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BackgroundNeonatal mortality reduction is a global goal, but its factors are seldom studied in most resource-constrained settings. This is the first study conducted to identify the factors affecting perinatal and neonatal deaths in Sao Tome & Principe (STP), the smallest Central Africa country.MethodsInstitution-based prospective cohort study conducted at Hospital Dr. Ayres Menezes. Maternal-neonate dyads enrolled were followed up after the 28th day of life (n = 194) for identification of neonatal death-outcome (n = 22) and alive-outcome groups (n = 172). Data were collected from pregnancy cards, hospital records and face-to-face interviews. After the 28th day of birth, a phone call was made to evaluate the newborn's health status. Crude odds ratios and corresponding 95% confidence intervals were obtained. A p value

Abstract Background Sao Tome & Principe (STP) has a high peri-neonatal mortality rate and access to high-quality care before childbirth has been described as one of the most effective means of reducing it. The country has a gap in the coverage-content of antenatal care (ANC) services that must be addressed to better allocate resources to ultimately improve maternal and neonatal health. Therefore, this study aimed to identify the determinants for adequate ANC utilization considering the number and timing of ANC contacts and screening completion. Methods A hospital based cross-sectional study was undertaken among women admitted for delivery at Hospital Dr. Ayres de Menezes (HAM). Data were abstracted from ANC pregnancy cards and from a structured face-to-face interviewer-administered questionnaire. ANC utilization was classified as partial vs adequate. Adequate ANC utilization was defined as having ANC 4 or more contacts, first trimester enrolment plus one or more hemoglobin tests, urine, and ultrasound. The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Multivariable logistic regression was used to identify determinants of adequate ANC utilization at P-value

Introduction Health information systems represent an opportunity to improve the care provided to people with multimorbidity. There is a pressing need to assess their impact on clinical outcomes to validate this intervention. Our study will determine whether using a digital platform (Multimorbidity Management Health Information System, METHIS) to manage multimorbidity improves health-related quality of life (HR-QoL).Methods and analysis A superiority, cluster randomised trial will be conducted at primary healthcare practices (1:1 allocation ratio). All public practices in the Lisbon and Tagus Valley (LVT) Region, Portugal, not involved in a previous pilot trial, will be eligible. At the participant level, eligible patients will be people with complex multimorbidity, aged 50 years or older, with access to an internet connection and a communication technology device. Participants who cannot sign/read/write and who do not have access to an email account will not be included in the study. The intervention combines a training programme and a customised information system (METHIS). Both are designed to help clinicians adopt a goal-oriented care model approach and to encourage patients and carers to play a more active role in autonomous healthcare. The primary outcome is HR-QoL, measured at 12 months with the physical component scale of the 12-item Short Form questionnaire (SF-12). Secondary outcomes will also be measured at 12 months and include mental health (mental component Scale SF-12, Hospital Anxiety and Depression Scale). We will also assess serious adverse events during the trial, including hospitalisation and emergency services. Finally, at 18 months, we will ask the general practitioners for any potentially missed diagnoses.Ethics and dissemination The Research and Ethics Committee (LVT Region) approved the trial protocol. Clinicians and patients will sign an informed consent. A data management officer will handle all data, and the publication of several scientific papers and presentations at relevant conferences/workshops is envisaged.Trial registration number NCT05593835.

Introduction: Frailty is a multidimensional syndrome characterized by the loss of functional reserve, associated with higher mortality and less functional survival in cardiac surgery patients. The Edmonton Frail Scale (EFS) is a comprehensive tool devised for brief frailty detection. To the best of our knowledge, there are no culturally adapted and validated frailty screening tools that enable the identification of vulnerability domains suited for use in the preoperative setting in Portugal. This was the motivation for this study. Objectives: To assess the validity and reproducibility of the Portuguese version of the EFS. Methods: Prospective observational study, in a sample of elective cardiac surgery patients. The Edmonton Frail Scale (EFS) translation and backtranslation were performed. Demographic and clinical data were collected, and the translated EFS translated, Geriatric Depression Scale, and Mini Mental State Examination Portuguese versions, Katz and Clinical Frailty Scales were administered. To assess validity Mann–Whitney test, Spearman's correlation coefficient, marginal homogeneity test and Kappa coefficient were employed. Reproducibility was assessed estimating kappa coefficient for the frailty diagnosis and the 11 EFS items. Intra-class correlation coefficients and the corresponding 95% confidence interval were estimated using linear mixed effects model. Results: The EFS Portuguese version revealed construct validity for frailty identification, as well as criterion validity for cognition and mood domains. Reproducibility was demonstrated, with k=0.62 (95% confidence interval (CI) 0.42–0.82) and intraclass correlation (ICC)=0.94 (95% CI 0.89–0.97) in inter-observer test and k=0.48 (95% CI 0.26–0.70) and ICC=0.85 (95% CI 0.72–0.92) in intra-observer test. Conclusions: The EFS Portuguese version is valid and reproducible for use, suiting pre-operative frailty screening in a cardiac surgery setting. Resumo: Introdução: A fragilidade é uma síndrome multidimensional caracterizada pela perda de reserva funcional, associada a maior mortalidade e menor sobrevivência funcional após cirurgia cardíaca. A Escala de Fragilidade de Edmonton (EFS) é uma ferramenta abrangente de deteção de fragilidade. Não existe ainda em Portugal uma ferramenta de rastreio culturalmente adaptada e validada que permita a identificação de domínios específicos de vulnerabilidade para utilização no pré-operatório. Objetivos: Avaliar a validade e reprodutibilidade da versão portuguesa da EFS. Métodos: Estudo prospetivo observacional, realizado numa amostra de doentes propostos para cirurgia cardíaca. A EFS foi traduzida e retrotraduzida. Colheram-se dados demográficos e clínicos, aplicaram-se as versões traduzidas da EFS, Escala de Depressão Geriátrica e MMSE, as escalas de Katz e Clinical Frailty Scale. Validade avaliada utilizando o teste de Mann-Whitney, o coeficiente de correlação de Spearman, o teste de homogeneidade marginal e o coeficiente Kappa. Reprodutibilidade avaliada pelo cálculo do coeficiente kappa para o diagnóstico de fragilidade e para os 11 itens da escala. Coeficientes de correlação intraclasse e correspondentes intervalos de confiança a 95% estimados usando um modelo linear de efeitos mistos. Resultados: A versão portuguesa da EFS demonstrou validade de constructo, assim como validade de critério nos domínios de cognição e humor. É reprodutível, com k=0,62 (95% IC 0,42-0,82) e CCI=0,94 (95% IC 0,89-0,97) no teste interobservador e k=0,48 (95% IC 0,26-0,70) e CCI=0,85 (95% IC 0,72-0,92) no teste intraobservador. Conclusões: A versão portuguesa da EFS é adequada para rastreio pré-operatório de fragilidade em cirurgia cardíaca.

Introduction: Molecular tests can contribute to improve the preoperative diagnosis of thyroid nodules. Tests available are expensive and not adapted to different populations. Aim: This study aimed to compare the cyto-histological genetic profile and to evaluate the reliability of molecular tests using ultrasound-guided fine needle aspiration cytology (US-FNAC) in accurately diagnosing differentiated thyroid carcinomas (DTCs) and predicting biologic behavior of papillary thyroid carcinomas (PTCs). Materials and Methods: The series included 259 patients with paired cyto-histological samples totaling 518 samples. The genetic alterations were analyzed via PCR/Sanger sequencing. The association with clinicopathologic features was evaluated in PTCs. Results/Discussion: From the 259 patients included, histologies were 50 (19.3%) benign controls and 209 (80.7%) DTC cases, from which 182 were PTCs; cytologies were 5.8% non-diagnostic, 18.2% benign, 39% indeterminate, and 37.1% malignant. In histology, indeterminate nodules (n = 101) were 22.8% benign and 77.2% malignant. Mutation frequencies in cytology and histology specimens were, respectively, TERTp: 3.7% vs. 7.9%; BRAF: 19.5% vs. 25.1%; and RAS: 11% vs. 17.5%. The overall cyto-histological agreement of the genetic mutations was 94.9%, with Cohen’s k = 0.67, and in indeterminate nodules agreement was 95.7%, k = 0.64. The identified mutations exhibited a discriminative ability in diagnosing DTC with a specificity of 100% for TERTp and BRAF, and of 94% for RAS, albeit with low sensitivity. TERTp and BRAF mutations were associated with aggressive clinicopathological features and tumor progression in PTCs (p < 0.001). The obtained good cyto-histological agreement suggests that molecular analysis via US-FNAC may anticipate the genetic profile and the behavior of thyroid tumors, confirming malignancy and contributing to referring patients to surgery.

BackgroundNewborns with one-or-more adverse birth outcomes (ABOs) are at greater risk of mortality or long-term morbidity with health impacts into adulthood. Hence, identifying ABO-associated factors is crucial for devising relevant interventions. For this study, ABOs were defined as prematurity (PTB) for gestational age 4 kg, asphyxia for a 5-minute Apgar score MethodsA hospital-based unmatched case‒control study was conducted among newborns from randomly selected mothers. Newborns with one-or-more ABO were the cases (ABO group), while healthy newborns were the controls (no-ABO group). Data were collected by a face-to-face interview and abstracted from antenatal care (ANC) pregnancy cards and medical records. Multivariable logistic regression analysis was performed to identify ABO-associated factors considering a level of significance of α = 0.05.ResultsA total of 519 newborns (176 with ABO and 343 no-ABO) were enrolled. The mean gestational age and birthweight of cases and controls were 36 (SD = 3.7) weeks with 2659 (SD = 881.44) g and 39.6 (SD = 1.0) weeks with 3256 (SD = 345.83) g, respectively. In the multivariable analysis, twin pregnancy [aOR 4.92, 95% CI 2.25-10.74], prolonged rupture of membranes [aOR 3.43, 95% CI 1.69-6.95], and meconium- fluid [aOR 1.59, 95% CI 0.97-2.62] were significantly associated with ABOs. Eight or more ANC contacts were found to be protective [aOR 0.33, 95% CI 0.18-0.60, pConclusionModifiable factors were associated with ABOs in this study and should be considered in cost-effective interventions. The provision of high-quality ANC should be a priority. Twin pregnancies and intrapartum factors such as prolonged rupture of membranes and meconium-stained amniotic fluid are red flags for ABOs that should receive prompt intervention and follow-up.

Objective: This study aimed to assess whether atrial fibrillation (AF) occurrence or its corresponding daily mean burden (in minutes/day) during the mid to late blanking period after pulmonary vein isolation (PVI), predicts AF recurrence. Methods: Analysis of consecutive first PVI ablation patients undergoing prolonged electrocardiogram (ECG) monitoring during the second and third months after PVI. The clinical variables, total AF burden, and their relationship with time to recurrence were studied. Results: 477 patients with a mean age of 56.9 (SD = 12.3) years (63.7 % male; 71.7 % paroxysmal AF), from which 317 (66.5 %) had an external event recorder between 30 and 90 days after ablation. Median follow-up of 16.0 (P 25:12.0: P 75:33.0) months, 177 (37 %) patients had an AF recurrence, with 106 (22.2 %) having the first episode after 12 months of follow-up. In the group of patients with an event recorder, 80 (25.2 %) had AF documented during the blanking period. Multivariable analysis showed that AF during the blanking period was associated with a 4-fold higher risk of recurrence (HR: 3.98; 95 %CI: 2.95–5.37), and, compared to patients in sinus rhythm, those with an AF burden ≥ 23 min/day had an approximately 7-fold higher risk of recurrence (HR estimate: 6.79; 95 %CI: 4.56–10.10). Conclusions: The probability of experiencing AF recurrence can be predicted by atrial tachyarrhythmia episodes during the second and third months after PVI. Atrial arrhythmias burden > 23 min/day has a high predictive ability for recurrence.

The optimal method for human milk (HM) fortification has not yet been determined. This study assessed whether fortification relying on measured HM macronutrient content (Miris AB analyzer, Upsala, Sweden) composition is superior to fortification based on assumed HM macronutrient content, to optimize the nutrition support, growth, and body composition in infants born at

Newborn mortality and adverse birth outcomes (ABOs) in Sao Tome & Príncipe (STP) are overwhelmingly high, and access to quality-antenatal care (ANC) is one of the strategies to tackle it. This study aimed to fill the gaps in ANC screenings with a focus on how to improve neonatal outcomes. We conducted a retrospective hospital-based study in which ANC pregnancy cards were reviewed. Screenings were described and compared according to the total number of ANC contacts: 1-3 (inadequate), 4-7 (adequate), and ≥8 (complete). The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Statistical significance was considered at a p-value ≤0.05. A total of 511 ANC pregnancy cards were reviewed. Mothers' mean age was 26.6 (SD = 7.1), 51.7% had a first trimester early booking, 14.9% (76) had 1-3 ANC contacts, 46.4% (237) had 4-7 and 38.7% (198) ≥8. Screening absence was found in 24%-41%, lack of money was registered in 36%. Pregnant women had no screening performed for HIV in 4.5%, syphilis in 8.8%, HBV 39.3%, malaria 25.8%, hemoglobin 24.5%, blood glucose 45.4%, urine 29.7%, stool exams 27.8% and 41.1% had no ultrasound. Screening completion for blood group, HIV, malaria, urine, hemoglobin, and coproparasitological exam were found to have a statistically significant difference (p

Background. Intestinal parasitic infections (IPIs) are a public health problem in developing countries such as Sao Tome and Principe (STP) although the pregnancy burden of IPIs is unknown in this endemic country. Thus, the aim of this study was to determine the prevalence of IPIs, prescribed anthelmintics, and associated factors among pregnant women admitted to Hospital Dr. Ayres de Menezes (HAM). Methods. A hospital-based cross-sectional study was conducted among pregnant women admitted to the HAM who had undergone antenatal copro-parasitological screening. Data were abstracted from antenatal care (ANC) cards regarding parasitological results and anthelmintic prescriptions. A structured questionnaire face-to-face interview was also applied. Pregnant women with an IPI (210) were compared to noninfected women (151). Data analysis was performed using SPSS version 25.0. Odds ratios (ORs) with 95% confidence intervals (CIs) for factors associated with IPIs were estimated using multiple logistic regression models. A p value

Aims: The aim of the study is to investigate the association between the degree of ischemia due to coronary microvascular dysfunction (CMD) and the left ventricular (LV) tissue characteristics, systolic performance, and clinical manifestations in hypertrophic cardiomyopathy (HCM).Methods and Results: This prospective study enrolled 75 patients with HCM without obstructive epicardial coronary artery disease. Each patient underwent cardiovascular magnetic resonance (CMR) including parametric mapping, perfusion imaging during regadenoson-induced hyperemia, late gadolinium enhancement (LGE) and three-dimensional longitudinal, circumferential, and radial strains analysis. Electrocardiogram, 24-h Holter recording, and cardiopulmonary exercise testing (CPET) were performed to assess arrhythmias and functional capacity. In total, 47 (63%) patients were men with the mean age of 54.6 (14.8) years, 51 (68%) patients had non-obstructive HCM, maximum wall thickness (MWT) was 20.2 (4.6) mm, LV ejection fraction (LVEF) was 71.6 (8.3%), and ischemic burden was 22.5 (16.9%) of LV. Greater MWT was associated with the severity of ischemia (β-estimate:1.353, 95% CI:0.182; 2.523, p = 0.024). Ischemic burden was strongly associated with higher values of native T1 (β-estimate:9.018, 95% CI:4.721; 13.315, p < 0.001). The association between ischemia and LGE was significant in following subgroup analyses: MWT 15–20 mm (β-estimate:1.941, 95% CI:0.738; 3.143, p = 0.002), non-obstructive HCM (β-estimate:1.471, 95% CI:0.258; 2.683, p = 0.019), women (β-estimate:1.957, 95% CI:0.423; 3.492, p = 0.015) and age 15% (AUC 0.766, sensitivity 0.724, specificity 0.659). Ischemia was also associated with atrial fibrillation or flutter (AF/AFL) (OR-estimate:1.481, 95% CI:1.020; 2.152, p = 0.039), but no association was seen for non-sustained ventricular tachycardia. Ischemia was associated with shorter time to anaerobic threshold (β-estimate: −0.442, 95% CI: −0.860; −0.023, p = 0.039).Conclusion: In HCM, ischemia associates with morphological markers of severity of disease, fibrosis, arrhythmia, and functional capacity.

Introduction: Increased life expectancy leads to older and frailer surgical patients. Co-management between medical and surgical specialities has proven favourable in complex situations. Selection of patients for co-management is full of difficulties. The aim of this study was to develop a clinical decision support tool to select surgical patients for co-management. Material and Methods: Clinical data was collected from patient electronic health records with an ICD-9 code for colorectal surgery from January 2012 to December 2015 at a hospital in Lisbon. The outcome variable consists in co-management signalling. A dataset from 344 patients was used to develop the prediction model and a second data set from 168 patients was used for external validation. Results: Using logistic regression modelling the authors built a five variable (age, burden of comorbidities, ASA-PS status, surgical risk and recovery time) predictive referral model for co-management. This model has an area under the curve (AUC) of 0.86 (95% CI: 0.81 - 0.90), a predictive Brier score of 0.11, a sensitivity of 0.80, a specificity of 0.82 and an accuracy of 81.3%. Discussion: Early referral of high-risk patients may be valuable to guide the decision on the best level of post-operative clinical care. We developed a simple bedside decision tool with a good discriminatory and predictive performance in order to select patients for comanagement. Conclusion: A simple bed-side clinical decision support tool of patients for co-management is viable, leading to potential improvement in early recognition and management of postoperative complications and reducing the ‘failure to rescue’. Generalizability to other clinical settings requires adequate customization and validation.

ABSTRACT: Background: Despite all efforts, the demand for organs increases. New and better strategies are still needed, critical in a crisis like pandemics. Methodology: A mathematical approach that integrates need, Opportunity, and Accessibility to kidney transplantation, was created. NOA method, corresponds to the lateral surface area of a trigonal pyramid with the need, Opportunity, and Accessibility as axis, resulting in an intuitional chart output (NOA chart) and a percentage score (NOA score). Higher NOA scores are associated with larger NOA chart areas. Method Application: We found some natural variability among the European Member States regarding Need, Opportunity, and Accessibility to kidney transplantation, concomitant with NOA scores. In 2019, in the European Union, 129 patients pmp on the waiting list for a kidney transplant were registered, 47 kidneys pmp were procured, and 36 kidneys pmp were transplanted, corresponding to 25% of kidney transplantation's response capacity. Conclusion: Transplantation is frequently the better treatment for end-stage kidney failure. NOA method may be, in the future, an indicator for evaluating the overall transplantation performance regarding the need for it and a tool for policy definition. With NOA method we seek to contribute for: • A transplantation overall performance normalizing score; • Transplantation response capacity evaluation.

Abstract Background Educational outreach visits are meant to improve the practice of health professionals by promoting face-to-face visits to deliver educational contents. They have been shown to change prescription behavior, but long-term effects are still uncertain. This trial aimed to determine if they improve family physician prescribing compared with passive guideline dissemination. Methods Parallel, open, superiority, and cluster-randomized trial. National Health Service primary care practices (clusters) were recruited in the Lisbon region—Portugal between March 2013 and January 2014. They could enter if they had at least four family physicians willing to participate and not planning to retire in the follow-up period. Three national guidelines were chosen for dissemination: acid secretion modifiers, non-steroidal anti-inflammatory drugs, and antiplatelets. Physicians in the intervention group received one 15 to 20 min educational outreach visit at their workplace for each guideline. Physicians in the control group had access to guidelines through the Directorate-General for Health’s website (passive dissemination). Primary outcomes were the proportion of COX-2 inhibitors prescribed within the NSAID class and the proportion of omeprazole within the PPI class at 18 months after the intervention. A cost-benefit analysis was performed. Practices were randomized by minimization. Data analyses were done at individual physician level using generalized mixed-effects regression models. Participants could not be blinded. Results Thirty-eight practices with 239 physicians were randomized (120 to intervention and 119 to control). Of 360 planned visits, 322 were delivered. No differences were found between physicians in the intervention and control groups regarding the proportion of omeprazole prescribed among PPIs 18 months after the visit (46.28 vs 47.15%, p = 0.971) or the proportion of COX-2 inhibitors among NSAIDs (12.07 vs 13.08%, p = 0.085). All secondary outcome comparisons showed no effect. There was no difference in cumulative drug costs at 18 months (3223.50€/1000 patients in the intervention group and 3143.92€/1000 patients in the control group, p = 0.848). Conclusions Educational outreach visits were unsuccessful in improving compliance with guideline recommendations among Portuguese family physicians. No effects were observed at 1, 6, and 18 months after the intervention, and there were no associated cost savings. Trial registration ClinicalTrials.gov NCT01984034. Registered 7 November 2013.

Introduction and Aims: Selecting patients for heart transplantation is challenging. We aimed to identify the most important risk predictors in heart failure and an approach to optimize the selection of candidates for heart transplantation. Methods: Ambulatory patients followed in our center with symptomatic heart failure and left ventricular ejection fraction ≤40% prospectively underwent a comprehensive baseline assessment including clinical, laboratory, electrocardiographic, echocardiographic, and cardiopulmonary exercise testing parameters. All patients were followed for 60 months. The combined endpoint was cardiac death, urgent heart transplantation or need for mechanical circulatory support, up to 36 months. Results: In the 263 enrolled patients (75% male, age 54±12 years), 54 events occurred. The independent predictors of adverse outcome were ventilatory efficiency (VE/VCO2) slope (HR 1.14, 95% CI 1.11-1.18), creatinine level (HR 2.23, 95% CI 1.14-4.36), and left ventricular ejection fraction (HR 0.96, 95% CI 0.93-0.99). VE/VCO2 slope was the most accurate risk predictor at any follow-up time analyzed (up to 60 months). The threshold of 39.0 yielded high specificity (97%), discriminated a worse or better prognosis than that reported for post-heart transplantation, and outperformed peak oxygen consumption thresholds of 10.0 or 12.0 ml/kg/min. For low-risk patients (VE/VCO2 slope

Abstract Background Obstructive sleep apnea (OSA) is associated with increased cardiovascular risk. This study aim to assess differences in changes in arterial stiffness of two groups of patients, defined as having daytime sleepiness or not, after continuous positive airway pressure (CPAP) treatment. Methods A selected cohort of consecutive male patients, under 65 years old, with moderate to severe OSA and without great number of comorbidities was studied. The diagnosis was confirmed by home respiratory poligraphy. Sleepiness was considered with an Epworth Sleepiness Scale (ESS) > 10. An ambulatory blood pressure (BP) monitoring and carotid-femoral pulse wave velocity (cf-PWV) measurements were performed, before and after four months under CPAP. Compliant patients, sleepy and non-sleepy, were compared using linear mixed effects regression models. A further stratified analysis was performed with non-sleepy patients. Results Thirty-four patients were recruited, with mean age 55.2 (7.9) years, 38.2% were sleepy, 79.4% with hypertension, 61.8% with metabolic syndrome and 82.4% with dyslipidaemia. In univariable analysis, cf-PWV was strongly related to systolic BP parameters and age, but also to antihypertensive drugs (p = 0.030), metabolic syndrome (p = 0.025) and daytime sleepiness (p = 0.004). Sleepy patients had a more severe OSA, with AHI 44.8 (19.0) vs 29.7 (15.7) events/h (p = 0.018), but sleep study parameters were not associated with cf-PWV values. On multivariable regression, a significant interaction between time (CPAP) and sleepiness (p = 0.033) was found. There was a weak evidence of a cf-PWV reduction after CPAP treatment (p = 0.086), but the effects of treatment differed significantly between groups, with no changes in non-sleepy patients, while in sleepy patients a significant decrease was observed (p = 0.012). Evaluating non-sleepy patients group under CPAP therapy, results showed that both higher pulse pressure (p = 0.001) and lower LDL-cholesterol levels (p = 0.015) at baseline were associated to higher cf-PWV changes. Conclusions Patients with daytime sleepiness had a more severe OSA and presented a greater arterial stiffness improvement after CPAP therapy, independently from age and BP. Besides sleepiness, cf-PWV reduction after CPAP therapy was mainly associated to CV risk factors, and less to sleep study parameters. Trial registration Clinicaltrials.gov NCT02273089 23.10.2014 retrospectively registered.

Introduction: Cardiac resynchronization therapy (CRT) has modified the prognosis of chronic heart failure (HF) with left ventricular systolic dysfunction. However, 30% of patients do not have a favorable response. The big question is how to determine predictors of response. Aims: To identify baseline characteristics that might influence echocardiographic response to CRT. Methods and Results: We performed a prospective single-center hospital-based cohort study of consecutive HF patients selected to CRT (NYHA class II-IV, left ventricular ejection fraction (LVEF)

Abstract Introduction The purpose of this study was to measure and to compare macular choroidal thickness (CT) between patients with mild Alzheimer's disease (AD), patients without AD, and elderly patients. Methods CT was measured manually in 13 locations at 500‐μm intervals of a horizontal and a vertical section from the fovea. Linear regression models were used to analyze the data. Results Fifty patients with a diagnosis of mild AD (73.1 years), 152 patients without AD (71.03 years), and 50 elderly without AD (82.14 years) were included. In the AD patients, CT was significantly thinner in all 13 locations (P

Background: Sleep Disorders (SlD) are frequently undervalued complaints in childhood. Several factors influence sleep, particularly socio-cultural environment and medical conditions such as breathing disorders. Poor sleep hygiene has physical, educational and social consequences. In Portugal, there are few published studies about children׳s sleep habits and rarely based on validated questionnaires. Aim: To study the prevalence of SlD and associated factors, in an outpatient pediatric population of a Primary Health Care Center (PHCC). Methods: Cross-sectional study of children admitted to a PHCC on a suburban area of Lisbon. Children Sleep Habits Questionnaire, validated for the Portuguese population (CSHQ-PT) for the screening of SlD (cut-off=44), was applied to parents, as well as a demographic inquiry. Body mass index z-score was evaluated. Children scoring 44 or above were sent to Pediatric Sleep Disorders consultation (PSDC). Parametric and non-parametric tests were used whenever appropriate. Results: From 128 children, 57.8% were male; the median age was 6.0 years (P25=5.0; P75=8.0). The median of cohabitants per family was 4.0 (P25=3.0; P75=5.0); 21.1% lived in a single-parent family. From CSHQ-PT, 59.4% (76) scored above the cut-off. Data showed that children from a single-parent family have more SlD (p=0.048), particularly parasomnia (p=0.019). Children with sleep disordered breathing (SDB) suffer more daytime sleepiness (p=0.034). From 63 children sent to PSDC, 33 attended. Regarding these children, a difference was found between BMI z-scores of those with and without SDB (p=0.06). Conclusion: Family structure plays a non-negligible role in children’s sleep habits. Daily performance of children with SDB may become compromised.

Introdução: A dor é uma experiência frequente nos doentes com cancro, especialmente naqueles em fase final de vida. Com este estudo, pretendemos estudar a intensidade de dor nos doentes com cancro avançado, referenciados aos cuidados paliativos, analisar os factores associados à ocorrência de dor moderada ou intensa e avaliar a sua relação com o tempo até à morte destes doentes. Material e Métodos: Estudo prospectivo observacional que incluiu consecutivamente todos os doentes referenciados aos cuidados paliativos com tumores sólidos metastizados e sem tratamento oncológico específico. Foi considerada a intensidade de dor da escala de Edmonton, de acordo com a graduação zero a 10, onde 0 = ausência de dor e 10 = máxima dor possível. Resultados: Entre outubro de 2012 e junho de 2015, foram incluídos 301 doentes, com idade mediana de 69 anos (37 - 94), 57% homens e 64,8% dos doentes com performance status 3/4. Aproximadamente 42% dos doentes apresentaram dor ≥ 4 e cerca de 74,4% estavam medicados com analgesia opióide. A intensidade de dor esteve associada ao performance status dos doentes, de acordo com a análise multivariável (OR: 1,7; IC 95%: 1,0 - 2,7; p = 0,045). A mediana do tempo de sobrevivência foi de 37 dias (IC 95%: 28 - 46), tendo os doentes com dor moderada ou intensa (intensidade de dor ≥ 4) uma mediana de sobrevivência de 29 dias (IC 95%: 21 - 37), comparada com os 49 dias (IC 95%: 35 - 63) para os doentes sem dor ou dor ligeira (p = 0,022). Discussão: O performance status, para além de ter estado associado a uma maior intensidade de dor, esteve associado a um menor tempo até à morte dos doentes com cancro avançado referenciados aos cuidados paliativos. Também o internamento, a presença de metastização intra-abdominal e a analgesia opióide estiveram associados de forma negativa ao tempo até à morte destes doentes. Conclusão: A dor oncológica continua a ser um problema clinicamente relevante nos doentes com cancro avançado.

Introduction: There are several risk scores for stratification of patients with ST-segment elevation myocardial infarction (STEMI), the most widely used of which are the TIMI and GRACE scores. However, these are complex and require several variables. The aim of this study was to obtain a reduced model with fewer variables and similar predictive and discriminative ability. Methods: We studied 607 patients (age 62 years, SD=13; 76% male) who were admitted with STEMI and underwent successful primary angioplasty. Our endpoints were all-cause in-hospital and 30-day mortality. Considering all variables from the TIMI and GRACE risk scores, multivariate logistic regression models were fitted to the data to identify the variables that best predicted death. Results: Compared to the TIMI score, the GRACE score had better predictive and discriminative performance for in-hospital mortality, with similar results for 30-day mortality. After data modeling, the variables with highest predictive ability were age, serum creatinine, heart failure and the occurrence of cardiac arrest. The new predictive model was compared with the GRACE risk score, after internal validation using 10-fold cross validation. A similar discriminative performance was obtained and some improvement was achieved in estimates of probabilities of death (increased for patients who died and decreased for those who did not). Conclusion: It is possible to simplify risk stratification scores for STEMI and primary angioplasty using only four variables (age, serum creatinine, heart failure and cardiac arrest). This simplified model maintained a good predictive and discriminative performance for short-term mortality. Resumo: Introdução: Existem vários scores para estratificação de risco em doentes com enfarte agudo miocárdico com elevação segmento ST (EAMCEST), sendo os mais utilizados o TIMI e o GRACE. Contudo, são complexos e necessitam de várias variáveis para o seu cálculo. Este estudo teve como objetivo encontrar um modelo de predição de risco, com menos variáveis e idêntica capacidade preditiva/discriminativa. Métodos: Estudaram-se 607 doentes (62 anos, SD=13; 76% sexo masculino), admitidos por EAMCEST e submetidos a angioplastia primária com sucesso. Consideraram-se como outcomes, a mortalidade intra-hospitalar e aos 30 dias de seguimento. Para identificar quais das variáveis dos referidos scores se revelaram mais influentes na previsão da mortalidade, foram efetuadas análises de regressão logística. Resultados: Dos dois scores clássicos, o GRACE foi o que apresentou melhor capacidade preditiva/discriminativa para a mortalidade intra-hospitalar, com resultados semelhantes para a mortalidade aos 30 dias. Na construção do modelo reduzido, as variáveis selecionadas foram a idade, a creatinina, a insuficiência cardíaca e a paragem cardíaca. As estimativas das probabilidades de morte intra-hospitalar, obtidas através de validação cruzada, foram comparadas com as do modelo original do score GRACE. As capacidades discriminativas foram idênticas tendo ainda sido obtida alguma melhoria nas estimativas das probabilidades de morte (aumento/diminuição para os doentes que morreram/não morreram). Conclusões: É possível uma simplificação dos scores de estratificação de risco para EAMCEST e angioplastia primária com apenas as variáveis idade, creatinina, insuficiência cardíaca e paragem cardíaca. O modelo simplificado manteve um bom desempenho preditivo/discriminativo para a mortalidade a curto-prazo. Keywords: Risk scores, Acute coronary syndromes, Prognosis, Palavras-chave: Scores de risco, Síndromas coronárias agudas, Prognóstico

Resumo: Introdução: O aumento da aurícula esquerda (AE) é um marcador de mortalidade na população geral. Os doentes com miocardiopatia dilatada (MCD) têm um amplo espetro de tamanhos de AE, mas a importância clínica desta observação tem sido pouco estudada. Objectivo: Avaliar a importância prognóstica a longo prazo do volume da AE (VAE) em doentes com MCD. Métodos: Estudo prospetivo de doentes admitidos durante o ano de 2004 com o diagnóstico de MCD, em ritmo sinusal. Foi realizado estudo ecocardiográfico completo em repouso e após stress farmacológico. O endpoint composto considerou a assistência ventricular mecânica (AVM), a transplantação cardíaca ou a morte. Resultados: Foram incluídos 35 doentes (68,6% sexo masculino, idade média 52,0), 82,9% etiologia não isquémica. Fração ejeção em repouso 31,1 ± 9,4%.Durante o seguimento, oito doentes morreram, um foi colocado em AVM e um foi transplantado. A análise de Cox univariável revelou potenciais marcadores ecocardiográficos de prognóstico na amostra tais como a dimensão da AE em modo M (HR-1,12; IC: 0,99-1,26; p = 0,067); VAE (HR-1,02; IC: 1,00-1,04; p = 0,046); VAE ajustado à superfície corporal (HR-1,03; IC: 1,00-1,07; p = 0,049); E/A (HR-0,99; IC: 0,99-1,81; p = 0,060); E/A > 2 (HR-7,00; IC:1,48-32,43; p = 0,014) e E/E’ mitral (HR-1,04; IC: 1,00-1,09; p = 0,074). Na análise multivariável a única variável que permaneceu no modelo foi o VAE com o ponto de corte de 63 ml (HR-7,7, IC: 0,97-60,61, p = 0,05). Conclusão: Nesta amostra, o VAE foi o único parâmetro ecocardiográfico determinante de AVM, transplantação cardíaca ou morte. Os parâmetros ecocardiográficos habitualmente utilizados para estratificação de risco, tais como a fração ejeção do ventrículo esquerdo, a dimensão do ventrículo esquerdo e a reserva contrátil não tiveram valor prognóstico na nossa amostra. Abstract: Background: Increased left atrial (LA) size is a prognostic marker of mortality in the general population. LA size varies considerably in patients with dilated cardiomyopathy (DCM), but its clinical significance has not been widely studied. Objective: To evaluate the long-term prognostic value of LA volume (LAV) in patients with DCM. Methods: We prospectively studied patients admitted from January to December 2004 with a diagnosis of DCM, in sinus rhythm. Complete echocardiographic study at rest and after pharmacological stress was performed in all patients.The composite endpoint of mechanical ventricular assistance (MVA), heart transplantation or death during follow-up was assessed by univariate and multivariate analysis using a Cox regression model. Results: The study population consisted of 35 patients (68.6% male, mean age 52.0) with DCM, 82.9% of non-ischemic etiology. Ejection fraction (EF) at rest was 31.1±9.4%.During follow-up, eight patients died, one was placed on MVA and one underwent transplantation. Univariate Cox analysis showed various potential echocardiographic markers of prognosis in our population, including LA size in M-mode (HR 1.12, CI: 0.99-1.26, p=0.067), LAV (HR 1.03, CI: 1.00-1.07, p=0.046), LAV adjusted for body surface area (HR 1.03, CI: 0.99-1.26, p=0.049), E/A ratio (HR 0.99; CI: 0.99-1.81; p=0.060); E/A >2 (HR 7.00, CI: 1.48-32.43, p=0.014) and mitral E/E’ ratio (HR 1.04, CI: 1.00-1.09, p=0.074).The only variable that remained in the multivariate model was LAV, with a cut-off value of 63 ml (HR 7.7, CI: 0.97-60.61, p=0.05). Conclusions: LAV was the only echocardiographic determinant of MVA, heart transplantation or death in our population with DCM. The echocardiographic parameters commonly used for risk stratification such as EF, left ventricular end-diastolic diameter and contractile reserve did not show prognostic significance in our study. Palavras-chave: Volume aurícula esquerda, Cardiomiopatia dilatada, Valor prognóstico ecocardiográfico, Keywords: Left atrial volume, Dilated cardiomyopathy, Echocardiographic prognostic value

Introdução: A prevalência de alergia a fármacos na população geral não se encontra devidamente caraterizada, existindo poucos estudos publicados que tenham abordado esta situação em crianças com idades inferior a seis anos de idade. Este estudo tem como objetivo principal estimar a prevalência de alergia a medicamentos reportada pelos pais de crianças de infantários de Lisboa e do Porto. Material e Métodos: No âmbito da Fase II do projeto “ENVIRH – Ambiente e Saúde em Creches e Infantários” foi aplicado um questionário sobre alergia a medicamentos aos pais das crianças, recrutadas por amostragem aleatória estratificada dos infantários. Resultados: Foram analisados 1 169 questionários, 52,5% de rapazes. A idade média foi de 3,5 ± 1,5 anos. A prevalência de alergia a medicamentos reportada foi de 4,1% (IC 95%: 3,0 - 5,2%). Os fármacos mais referidos foram os antibióticos (em 27 reações) e os AINEs (em seis reações). Na análise multivariável, a alergia a medicamentos reportada associou-se diretamente com a idade da criança (OR 1,19; IC 95% 1,01 - 1,41) e com a referência a alergia alimentar (OR 3,19; IC95% 1,41 - 7,19) e inversamente com o nível de escolaridade dos pais (OR 0,25; IC95% 0,10 - 0,59). Discussão: Apesar das limitações do estudo, os resultados encontram-se de acordo com o reportado por outros autores e sugerem que a prevalência reportada de alergia a medicamentos seja elevada no grupo etário estudado. Conclusão: Torna-se necessário que situações de alergia a medicamentos reportadas pelos pais sejam devidamente estudadas, no sentido de evitar evicções desnecessárias que possam condicionar opções terapêuticas em futuras situações de doença. Palavras-chave: Creches; Criança; Hipersensibilidade a Medicamentos; Prevalência; Portugal.