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Medication Reconciliation in an Emergency Department: a Process of Continuous Improvement
No full textObjetivos: estruturar o plano de melhoria para a reconciliação da medicação num serviço de urgência português.
Método: elaborou-se o projeto de melhoria com a metodologia Plan, Do, Act, Plan (PDSA), em um estudo observacional, descritivo, quantitativo. Na etapa Plan, participaram 282 pacientes admitidos em serviço de urgência, cujo familiar teve teleconsulta de Enfermagem; e 447 na etapa Study. Realizada a estruturação da teleconsulta com a técnica Identify, Situation, Background, Assessment e Recommendation (ISBAR); formação da equipe.
Resultados: na prática habitual dos enfermeiros, identificaram-se 4,6% (n=13) discrepâncias não intencionais entre a prescrição e a medicação em uso no domicílio. Observou-se o aumento para 9,4% (n=42) de discrepâncias após a estruturação da teleconsulta, que passou a incluir as questões sobre a medicação habitual. A interrupção, sobretudo de medicamentos que atuam no sistema nervoso central, dose/frequência incorreta, foi a discrepância mais frequente, posteriormente corrigida.
Conclusão: o estudo contribuiu para identificar/corrigir as falhas na reconciliação de medicação, a fim de evidenciar a importância da participação da Enfermagem e da famíli
O Procedimento de Ross na Substituição da Válvula Aórtica: Perspetivas a Longo Prazo e Perspectivas Futuras
No full textFrom Childhood to Adulthood: A Case of Congenital Tracheal Stenosis.
No full textCongenital tracheal stenosis (CTS) is a rare and potentially life-threatening malformation, often associated with cardiovascular anomalies, such as pulmonary artery sling. We report a 20-year-old woman with a history of pulmonary artery sling surgically corrected in infancy, who presented with diffuse CTS. Early symptoms of dyspnea, wheezing, and episodes of airway obstruction prompted evaluation, and imaging with computerized tomography and flexible bronchoscopy confirmed complete tracheal rings with a lumen of 6-8 mm. Pulmonary function tests showed fixed airway obstruction and flattening of inspiratory and expiratory flow-volume curves. At 19 years, she remained symptomatic with exertional stridor but preserved exercise tolerance, and follow-up imaging demonstrated stable diffuse stenosis. Given relative clinical stability and diffuse involvement unsuitable for endoscopic intervention, conservative management with regular multidisciplinary follow-up and symptomatic therapy was pursued. This case highlights the diagnostic and therapeutic challenges of CTS in adulthood and emphasizes the importance of early recognition, functional assessment, and individualized multidisciplinary management. Further studies are needed to determine long-term outcomes and optimal surveillance strategies in adults with persistent diffuse tracheal stenosis
Atualização Sobre Psoríase Pustulosa Generalizada
No full textGeneralized pustular psoriasis (GPP) is a rare but severe inflammatory skin disease characterized by the eruption of widespread sterile pustules, often accompanied by systemic inflammation. Although GPP can coexist with plaque psoriasis, it is increasingly recognized as a distinct entity with unique clinicopathological, immunologic, and genetic features. The dysregulated IL-36 pathway, including mutations in the IL36RN gene, is implicated in GPP pathogenesis, providing a molecular basis for targeted therapies. Diagnosing GPP requires a comprehensive evaluation, including clinical presentation, potential triggers, patient history, histopathologic findings, and laboratory results. Disease severity must be assessed through both cutaneous symptoms and systemic involvement, as GPP flares can lead to life-threatening complications such as sepsis and multi-organ failure. Historically, GPP treatment primarily relied on therapies approved for plaque psoriasis, despite their limited specificity for this condition. Recent advances in understanding the molecular mechanisms of GPP, particularly the central role of interleukin-36 pathway, have led to the development of targeted therapies for this rare condition. Currently, spesolimab is the only therapy specifically approved for treating GPP flares in adolescents and adults, in both Europe and the United States of America. However, the management of GPP remains complex and challenging. This narrative review provides an overview of the epidemiology, pathophysiology, clinical features, comorbidities, and evolving therapeutic strategies for GPP.A psoríase pustulosa generalizada (PPG) é uma doença inflamatória da pele, rara embora potencialmente grave, caracterizada pelo aparecimento de pústulas estéreis generalizadas, frequentemente acompanhadas por inflamação sistémica. Embora possa coexistir com psoríase em placas, a PPG é cada vez mais reconhecida como uma entidade distinta, com características clinicopatológicas, imunológicas e genéticas únicas. A desregulação da via da interleucina-36, incluindo mutações no gene IL36RN, está implicada na patogénese da PPG, proporcionando uma base molecular para terapêutica dirigidas. O diagnóstico de PPG requer uma avaliação abrangente, incluindo as características clínicas, possíveis fatores desencadeantes, antece-dentes do doente, achados histopatológicos e resultados laboratoriais. A gravidade da doença deve ser avaliada através do atingimento cutâneo e do envolvimento sistémico, uma vez que as exacerbações da PPG podem levar a complicações com potencial risco de vida, incluindo sépsis e falência multiorgânica. Historicamente, o tratamento da PPG era baseado em terapêuticas aprovadas para a psoríase em placas, apesar da sua limitada espe-cificidade para esta condição. Os avanços recentes na compreensão dos mecanismos moleculares da PPG, particularmente o papel central da via de interleucina-36, levaram ao desenvolvimento de moléculas direcionadas para esta doença rara. Atualmente, o spesolimab é a única terapêutica espe-cificamente aprovada para o tratamento de exacerbações da PPG em adolescentes e adultos, tanto na Europa como nos Estados Unidos da América. No entanto, a gestão da PPG continua a ser complexa e desafiante. Esta revisão narrativa oferece uma visão geral da epidemiologia, fisiopatologia, características clínicas, comorbilidades e estratégias terapêuticas em evolução para a PPG
Marantic Endocarditis in Malignancy: A Case Report of a Challenging Diagnosis.
No full textMarantic endocarditis is a condition characterized by sterile vegetations in the heart valves, and is much rarer than infectious endocarditis. It's typically associated with conditions such as cancer or autoimmune diseases. We report the case of a patient with stage four lung cancer, presenting with fever after chemotherapy, and diagnosed with marantic endocarditis, after extensive testing to exclude an infectious agent. The patient's imaging techniques suggested infectious embolization to the liver and spleen, which supported the diagnostic hypothesis of infectious endocarditis, but the liver biopsy was positive for metastasis. Oncology was consulted for follow-up, and the patient was discharged on anticoagulation therapy, the standard treatment for marantic endocarditis. This case underscores the difficulty of diagnosing marantic endocarditis and the extensive testing required, considering its poor prognosis and the importance of treatment
A Reconciliação da Medicação nos Cuidados de Saúde Primários: Práticas, Conhecimentos e Atitudes na Região de Saúde de Lisboa e Vale do Tejo
No full textDespite the importance of medication reconciliation for the continuity of care, there is currently no information on the practices, knowledge, and attitudes of Portuguese family doctors on this subject. This study aimed to characterize the formal medication reconciliation procedures in the Lisbon and Tagus Valley Health Region, as well as the perception of family doctors in this region about what they know, how they think and how they practice medication reconciliation.A total of 89 primary healthcare units and 208 family doctors participated in the study (31% and 12% response rates, respectively). Only one in four units (n = 22/89) had a formal medication reconciliation procedure. Among the units with a formal procedure, there was variability in some parameters, although all procedures included physicians. More than 70% (n = 150; 72.1%) of family physicians reported having previous contact with the term 'medication reconciliation', and a half (n = 104; 50.0%) reported carrying out medication reconciliation in more than 75% of consultations after hospital discharge. No differences were identified regarding the frequency with which family physicians practice medication reconciliation after hospital discharge depending on age, gender, type of unit where they work, and volume of consultations. Most family physicians (n = 155; 74.5%) included the three steps recommended by the Directorate-General for Health at the time and resolved discrepancies without contacting the hospital physician (n = 168; 88.8%). Family physicians recognize the importance of medication reconciliation (more than 95% agree/completely agree), although the level of agreement regarding their responsibility for this practice is lower.The proportion of primary health care units with a formal medication reconciliation procedure is low. Family doctors in the Lisbon and Tagus Valley Region value medication reconciliation, although they do not include it in all consultations after hospital admission. Communication between levels of care and the standardization of processes are areas with potential for improvement to promote the safe and patient-centered use of medication.We conducted an observational, cross-sectional and descriptive study, using two observation units: primary health care units (study 1) and family doctors (study 2) in the Lisbon and Tagus Valley Health Region. Data was collected through two self-completed questionnaires, which were made available online.Introdução: Apesar da relevância da reconciliação da medicação para a continuidade dos cuidados, atualmente, não existe informação relativa às práticas, conhecimentos e atitudes dos médicos de família nacionais sobre este assunto. Este estudo teve como objetivos caracterizar os procedimentos formais de reconciliação da medicação em vigor na Região de Saúde de Lisboa e Vale do Tejo, bem como a perceção dos médicos de família desta região sobre o que sabem, como pensam e como praticam a reconciliação da medicação. Métodos: Foi conduzido um estudo observacional, transversal e descritivo, utilizando duas unidades de observação: unidades de cuidados de saúde primários (estudo 1) e médicos de família (estudo 2) da Região de Saúde de Lisboa e Vale do Tejo. A recolha de dados realizou-se através de dois questionários de autopreenchimento, disponibilizados online. Resultados: Participaram 89 unidades de cuidados de saúde primários e 208 médicos de família (taxas de resposta de 31% e 12%, respetivamente). Verificou-se que apenas uma em cada quatro unidades (n = 22/89) tinha um procedimento formal de reconciliação da medicação em vigor. Entre as unidades com procedimento formal, existe variabilidade em alguns parâmetros, ainda que todos incluam os médicos. Mais de 70% (n = 150; 72,1%) dos médicos referiram ter contacto prévio com o termo ‘reconciliação da medicação’, e metade (n = 104; 50,0%) referiu realizar reconciliação da medicação em mais de 75% das consultas após alta hospitalar. Não se identificaram diferenças relativamente à frequência com que os médicos praticam reconciliação da medicação após alta hospitalar em função da sua idade, sexo, tipo de unidade onde trabalham e volume de consultas. A maioria dos médicos (n = 155; 74,5%) inclui no processo os três passos preconizados pela Direção-Geral da Saúde à data, e resolve as discrepâncias sem contactar o médico hospitalar (n = 168; 88,8%). Os médicos reconhecem a importância da reconciliação da medicação (mais de 95% estão de acordo/totalmente de acordo), ainda que o nível de concordância quanto à sua responsabilização sobre esta prática seja inferior. Conclusão: A proporção de unidades de cuidados de saúde primários com procedimento formal de reconciliação da medicação é baixa. Apesar dos médicos de família da Região de Saúde de Lisboa e Vale do Tejo valorizarem a reconciliação da medicação, não a incluem em todas as consultas após internamento hospitalar. A comunicação entre níveis de cuidados e a padronização dos processos são áreas com potencial de melhoria, com vista ao objetivo de promover a segurança da utilização dos medicamentos, centrada no doente
Contraceção Oral Combinada e sua Associação ao Cancro da Mama: uma Revisão Sistemática
No full textO cancro da mama é a doença maligna mais frequentemente diagnosticada nas mulheres em todo o mundo, com incidência e mortalidade crescentes, pelo que o conhecimento dos seus fatores de risco é de grande importância para se poder investir em medidas de prevenção primária eficazes. O contracetivo oral combinado (COC) é o método contracetivo mais utilizado em mulheres em idade fértil, com utilização média de 5 anos. Esta revisão sistemática pretende avaliar se existe maior incidência de cancro da mama em mulheres em idade fértil com exposição a COC superior a 5 anos, comparativamente
a exposição inferior a 5 anos.Breast cancer is the most frequently diagnosed malignant disease in women worldwide, with increasing incidence and mortality, therefore the knowledge of its risk factors is of great importance to be able to invest in effective primary prevention measures. The combined oral contraceptive (COC) is the most widely used contraceptive method in women of childbearing age, with an average use of 5 years. This systematic review aims to assess whether there is a higher incidence of breast cancer in women of childbearing age with exposure to COC for more than 5 years, compared to less than 5 years of exposur
The Impact of Digital CBT-I on the Treatment of Insomnia Disorder, an Evidence Based Practice
No full textIntrodução: Em Portugal, a insónia tem uma prevalência estimada de 10%. O tratamento de primeira linha é a terapia cognitivo-comportamental dirigida à insónia (TCC-I), no entanto há escassez de terapeutas disponíveis. O objetivo desta revisão baseada na evidência foi averiguar a eficácia das TCC-I através de meios digitais (TCC-ID) em adultos.
Métodos: Foi realizada pesquisa de metanálises, metanálises em rede (MAR), revisões sistemáticas, ensaios clínicos randomizados (ECR) e normas de orientação clínica, publicados entre janeiro de 2018 e dezembro de 2022. Termos MeSH: “cognitive behavioural therapy”, “insomnia disorder”, “telemedicine” e “digital technology”. Fontes de dados: Cochrane
Library, DARE, NICE, Direção-Geral de Saúde, Google Scholar e PubMed.
Resultados: Foram obtidos 101 artigos e selecionados uma MAR e três ECR. A TCC-ID (Somryst®) apresenta uma probabilidade de 56% de ser o tratamento mais eficaz na insónia e uma probabilidade de 64% de ser o tratamento mais eficaz na sua remissão às 6 a 12 semanas. Em grávidas com insónia, a TCC-ID (Sleepio®) apresenta uma redução superior do score
Índice de Severidade da Insónia (ISI) comparativamente com as terapias convencionais (p = 0,08). As taxas de remissão de insónia aos seis meses pós-parto foram superiores no grupo da TCC-ID (p = 0,02). Verificou-se uma melhoria no score ISI às 4 semanas (p = 0,063) após TCC-ID (StudiCare Sleep-e®) e às 12 semanas a diferença tornou-se estatisticamente
significativa (p < 0,001). Tanto a TCC-I como TCC-ID apresentam impacto positivo na gravidade dos sintomas de insónia.
No grupo que recebeu TCC-ID (WeChat®), houve uma melhoria estatisticamente significativa do score Pittsburgh Sleep Quality Index (p < 0,001).
Discussão: A evidência demonstra não inferioridade entre TCC-ID e TCC-I convencional em adultos. A presente revisão apresenta limitações: amostra pouco heterogénea e inclusão de aplicações em língua estrangeira.
Conclusão: A TCC-ID pode ser recomendada como alternativa à TCC-I convencional (Strength of Recommendation Taxonomy A).Introduction: The estimated prevalence of insomnia disorder in Portugal is 10%. The first line treatment is cognitive behavioral therapy for insomnia (CBT-I), nevertheless there is a lack of available therapists. The aim of this evidence-based practice is to verify the efficacy of CBT-I through digital media (CBT-ID) in adults.
Methods: A search of meta-analyses, network meta-analyses (NMA), systematic reviews, randomized clinical trials (RCT) and clinical guidelines published between january 2018 and december 2022 was carried out. MeSH terms: “cognitive behavioral therapy”, “insomnia disorder”, “telemedicine” and “digital technology”. Data sources: Cochrane Library, DARE,
NICE, Directorate-General for Health, Google Scholar and PubMed.
Results: 101 articles were obtained and one MAR and three RCT were selected. CBT-ID (Somryst®) has a probability greater than 56% of being the most effective treatment in insomnia and greater than 64% of being the most effective treatment in insomnia remission (6 to 12 weeks). In pregnant women with insomnia, there is a higher reduction of the Insomnia Severity Index (ISI) score with CBT-ID (Sleepio®) in comparison with conventional therapies (p = 0.08). Remission rates at six months postpartum were higher in the group receiving CBT-ID (p = 0.02). There was an improvement in the ISI score at four weeks (p = 0.063) after CBT-ID (StudiCare Sleep-e®) and at 12 weeks the difference was more evident, becoming statistically significant (p < 0.001). Both CBT-I and CBT-ID show a positive impact in severity of insomnia symptoms. In the group that received CBT-ID (WeChat®), there was a statistically significant improvement in the Pittsburgh Sleep Quality
Index score (p < 0.001).
Discussion: The evidence demonstrates non-inferiority between CBT-ID and conventional CBT-I in adults. This review has limitations: a sample with low heterogeneity and the inclusion of applications in a foreign language.
Conclusion: CBT-ID can be recommended as an alternative to conventional CBT-I (Strength of Recommendation Taxonomy A)
The Impact of Demographics and Positioning on the Imaging Features of the Optic Nerve Sheath and Ophthalmic Vessels.
No full textBackground: There are significant discrepancies in the optic nerve sheath diameter (ONSD) reported in the literature. We aimed to determine the ultrasonographic imaging features of ONSD and ophthalmic vessels in a healthy population, using a standardized protocol, and to estimate the effect of demographics and positioning changes on imaging measurements.
Methods: We measured the mean values of the ONSD in supine and sitting position and the Doppler imaging parameters of the ophthalmic, central retinal and short posterior ciliary arteries. Inter-observer reliability was assessed using intraclass correlation coefficient (ICC). Linear regression models were fitted to predict the effect of demographic and clinical determinants on the imaging features.
Results: A total of 50 measurements were obtained for each observer. The mean ONSD was 5.9 mm and there was a mean reduction of 0.2 mm when assessed in sitting position (p < 0.001). Doppler analysis showed higher peak-systolic velocity and resistive index in the ophthalmic artery (35.6 cm/s vs. 12.0 cm/s; 0.78 vs. 0.70) compared to the central retinal artery (p < 0.001). Age, sex, heart rate and systolic blood pressure were significant determinants of the imaging features, with ONSD being larger in males (p < 0.001) and increasing with heart rate (p = 0.001). ICC estimates indicated 'good' inter-observer reliability of the ONSD and the ophthalmic and central retinal arteries velocities and resistance.
Conclusions: Our findings suggest a significant impact of patient demographics and positioning during ultrasonography on the normal imaging features of the ONSD and ophthalmic vessels. The heterogeneity in methodology and clinical cohorts may justify previous discrepancies in the literature. These findings can assist in the interpretation of imaging features in clinical settings and in the standardization of point of care ONSD ultrasonography
Determinants of HIV-1 Transmission Clusters and Transmitted Drug Resistance in Men Who Have Sex With Men: a Multicenter Study in Portugal (2014-2019).
No full textIntroduction: In the EU/EEA, men who have sex with men (MSM) is a priority group for the prevention and control of HIV-1 infection. In Portugal, the 2023 HIV incidence rate was 8.2 per 100,000 inhabitants, with 876 new infections, 41.7% in MSM. We aim to characterize HIV-1 transmission clusters (TC) and transmitted drug resistance (TDR) and its sociodemographic, behavioral, clinical, and viral genomic determinants in MSM newly diagnosed in Portugal between 2014 and 2019.
Methods: A total of 340 MSM newly diagnosed with HIV-1 infection at 17 hospitals in Portugal were included. TC was identified with branch support ≥90% and 1.5% genetic distance. Logistic regression models were used to examine factors associated with TC and TDR.
Results: We identified 38 TC with 104 MSM, which includes 81 (26.6%) of the 305 MSM from our sample included in cluster analysis. The overall prevalence of TDR was 8.2%. Only HIV-1 subtype C was significantly associated with TDR. Overall, 10.5% of the clusters had at least 1 surveillance drug resistance mutation. There was no significant difference in the prevalence of TDR or the proportion of Portuguese and migrant MSM inside and outside clusters. Age at diagnosis, district of residence, unprotected sex with a woman, HIV testing, presenter status, and HIV-1 subtype were significantly associated with TC.
Conclusion: Specific subgroups of MSM are contributing to HIV-1 clustered transmission in Portugal. However, no association was found between TDR and sociodemographic or behavioral factors. Directed prevention measures should focus on those subgroups