F&V consumption closer to the recommendations. Adjusting for other factors, length of residence appears as a risk factor (15 or more years vs. 0⁻9 years: OR = 0.52, 95% CI = 0.50⁻0.53), ( p = 0.000) for adequate F&V intake. Policies aiming to promote adequate F&V consumption should consider both populations groups, and gender-based strategies should address proper sociodemographic, anthropometric, and lifestyle determinants.

Objectives: Early diagnosis and treatment of Rheumatoid Arthritis (RA) and axial Spondylarthritis (axial SpA) can limit the impact of disease outcomes. This study evaluated the effectiveness of a referral program on the identification of patients with RA and axial SpA., Methods: This was an observational, prospective, randomized (by clusters) study conducted in Portugal to evaluate the impact of the implementation of a set of referral support actions (RSA). The study was divided in two sub-studies, the RA sub-study and the axial SpA sub-study. 28 participating primary care units were randomly (by clusters) assigned to RSA or control group (with no intervention). Both RSA and control groups identified and referred patients with suspected RA or axial SpA to the rheumatology unit of the reference hospital. The primary objective was to evaluate the correct diagnosis of RA or axial SpA cases confirmed by the rheumatologist of the reference hospital., Results: RA-Substudy: A total of 340 patients were recruited (144 in the RSA-exposed group; 196 in the control). RA diagnosis confirmation was 7.3% (95%CI, 2.1-12.5%) in RSA group versus 2.7% (95%CI, 0.0-5.7%) in control group RSA effect was positive but moderate (4.6%) and not statistically significant (95% CI, 0.0%-11.8%; p=0.222, adjusted for clustering effect). Rate of confirmed arthritis of any type was 16.9% (n=14/83) in the RSA group and 6.0% (n=5/83) in the control group. This difference was statistically significant and favorable to RSA group (OR=3.2; 95% CI 1.1-9.2; p=0.028). Axial SpA-Substudy: A total of 231 patients were recruited (108 in the RSA-exposed group; 123 in the control). Axial SpA diagnosis confirmation was 8.7% (95% CI, 2.1-15.4%) in RSA group versus 5.6% (95% CI, 0.0-11.73%) in control group. RSA effect was positive (3.1%) but not statistically significant (95% CI, -7.5- 12.9%; p=0.568, adjusted for clustering effect)., Conclusions: This study showed a positive tendency for the RSA program, most relevantly on the diagnosis of patients with any type of arthritis in the RA sub-study. It is possible that a referral program more comprehensive than the one herein tested might improve early diagnosis of RA and SpA.

Background: A contemporary US study showed an increase in the use of chemotherapy in the last decade for some patients with stage-I breast cancer; with a rise in more intensive regimens, and declining use of anthracyclines. Nevertheless, there is still uncertainty on the absolute benefit of chemotherapy for these patients and the optimal regimen. In this study we compare those findings with the patterns of care among a Portuguese cohort of stage-I breast cancers., Methods: Retrospective cohort study of patients with stage-I breast cancer diagnosed from 2006 to 2008 at four Portuguese institutions. The use and type of chemotherapy was evaluated., Results: Among patients with stage I-III breast cancer 39.4% (n = 682) had stage I disease. Of the 595 eligible patients, 22.4% were treated with chemotherapy, 33.9% aged <55 years vs. 12.7% aged >65 years (p < 0.001). Thirteen percent of patients with hormone receptor (HR)+/HER2- tumors, 52.7% of patients with HER2+ and 66.0% of patients with HR-/HER2- received chemotherapy (p < 0.001). In addition, we found inter-institutional variability, with the use of chemotherapy ranging from 0.0% to 43.4% (p < 0.001). Eighty-five percent of patients treated with chemotherapy received less-intensive regimens with anthracycline-based regimens, such as doxorubicin and cyclophosphamide, being the most frequently used, while docetaxel and cyclophosphamide was only used in 1.5% of cases., Conclusions: Overall, almost one-quarter of patients received chemotherapy with institutional variability. When treated, mostly less-intensive associations including anthracyclines were used, which contrasts with contemporary US practice. This study highlights the need for health-services research to understand local practices and tailor quality improvement interventions., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: To quantify the prevalence of FM (FM research criteria), to describe its components-symptom severity score (SSS) and widespread pain index (WPI)-and to identify biopsychosocial predictors of the severity of SSS as well as WPI using a population-based sample of young adults., Methods: Participants were part of the 21-year-old follow-up of the EPITeen cohort, which was set up during the 2003-04 school year and comprised subjects born in 1990 attending schools in Porto, Portugal (n = 1719, 51.4% women). Data on biopsychosocial characteristics were collected, and FM-related information was gathered using the Fibromyalgia Survey Questionnaire. Sex-specific multivariate log-binomial regression coefficients (β) and 95% CI were used to quantify the associations between adverse biopsychosocial characteristics and high scores in SSS and WPI., Results: The overall point-prevalence of FM was 1.0%. Women scored significantly higher in SSS and WPI when compared with men. Global psychological distress was strongly and significantly associated with high scores in SSS in women and men (respectively, low sleep quality, β = 1.44, 95% CI 1.05, 1.84 and β = 1.19, 95% CI 0.78, 1.61; depressive symptoms, β = 1.64, 95% CI 1.23, 2.06 and β = 1.14, 95% CI 0.60, 1.70; eating disorders, β = 1.17, 95% CI 0.71, 1.63 and β = 1.15, 95% CI 0.52, 1.78). In women, adverse socioeconomic factors were predictors of high scores in SSS, whereas in men these contexts were significantly associated with high scores in WPI., Conclusion: In young adulthood, psychological distress was particularly consistent in predicting SSS and may become useful as a red flag for the establishment of clinical disease., (© The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Although the survival rate has considerably improved, many patients with systemic lupus erythematosus (SLE) develop irreversible organ damage., Objectives: The objectives of this paper are to characterize cumulative damage in SLE patients and identify variables associated with its presence and severity., Methods: A cross-sectional analysis of SLE patients from the Portuguese Lupus register Reuma.pt/SLE in whom damage assessment using the SLICC/ACR-Disability Index (SDI) was available was performed. Predictor factors for damage, defined as SDI ≥ 1, were determined by logistic regression analyses. A sub-analysis of patients with severe damage (SDI ≥ 3) was also performed., Results: In total, 976 patients were included. SDI was ≥1 in 365 patients, of whom 89 had severe damage. Musculoskeletal (24.4%), neuropsychiatric (24.1%) and ocular (17.2%) domains were the most commonly affected. Older age, longer disease duration, renal involvement, presence of antiphospholipid antibodies and current therapy with steroids were independently associated with SDI ≥ 1. The subpopulation with severe damage had, in addition, a greater interval between the first manifestation attributable to SLE and the clinical diagnosis as well as and more frequently early retirement due to SLE., Conclusions: This large lupus cohort confirmed that demographic and clinical characteristics as well as medication are independently associated with damage. Additionally, premature retirement occurs more often in patients with SDI ≥ 3. Diagnosis delay might contribute to damage accrual., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objectives: To investigate whether CCR5 deletion is associated with susceptibility to Behçet's disease (BD) in a Portuguese population., Methods: A total of 122 BD patients and 227 ethnically-matched controls were studied. Genotyping of the CCR5Δ32 polymorphisms was performed using polymerase chain reaction product sizing., Results: No significant differences were observed in the allelic frequencies of CCR532 between patients and controls (OR=0.820; p=0.512). Stratification for gender and for the presence of HLA-B*51 did not reveal any significant differences., Conclusions: These results indicate that CCR5Δ32 is unlikely to contribute to susceptibility to BD in Portuguese patients. This may be explained by the known functional redundancy of this signalling system.

Aim: The aim of our study was to characterize the association of clinicopathological variables and the SLC19A1/RFC-1 G80A polymorphism in methotrexate (MTX)-related toxicity in Portuguese patients with rheumatoid arthritis., Patients & Methods: The study included 233 consecutively recruited patients with rheumatoid arthritis under MTX treatment. The SLC19A1 G80A polymorphism was evaluated by PCR-RFLP., Results: Statistical analysis revealed that SLC19A1 80G carriers had increased risk of gastrointestinal toxicity (odds ratio [OR]: 2.61, p = 0.019) and that regular folic acid supplementation was associated with both overall and gastrointestinal toxicity protection (OR: 0.15, p < 0.001 and OR: 0.19, p < 0.001, respectively). Multivariate analysis confirmed the association of SLC19A1 80G and regular folic acid supplementation to gastrointestinal toxicity (OR: 5.53 and 0.13, respectively). Moreover, a multivariate Cox regression model demonstrated a higher risk of earlier gastrointestinal toxicity in SLC19A1 80G carriers (hazard ratio: 3.63, p = 0.002)., Conclusion: SLC19A1 G80A genotyping may be a useful tool for clinicians to identify patients at higher risk for developing gastrointestinal toxicity related to MTX treatment.

Introduction: The objective of this study was to develop a Portuguese version of the World Health Organization fracture risk assessment tool (FRAX®)., Methods: All cases of hip fracture occurred at or after 40 years of age were extracted from the Portuguese National Hospital Discharge Register from 2006 to 2010. Age and sex-ranked population estimates and mortality rates were obtained from National Statistics. Age- and gender stratified incidences were computed and the average of the five years under consideration was taken. Rates for other major fractures were imputed from the epidemiology of Sweden, as undertaken for most national FRAX® models. All methodological aspects and results were submitted to critical appraisal by a wide panel of national experts and representatives of the different stakeholders, including patients., Results: Hip fracture incidence rates were higher in women than in men and increased with age. The lowest incidence was observed in 40-44 years group (14.1 and 4.0 per 100,000 inhabitants for men and women, respectively). The highest rate was observed among the 95-100 age-group (2,577.6 and 3,551.8/100,000 inhabitants, for men and women, respectively). The estimated ten-year probability for major osteoporotic fracture or hip fracture increased with decreasing T-score and with increasing age., Conclusions: Portugal has one of the lowest fracture incidences among European countries. The FRAX® tool has been successfully calibrated to the Portuguese population, and can now be used to estimate the ten-year risk of osteoporotic fractures in this country. All major stakeholders officially endorsed the Portuguese FRAX® model and co-authored this paper.

1. Bacterial resistance to β-lactam antibiotics has risen dramatically in Escherichia coli from food animals. In a previous study, 29 randomly selected chicken products, collected in Portugal, were analysed for the presence of extended-spectrum β-lactamases (ESBLs)-producing E. coli; and during this study the genetic characterisation of ESBLs genes was investigated. 2. The presence of genes encoding TEM, OXA, SHV, and CTX-M type beta-lactamases was studied by PCR followed by sequencing. Additionally, other mechanisms of antimicrobial resistance, phylogenetic groups and the presence of virulence determinants were evaluated among the isolates. 3. β-lactamases genes were identified as follows: bla (CTX-M-14) (n = 4), bla (CTX-M-1) (n = 2), bla (CTX-M-9) (n = 4) and bla (TEM-52) (n = 13). Mutations at positions -42, -18, -1, and +58 of ampC promoter region were identified in 4 non-ESBL-producing isolates. The tet(A) or tet(B) genes were identified in all tetracycline-resistant isolates; the aadA gene detected in 8 of 10 streptomycin-resistant isolates; the aac(3)-II gene in all gentamicin-resistant isolates; the cmlA gene in the chloramphenicol-resistant isolate; and sul1 and/or sul2 and/or sul3 genes were found in all trimethoprim-sulfamethoxazole-resistant isolates. The intI1 gene was detected in 8 trimethoprim-sulfamethoxazole-resistant isolates and the intI2 gene in 4 isolates; one gene cassette arrangements were identified among class 1 integrons (dfrA1 + aadA1) and among the class 2 integrons (dfrA1 + sat2 + aadA1). Among cefotaxime-resistant isolates, 16 belonged to A or B1 phylogenetic groups, while 11 isolates were classified into the D or B2 phylogroups. At least one virulence-associated gene (aer, fimA, or papC) was detected in 74·1% of the cefotaxime-resistant isolates. 4. Because ESBLs-producing bacteria are resistant to a broad range of β-lactams, infections caused by these organisms complicate therapy and limit treatment options.

The authors present the revised version of the Portuguese Society of Rheumatology (SPR) guidelines for the treatment of Rheumatoid Arthritis (RA) with biological therapies. In these guidelines the criteria for introduction and maintenance of biological agents are discussed as well as the contraindications and procedures in the case of nonresponders. Biological treatment (with a tumour necrosis factor antagonist, abatacept or tocilizumab) should be considered in RA patients with a disease activity score 28 (DAS 28) equal to or greater than 3.2 despite treatment with at least 20mg-weekly-dose of methotrexate (MTX) for at least 3 months or, if such treatment is not possible, after 3 months of other conventional disease modifying drug or combination therapy. A DAS 28 score between 2.6 and 3.2 with a significant functional or radiological deterioration under treatment with conventional regimens could also constitute an indication for biological treatment. The treatment goal should be remission or, if that is not achievable, at least a low disease activity, defined by a DAS28 lower than 3.2, without significative functional or radiological worsening. The response criteria, at the end of the first 3 months of treatment, are a decrease of at least 0.6 in the DAS28 score. After 6 months of treatment res­ponse criteria is defined as a decrease greater than 1.2 in the DAS28 score. Non-responders, in accordance to the Rheumatologist’s clinical opinion, should try a switch to another biological agent (tumour necrosis factor antagonist, abatacept, rituximab or tocilizumab).

Background: Skeletal-related events (SREs) occur frequently in patients with bone metastases as a result of breast (BC) and prostate (PC) cancers. They increase both morbidity and mortality and lead to extensive health-care resource utilization., Methods: Health care resource utilization by BC/PC patients with at least one SRE during the preceding 12 months was assessed through retrospective chart review. SRE-treatment costs were estimated using the Portuguese Ministry of Health cost database and analyzed using generalized linear models., Results: This study included 152 patients from nine hospitals. The mean (SD) annual SRE-treatment cost per patient was €5963 (€3646) and €5711 (€4347), for BC (n=121) and PC (n=31) patients, respectively. Mean cost per single episode ranged between €1485 (radiotherapy) and €13,203 (spinal cord compression). Early onset of bone metastasis (P = 0.03) and diagnosis of bone metastases at or after the occurrence of the first SRE (P < 0.001) were associated with higher SRE-treatment costs., Conclusion: These results reveal the high hospital SRE-treatment costs, highlighting the need for early diagnosis and treatment, and identify key factors determining the economic value of therapies for patients with skeletal metastases., (Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Objectives: Osteoporotic hip fractures (HF) are a major cause of morbidity and mortality with increasing familial, social and economic repercussions. The objectives of this paper were to evaluate the status vitae at 6 and 12 months of a cohort of patients with an osteoporotic HF and the risk factors for 12-month mortality as well as to evaluate the functional outcome and the overall health perception of these patients., Patients and Methods: We conducted a 12-month follow-up evaluation of a cohort of 184 patients older than 65 years admitted to our centre with a non-pathological osteoporotic HF from January 1st to December 31st 2007. Baseline data collection was performed in the first 72 hours after admission and, 12 months later, a second evaluation was conducted, by telephone in order to ascertain their status vitae and functional status. The magnitude of sex--specific, age-adjusted associations between potential prognostic factors and mortality was estimated using hazard ratios (HR) and respective 95% confidence intervals (95%CI), calculated using Cox's proportional hazards model., Results: It was possible to ascertain the status vitae in 164 (89.1%) patients. Overall 12-months mortality was 26.8% (48.3% in males and 22.2% in females). Mortality was higher in patients that became bedridden, were unable to walk again, were admitted to a hospital during the follow-up for any cause and who became dependent in their daily living activities. After discharge, physical therapy and ability to walk again were associated with a lower risk of death. Most of the patients reported a decline of their overall health-related quality of life. More than 75% of patients became totally dependent after HF., Conclusion: This study reinforces the HF poor outcome. Twelve-month mortality rates were similar to the estimates obtained in other studies, although the 6-month's mortality was higher. Physical deterioration and loss of independence in activities of daily living were evident in this study and constituted major factors for low self-esteem and deterioration of quality of life. Our findings may constitute an evidence for action in this particular population, with an active search for means to improve the outcome of HF in these patients.

Introduction: We aimed to describe the pharmacological management of osteoporosis in the general population, with emphasis on the inclusion of calcium supplementation., Methods: We interviewed 1511 participants in an evaluation of a cohort of Portuguese adults. Antiresorptive therapy and calcium supplementation in the previous year were recorded. Socio-demographic characterisation included education, occupation, marital status and source of medical care. The participants' osteoporosis history and menopause age were noted. Dietary calcium intake was quantified using a food frequency questionnaire and a calcaneus quantitative ultrasound was conducted., Results: Antiresorptive drugs had been used by 11.4% of women and 1.2% of men in the previous year. Bisphosphonates were the most referred subgroup (88% of all therapies), followed by raloxifen, and calcitonin. Overall, 43% of women reported using calcium in combination with bone-sparing drugs. Combination therapy was more frequent among older women (> or =70 years old: 63%), those with the highest educational level (>12 schooling years: 49%), blue-collar occupations (55%) and private healthcare (43%). Women with longer postmenopausal periods (>10 years: 42%) and those with the highest spontaneous calcium intakes (highest tertile: 44%) reported combination therapy more frequently., Conclusion: Although treatment with bone-sparing drugs is frequent, the management of osteoporosis does not systematically include the recommended calcium supplementation.

Objectives: To develop Portuguese evidence-based recommendations for the use of methotrexate (MTX) in daily clinical practice in rheumatic disorders., Methods: The Portuguese project was integrated in the multinational 3E Initiative (Evidence, Expertise, Exchange) 2007-2008 where a total of 751 rheumatologists from 17 countries have participated. Ten clinical questions concerning the use of MTX in rheumatic diseases were formulated and the Portuguese group added three more questions. A systematic literature search in Medline, Embase, Cochrane Library and 2005-2007 ACR/EULAR meeting abstracts was conducted. Selected articles were systematically reviewed and the evidence was appraised according to the Oxford Levels of Evidence. In Portugal, a national meeting was held in Obidos on February 15th and 16th, 2008, involving 50 rheumatologists who discussed and voted by Dephi method the recommendations. Finally, the agreement among the rheumatologists and the potential impact on their clinical practice was assessed., Results: Thirteen national key recommendations on the use of MTX were formulated: work-up before starting MTX, optimal dosage and route of administration, use of folic acid, monitoring, management of hepatotoxicity, long-term safety, mono versus combination therapy, management in the peri-operative period, during infections, before/during pregnancy and after clinical remission, screening and treatment of tuberculosis and the role of MTX as a steroid-sparing agent in rheumatic diseases., Discussion: The Portuguese recommendations for the use of MTX in daily clinical practice were developed, which are evidence-based and supported by a panel of 50 rheumatologists, enhancing their validity and practical use. This project was integrated in a multinational initiative that led to the recent publication of ten multinational recommendations which differ from ours in some specific aspects.

Human leukocyte antigen (HLA)-B*51 is a well-known genetic factor associated with Behçet's disease (BD). To analyse the influence of HLA-B*51 and other HLA class I alleles in BD susceptibility in a Portuguese population and its association with disease severity, we studied 78 BD patients and 208 healthy controls. The patients were classified into two severity groups as described by Gul et al. As expected, a higher frequency of HLA-B*51 was found. The frequency of HLA-Cw*16 alleles was significantly higher in patients. Regarding severity, HLA-B*27 frequency was higher in the severe group compared with controls and with the mild group. Thus, HLA-B*51 and HLA-Cw*16 seem to confer susceptibility to BD in this patients. HLA-B*27 may be important as a prognostic factor.

Aim: In this study we aimed to estimate the prevalence of osteoporosis and to identify the factors associated with bone mineral density in Portuguese men and to quantify age-related bone loss., Participants and Methods: We designed a cross-sectional evaluation of 739 apparently healthy men 20-82 years recruited during general practice routine visits who volunteered for bone mineral density measurement. Men reporting secondary causes for osteoporosis or using medication known to interfere with bone metabolism were excluded n = 82. Distal forearm bone mineral density was measured using single X-ray absorptiometry DTX 100 Hologic and information on demographic anthropometric and behavioural aspects was recorded., Results: Forearm bone mineral density decreased significantly with age r = -0.29 p < 0.001 and was higher in overweight men and among those who reported moderate or intense physical activity. The prevalence of osteoporosis increased from 1.9% at 40-49 years to 18.6% after 70 years p < 0.001. Increasing age was a risk factor and body mass index was protective against the condition., Conclusion: This study showed that bone loss is an important problem in ageing men in our country.

Objectives: To study the smoking habits of 6th year Portuguese medical students and assess their knowledge and acceptance of anti-smoking measures and how they felt these would impact on public health., Material and Methods: We conducted a descriptive cross-sectional study, in which a self-administered, anonymous questionnaire was made available online to the target population (6th year Portuguese medical students). The relationships between some of the variables were analysed using contingency tables and the chi2 test, with p<0.05 taken as statistically significant., Results: We obtained 255 answers to our questionnaire. We found an 18.04% prevalence of smokers. The majority of smokers smoked 1 - 10 cigarettes per day, with men smoking more, and most of them had begun their habit between 13 and 18 years of age, with women beginning later. 36.96% of smokers had already made an attempt to quit smoking.

Introduction: The drugs available in the Portuguese market, for the treatment of osteoporosis, have different mechanisms of action, efficacy, indications, safety profile, and cost, which may influence prescription and acquisition by patients., Objectives: To describe the use of drugs for osteoporosis treatment (estimated by sales), between 1998 and 2004, and the geographical variation in the drug utilization, in 2004., Methods: Data was obtained from IMS Health for the sales of drugs used in the ambulatory treatment of osteoporosis, in the whole country, from 1998 to 2004, and by region, in 2004. For each group (bisphosphonates, raloxifene, calcitonins, Hormone replacement therapy (HRT) and calcium and vitamin D), we computed the sum of the amount of packages and the value of the sales in each year, regardless of the strength or the package size. For bisphosphonates, raloxifene and calcitonins, we computed the DDD (Defined Daily Dose) sold in Portugal. All consumption data are presented by women aged 45 to 74 years. National data was used to describe the trends in sales, from 1998 to 2004, and regional data was used to map the 2004 consumptions., Results: The expenses with drugs used in osteoporosis increased 60% from 1998 to 2004. The bisphosphonates sales increased more than five times, and in 2004 this group was responsible for 60% of the national market of drugs for osteoporosis treatment. Raloxifene represented approximately 10% of the sales in 2004. The consumption of calcitonins decreased nearly 70% in the observation period. The use of HRT increased 30% to 40% until 2001/2002, and decreased just about the same from there on. Geographical differences were observed in the sales of osteoporosis drugs in 2004, the amplitude of variation ranging from two (bisphosphonates, calcium and vitamin D, HRT) to three times (raloxifene, calcitonins) across regions. The lowest consumptions were observed in Beja and Bragança, and the highest in Aveiro. Raloxifene is used mainly in the Northwest of the country, and HRT in the sea side regions., Conclusions: In Portugal, the trends in the consumption of drugs used for osteoporosis treatment, as well as the relative weight of each pharmacological group, follow a similar pattern to the observed in other countries. The differences in consumption across the years and regions may reflect a variation in the frequency of disease or in the proportion of subjects being treated, but the magnitude of the variation suggests that there are unmet needs in diagnosis and treatment of osteoporosis in our country, and that social and economic factors may contribute to the regional differences observed.

This study evaluated T cell immune responses to purified protein derivative (PPD) and Mycobacterium tuberculosis (Mtb) in health care workers who remained free of active tuberculosis (HCWs w/o TB), health care workers who went on to develop active TB (HCWs w/TB), non-health care workers who were TB free (Non-HCWs) and tuberculosis patients presenting with minimal (Min TB) or advanced (Adv TB) disease. Peripheral blood mononuclear cells (PBMC) were stimulated with Mtb and PPD and the expression of T cell activation markers CD25+ and HLA-DR+, intracellular IL-4 and IFN-gamma production and cytotoxic responses were evaluated. PBMC from HCWs who developed TB showed decreased percentages of cells expressing CD8+CD25+ in comparison to HCWs who remained healthy. HCWs who developed TB showed increased gammadelta TCR+ cell cytotoxicity and decreased CD3+gammadelta TCR- cell cytotoxicity in comparison to HCWs who remained healthy. PBMC from TB patients with advanced disease showed decreased percentages of CD25+CD4+ and CD25+CD8+ T cells that were associated with increased IL-4 production in CD8+ and gammadelta TCR+ phenotypes, in comparison with TB patients presenting minimal disease. TB patients with advanced disease showed increased gammadelta TCR+ cytotoxicity and reduced CD3+gammadelta TCR- cell cytotoxicity. Our results suggest that HCWs who developed TB show an early compensatory mechanism involving an increase in lytic responses of gammadelta TCR+ cells which did not prevent TB.