Journal Cover Acta Médica Portuguesa
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  This is an Open Access Journal Open Access journal
   ISSN (Print) 0870-399X - ISSN (Online) 1646-0758
   Published by Ordem dos Médicos Homepage  [1 journal]
  • Diabetes in Coronary Disease: The Risk of Non-Diagnosis

    • Authors: João Filipe Raposo
      Pages: 429 - 430
      Abstract: N/A.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Health Governance and Proximity Management: The Need for Autonomy in
           Management in Primary Health Care Systems

    • Authors: João Firmino-Machado, Inês Magalhães, João Rodrigues, Victor Ramos, Sofia Baptista, Bernardo Vilas-Boas
      Pages: 431 - 433
      Abstract: N/A.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Diabetes Screening in Patients with Macrovascular Coronary Disease: Are
           the New European Guidelines a Step Backwards'

    • Authors: Andreia Ribeiro, Sérgio Bravo Baptista, Mariana Faustino, Paulo Alves, Pedro Farto e Abreu, Victor Machado Gil, Carlos Morais
      Pages: 434 - 442
      Abstract: Background: The new European guidelines on diabetes mellitus and cardiovascular diseases propose that the FINnish Diabetes RIsk SCore should be used to evaluate the risk of diabetes mellitus and that diabetes mellitus screening in coronary artery disease patients should be based on fasting glucose and HbA1c. The 2 hour oral glucose tolerance test, recommended for all pts in the previous guidelines, is now only recommended for ‘inconclusive’ cases. We aimed to evaluate this new strategy.
      Material and Methods: Fasting glucose, HbA1c and glucose tolerance test (75 g, 2h) were prospectively evaluated in a consecutive group of pts with coronary artery disease. ADA criteria (both glucose tolerance test and HbA1c) were used to define diabetes mellitus and pre-diabetes mellitus. Diabetes mellitus risk was evaluated according to the FINnish Diabetes RIsk SCore.
      Results: A total of 135 patients were included (mean age 62.3 +/- 13.1 years, 99 males). Glucose tolerance test and HbA1c together diagnosed 18 (13.3%) new cases of diabetes mellitus and 77 (57.0%) patients with pre-diabetes mellitus. Fasting glucose + HbA1c (guidelines strategy) identified 12/18 patients with diabetes mellitus (Sens 66.7%; negative predictive value 95.1%; Kappa 0.78; p < 0.0001) and 83/95 patients with glucose anomalies (pre- diabetes mellitus + diabetes mellitus) (Sens 87.4%; negative predictive value 76.9%). Performing glucose tolerance test in the 29 patients with an elevated FINnish Diabetes RIsk SCore would allow identifying 15/18 patients with diabetes mellitus (Sens 83.3%; negative predictive value 97.5%; Kappa 0.85; p < 0.0001) and 86/95 patients with glucose anomalies (Sens 90.5%; negative predictive value 81.6%).
      Discussion: Although this strategy improved the screening accuracy, one in each six patients with diabetes mellitus would still remain undiagnosed, as compared to measuring HbA1c and performing an glucose tolerance test in all patients.
      Conclusion: Using the FINnish Diabetes RIsk SCore to select candidates to additional glucose tolerance test improves the accuracy for identifying diabetic patients, as compared with fasting glucose + HbA1c alone. However, 1/6 patients diabetes mellitus is still left undiagnosed with this strategy proposed by the current guidelines.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Visceral Leishmaniasis in HIV-Infected Patients: The Challenge of Relapse
           and Treatment Failure

    • Authors: Patrícia Cipriano, Ana Cláudia Miranda, Isabel Antunes, Kamal Mansinho
      Pages: 443 - 448
      Abstract: Introduction: Visceral leishmaniasis is an endemic disseminated infection, considered to be the third most frequent opportunistic parasitic infection in Europe. It is especially prevalent in patients co-infected with human immunodeficiency virus, in whom it poses a great therapeutic challenge due to increased risk of relapse. The goal of this study is to characterize a population of co-infected patients, as well as the efficiency of the adopted treatment strategies.
      Material and Methods: Retrospective study with a sample composed of all patients with visceral leishmaniasis and human immunodeficiency virus admitted in an Infectious Diseases ward over a period of 10 years.
      Results: Of the 23 enrolled patients, two were female (8.7%). The mean TCD4+ cell count was 104.4 cells/uL (± 120.3cells/uL), only two patients had undetectable viral load (< 20 copies/mL) and 16 (69.6%) were not under antiretroviral therapy at the time of diagnosis. Treatment-wise, liposomal amphotericin B was used in 18 patients, meglumine antimoniate in four and miltefosine in one. Fourteen (60.9%) were adherent to secondary prophylaxis protocol. A relapse rate of 26.1% was observed (six patients).
      Discussion: Co-infection is responsible for higher treatment failure rates and more relapses. TCD4+ cell count is the main predictive factor of relapse, and strict adherence to chemoprophylaxis protocols unequivocally results in a reduction of relapse rate. Combined treatment strategies using liposomal amphotericin B and miltefosine yield fewer therapeutic failures than the classic approach.
      Conclusion: We therefore conclude that alternative, combined therapeutic protocols seem to be a viable solution for these patients.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • A Retrospective Analysis of the Real-Life Utilization of Ranibizumab in
           Patients with Wet Age-Related Macular Degeneration from Portugal

    • Authors: Rufino Silva, Carla Goncalves, Angela Meireles, Carla Teixeira, Paulo Rosa, Manuel Monteiro-Grillo, Joaquim Canelas, Angela Carneiro, Rita Flores
      Pages: 449 - 456
      Abstract: Introduction: Anti-vascular endothelial growth factor therapy has revolutionized the treatment of wet age-related macular degeneration; however, it is important to monitor actual use of ranibizumab and related treatment outcomes in routine practice.
      Material and Methods: This was a retrospective, observational study to monitor the 2-year outcomes following ranibizumab treatment for wet age-related macular degeneration in Portugal. Patients treated between January 2009 and December 2009 were retrospectively evaluated. All decisions were made by the treating physician in accordance with their usual routine clinical practice. The primary assessment was mean change in visual acuity score using Early Treatment Diabetic Retinopathy Study or Snellen equivalent.
      Results: A total of 128 patients with wet age-related macular degeneration were analyzed (mean age 79.4 years; mean visual acuity score 54.2 letters). Mean change in visual acuity score from baseline was –1.6 letters (n = 82) at year one and –5.1 letters (n = 72) at year two. The mean number of ranibizumab injections was 3.8 (year one) and 1.6 (year two). On average, patients attended 8.6 and 5.0 visits and optical coherence tomography was used in 75.0% of patients in year one and in 56.3% of patients in year two, respectively.
      Discussion: Despite a relatively high number of visits, including monitoring visits and use of optical coherence tomography - guided therapy, few injections were administered and visual acuity was not improved.
      Conclusion: These findings indicate that as-needed treatment resulted in under-dosing in a real-life setting in Portugal. Such limitations may also be related to increasing numbers of patients, resulting in clinic saturation.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Paediatric Invasive Pneumococcal Disease Before Universal Vaccination:
           1995 - 2015

    • Authors: Muriel Ferreira, Henrique Oliveira, Nuno Costa e Silva, Luís Januário, Fernanda Rodrigues
      Pages: 457 - 462
      Abstract: Introduction: Pneumococcal conjugate vaccine was introduced in the private market in Portugal in 2001, reaching over the years a moderately high coverage. In July 2015, it was included in the National Immunisation Program. The aim of this study was to characterize invasive pneumococcal disease in a pediatric hospital before universal use of the vaccine.
      Material and Methods: Retrospective analysis of medical records of all children with Streptococcus pneumoniae identified by culture and/or molecular biology (available since 2008), in products obtained from sterile sites, from January 1995 to June 2015. We evaluated demographic, clinical and microbiological data. Serotype results are available since 2004.
      Results: Over those 20 years, 112 invasive pneumococcal disease cases were identified, with a median age of 15 months (1 month - 15 years). The median number of cases /year was 4, the highest between 2001 - 2002 (8/year) and 2007 - 2012 (7 - 11/year). The identification occurred mostly in blood culture (72), cerebrospinal fluid (24), pleural fluid (11) an others (5). The most frequent diagnoses were pneumonia (38%), occult bacteraemia (34%) and meningitis (21%). Over the period under review, there was an increase of pneumonia and slight increase of OB, with meningitis cases remaining relatively unchanged.
      Discussion: In the last two decades, there was no reduction in the number of cases of invasive pneumococcal disease. There was an increase in isolates from pneumonia and occult bacteraemia that might be due to the introduction of molecular biological methods for Streptococcus pneumoniae detection. Vaccine serotypes were predominant.
      Conclusion: This retrospective analysis before universal vaccination will contribute to evaluate the impact of vaccination in the Portuguese pediatric population.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Functional, Sensorial, Mobility and Communication Difficulties in the
           Portuguese Oldest Old (80+)

    • Authors: Daniela Brandão, Óscar Ribeiro, Constança Paúl
      Pages: 463 - 471
      Abstract: Introduction: The ageing of populations is evident in most developed countries, and the oldest old group is one of the segments with the fastest growing. The aim of this paper is to examine sociodemographic and health related characteristics of the portuguese oldest old, using a census-based approach.
      Material and Methods: A descriptive study considering all residents aged 80 years and older at the time of the 2011 Census (n = 532 219) was conducted. Information on sociodemographic characteristics, sensory functions (seeing, hearing), functional status (walking/climbing stairs, bathing/dressing alone), cognition (memory/concentration), and communication (understanding others/being understood) as assessed by the Portuguese census official questionnaires were analyzed.
      Results: Findings revealed that most of the oldest old are women (64.5%), widowed (53.9%), illiterate (46.1%) and live in private households (88.8%). Walking/climbing stairs (57.1%), vision (39.1%) and hearing (35.1%) were the dimensions where the oldest old presented major constrains. In parallel, understanding others/being understood (25.9%) and memory/concentration (34.4%) were the dimensions with lower percentages of difficulties. Significant differences were found between octogenarians/nonagenarians and centenarians for vision, walk/climb stairs, and bathing/dressing alone, with centenarians presenting a higher percentage of difficulties.
      Discussion: Portuguese oldest old showed significant difficulties in activities of daily living, nevertheless cognitive and communication capacities seem to be commonly maintained. Taken together, these findings suggest the need for functional assistance, which can be ultimately managed by the older person him/herself.
      Conclusion: Based on the observed differences between centenarians and younger oldest old, specific interventions should be equated to better respond to their potentially distinctive needs.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Fine-needle Aspiration of Thyroid Nodules: Is it Worth Repeating'

    • Authors: Vera Fernandes, Tânia Pereira, Catarina Eloy
      Pages: 472 - 478
      Abstract: Introduction: The fine-needle aspiration has a significant role in assessing the malignancy risk of thyroid nodules. There is uncertainty regarding the value of repeat fine-needle aspiration in benign nodules. This study aims to evaluate the concordance of results in consecutive fine-needle aspiration and to study the relevance of repetition in benign results.
      Material and Methods: Retrospective study of the 4800 thyroid nodules fine-needle aspiration held in Instituto de Patologia e Imunologia Molecular da Universidade do Porto between January 1, 2014 and May 2, 2016. Of the initial sample, we selected the repeated fine-needle aspiration on the same nodule.
      Results: The first fine-needle aspiration result of the 309 nodules underwent revaluation was non-diagnostic in 103 (33.3%), benign in 120 (38.8%) and atypia/follicular lesion of undetermined significance in 86 (27.8%). The agreement between the first and second fine-needle aspiration was significantly higher in cases with an initial benign result (benign: 85.8%, non-diagnostic: 27.2% and atypia/ follicular lesion of undetermined significance: 17.4%, p < 0.005). The fine-needle aspiration repeating motifs in initially benign nodules (n = 78) were repetition suggestion in 58, nodule growth in 17 and suspicious ultrasonographic features in 3.
      Discussion: The fine-needle aspiration repetition in nodules with initial non-diagnostic and atypia/follicular lesion of undetermined significance result changed the initial diagnosis in a significant proportion of patients, modifying their therapeutic approach. The high concordance of results in initially benign nodules makes fine-needle aspiration repetition not cost-effective in most cases.
      Conclusion: The fine-needle aspiration should be repeated when the initial cytology result is non-diagnostic or atypia/follicular lesion of undetermined significance.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention
           Leads to the Best Outcomes'

    • Authors: Andreia Fonseca, Rita Silva, Inês Rato, Ana Raquel Neves, Carla Peixoto, Zita Ferraz, Inês Ramalho, Ana Carocha, Nisa Félix, Sandra Valdoleiros, Ana Galvão, Daniela Gonçalves, Joana Curado, Maria João Palma, Isabel Lobo Antunes, Nuno Clode, Luís Mendes Graça
      Pages: 479 - 484
      Abstract: Introduction: The best route of delivery for the term breech fetus is still controversial. We aim to compare maternal and neonatal outcomes between vaginal and cesarean term breech deliveries.
      Material and Methods: Multicentric retrospective cohort study of singleton term breech fetuses delivered vaginally or by elective cesarean section from January 2012 - October 2014. Primary outcomes were maternal and neonatal morbidity or mortality.
      Results: Sixty five breech fetuses delivered vaginally were compared to 1262 delivered by elective cesarean. Nulliparous women were more common in the elective cesarean group (69.3% vs 24.6%; p < 0.0001). Gestational age at birth was significantly lower in the vaginal delivery group (38 ± 1 weeks vs 39 ± 0.8 weeks; p = 0.0029) as was birth weight (2928 ± 48.4 g vs 3168 ± 11.3 g; p < 0.0001). Apgar scores below seven on the first and fifth minutes were more likely in the vaginal delivery group (1st minute: 18.5% vs 5.9%; p = 0.0006; OR 3.6 [1.9 - 7.0]; 5th minute: 3.1% vs 0.2%; p = 0.0133; OR 20.0 [2.8 - 144.4]), as was fetal trauma (3.1% vs 0.3%: p = 0.031; OR 9.9 [1.8-55.6]). Neither group had cases of fetal acidemia. Admission to the Neonatal Intensive Care Unit, maternal postpartum hemorrhage and the incidence of other obstetric complications were similar between groups.
      Discussion: Although vaginal breech delivery was associated with lower Apgar scores and higher incidence of fetal trauma, overall rates of such events were low. Admission to the neonatal intensive care unit and maternal outcomes were similar.
      Conclusion: Both delivery routes seem equally valid, neither posing high maternal or neonatal complications’ incidence.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • The Calcium/Phosphorus Homeostasis in Chronic Kidney Disease: From
           Clinical Epidemiology to Pathophysiology

    • Authors: Ana Pires, Luis Sobrinho, Hugo Gil Ferreira
      Pages: 485 - 492
      Abstract: Introduction: A simple data filtering process together with some basic concepts of control theory applied to electronically stored clinical data were used to identify some of the pathophysiological mechanisms underlying the perturbations of the calcium/phosphorus homeostasis in chronic kidney disease.
      Material and Methods: Retrospective data (a set per patient of serum single value concentrations of creatinine, calcium, phosphorus, parathormone, 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D) from 2507 patients with stable chronic kidney disease not on renal replacement therapy were studied. The variables were paired and subjected sequentially to a moving average and partioned into frequency classes. The plots were interpreted using the concept of a feedback loop comprising two branches of opposite sign and of set point of the loop. The set point for each pair of variables is displaced in the course of the disease and this displacement indicates which of the two factors involved (the serum concentrations of calcium or parathormone, for example) is primarily affected.
      Results: This analysis showed that in the course of the development of chronic kidney disease the relationships between the observed variables progressed following a monotonous, a biphasic or a triphasic pattern.
      Discussion: As chronic kidney disease progresses, calcium/phosphorus metabolism regulation evolves through different phases. Later, there is a progressive loss of the parathyroid gland sensitivity to the control by the serum concentrations of calcium and phosphorus. The sensitivity to the inhibitory action of 1,25-dihydroxyvitamin D decreases monotonously but never releases the gland.
      Conclusion: The clinical data analysis used permits to illustrate the underlying pathophysiological mechanisms.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Secondary Arterial Hypertension: Uncertainties in Diagnosis

    • Authors: Paulo Gomes Dinis, Maria Carmo Cachulo, Andreia Fernandes, Luis Paiva, Lino Gonçalves
      Pages: 493 - 496
      Abstract: Arterial hypertension is regarded today as a global public health problem, and the prevalence rate in Portugal is 26.9%. According to the etiology, is classified into primary or secondary arterial hypertension. In about 90% of cases it is not possible to establish a cause, so is called primary arterial hypertension. In the remaining 5 to 10%, it can be identified secondary causes, which are potentially treatable. For secondary arterial hypertension study to be cost-effective, it is essential to understand which patients investigate, and evaluate the best strategy to adopt. The main causes identified as responsible for secondary arterial hypertension are: kidney disease; endocrine and vascular diseases and obstructive sleep apnea. Among these some are consensual, and others more controversial in the literature. In this regard we present two cases of arterial hypertension, which are potentially secondary in etiology, but still focus of debate.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Klebsiella pneumoniae from K1 and Hypervirulent Clone ST23: First
           Documented Case in Portugal

    • Authors: Aida Pereira, Tiago Petrucci, Maria João Simões
      Pages: 496 - 499
      Abstract: The hypervirulent K1 serotype Klebsiella pneumoniae is responsible for a new invasive syndrome, typically associated to hepatic abscesses with extra-hepatic complications. Initially described in Taiwan, it has significantly spread to several Asian countries and more recently to Europe and North America, thus constituting an emerging and global problem. The authors describe a case report of a 64-years-old portuguese caucasian woman without any previous diseases or epidemiological risk factors such as trips or contact with Asian products or population, diagnosed with a pyogenic liver abscess with pleural effusion caused by this hyper-virulent strain. A successful clinical cure was achieved after the etiological identification and treatment with antimicrobial therapy combined with catheter drainage. This is the first identification of hypervirulent Klebsiella pneumonia ST 23 clone in Portugal in the context of an invasive syndrome.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Target Sign: Endoscopic Sign of the Colonic Perforation

    • Authors: Juliana Moura Costa, João Bruno Soares
      Pages: 500 - 500
      Abstract: N/A.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Fatal Hemoptysis

    • Authors: Cristina Gonçalves Costa, Céline Gama
      Pages: 501 - 501
      Abstract: N/A.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
  • Investigation of Genetic Aetiology in Neurodegenerative Ataxias:
           Recommendations from the Group of Neurogenetics of Centro Hospitalar São
           João, Portugal

    • Authors: Tiago Gomes, Joana Guimaraes, Miguel Leão, Em nome do Grupo de Neurogenética do Centro Hospitalar São João
      Pages: 502 - 512
      Abstract: In recent decades, a long and increasing list of monogenic neurodegenerative ataxias has been identified, allowing for better characterization of the pathophysiology, phenotype and prognosis of this heterogeneous group of disorders, while also revealing potential new therapeutic targets. However, the heterogeneity and complexity of the genotype-phenotype relationships and the high costs of molecular genetics often make it difficult for clinicians to decide on a molecular investigation based on an unbiased rational plan. Clinical history is essential to guide the diagnostic workup, but often the phenotype does not hold enough specificity to allow for predicting the genotype. The Group of Neurogenetics of the Centro Hospitalar São João, a multidisciplinary team of neurologists and geneticists with special interest in neurogenetic disorders, devised consensus recommendations for the investigation of the genetic aetiology of neurodegenerative ataxias in clinical practice, based on international consensus documents (currently containing potentially outdated information) and published scientific evidence on this topic. At the time these recommendations were written, there were around 10 well described autosomal recessive loci and more than 27 autosomal dominant loci for neurodegenerative ataxias. This document covers, in a pragmatic way, the rational process used for the genetic diagnosis of neurodegenerative ataxias, with specific recommendations for the various groups of these heterogeneous diseases, per the Portuguese reality.
      PubDate: 2017-06-30
      Issue No: Vol. 30, No. 6 (2017)
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