Assessment System of Narrative Change

The Assessment System of Narrative Change (ASNC) is a method to evaluate narratives in systemic post-modern therapies. ASNC was conceived to describe narrative changes of the system (families, couples, or/and individuals) and integrates seven main dimensions: (A) singularities, (B) nature of the story, (C) narrative connotation, (D) telling of the story, (E) narrative reflexivity, (F) central themes of the session, and (G) alternative behaviors. This system foresees investigation uses (description of system narratives, identification of relevant changing dimensions), clinical uses (narrative diagnoses and evaluation of changing potential, therapy orientation) and training uses (development of skills in educational systemic post-modern orientated programs for therapists)

Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers : systematic review and meta-analysis

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/bync/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.OBJECTIVE: To systematically review longitudinal studies evaluating use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and risk of pneumonia. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline through PubMed, Web of Science with conference proceedings (inception to June 2011), and US Food and Drug Administration website (June 2011). Systematic reviews and references of retrieved articles were also searched. STUDY SELECTION: Two reviewers independently selected randomised controlled trials and cohort and case-control studies evaluating the use of ACE inhibitors or ARBs and risk of pneumonia and retrieved characteristics of the studies and data estimates. DATA SYNTHESIS: The primary outcome was incidence of pneumonia and the secondary outcome was pneumonia related mortality. Subgroup analyses were carried according to baseline morbidities (stroke, heart failure, and chronic kidney disease) and patients' characteristics (Asian and non-Asian). Pooled estimates of odds ratios and 95% confidence intervals were derived by random effects meta-analysis. Adjusted frequentist indirect comparisons between ACE inhibitors and ARBs were estimated and combined with direct evidence whenever available. Heterogeneity was assessed using the I(2) test. RESULTS: 37 eligible studies were included. ACE inhibitors were associated with a significantly reduced risk of pneumonia compared with control treatment (19 studies: odds ratio 0.66, 95% confidence interval 0.55 to 0.80; I(2) = 79%) and ARBs (combined direct and indirect odds ratio estimate 0.69, 0.56 to 0.85). In patients with stroke, the risk of pneumonia was also lower in those treated with ACE inhibitors compared with control treatment (odds ratio 0.46, 0.34 to 0.62) and ARBs (0.42, 0.22 to 0.80). ACE inhibitors were associated with a significantly reduced risk of pneumonia among Asian patients (0.43, 0.34 to 0.54) compared with non-Asian patients (0.82, 0.67 to 1.00; P<0.001). Compared with control treatments, both ACE inhibitors (seven studies: odds ratio 0.73, 0.58 to 0.92; I(2)=51%) and ARBs (one randomised controlled trial: 0.63, 0.40 to 1.00) were associated with a decrease in pneumonia related mortality, without differences between interventions. CONCLUSIONS: The best evidence available points towards a putative protective role of ACE inhibitors but not ARBs in risk of pneumonia. Patient populations that may benefit most are those with previous stroke and Asian patients. ACE inhibitors were also associated with a decrease in pneumonia related mortality, but the data lacked strength.info:eu-repo/semantics/publishedVersio

Desenvolvimento Comunitário: das Teorias às Práticas: Turismo, Ambiente e Práticas Educativas em São Tomé e Príncipe

FCT - PTDC/AFR/69094/200

Avaliação económica de Fidaxomicina no tratamento de infeções por Clostridium difficile graves ou recorrentes

Objectives: Fidaxomicin is a macrocyclic antibiotic drug indicated for the treatment of Clostridium difficile infections (CDI). The purpose of this study was to evaluate from a societal perspective the cost-effectiveness and cost-utility of fidaxomicin in the treatment of severe or recurrent CDI compared to the recommended alternative therapy, vancomycin. Methods: The effectiveness estimates of fidaxomicin and vancomycin, provided by two clinical trials in addition to other studies, were extrapolated to 10 days cycles and a time horizon of 1 year using a Markov model. The costs considered in the study included medication, hospitalization, complications and outpatient visits. Estimates of the indirect costs generated by productivity losses due to absenteeism were not included, for lack of relevant evidence for the Portuguese reality and because the population affected by CDI tends to be no longer active in the labor market. Results: Over a one year horizon and compared to vancomycin treatment, in the base case, fidaxomicin treatment in patients with severe ICD is associated with a gain of 0.010 QALY and a cost increase of 138 €. The treatment of patients with recurrent CDI with fidaxomicin is associated with a gain of 0.019 QALYs and a cost reduction of 626 €. Fidaxomicin treatment has an acceptable incremental cost-utility ratio in patients with severe CDI (ICUR: 13,245 €/ QALY) and dominates in patients with recurrent CDI (ICUR: -33,701 €/ QALY). Fidaxomicin treatment in patients with severe and recurrent CDI is also associated with a reduction in the number of recurrences (ICER: 321 €/ recurrence avoided in patients with severe CDI and ICER: -828 €/ recurrence avoided in patients with recurrent CDI). These results are sensitive to the cost of hospitalization, decreasing with a rising cost of hospitalization. In the probabilistic sensitivity analysis the model predicts that the probability of cost-effectiveness of fidaxomicin is 44,9% in the case of severe CDI and 58% for recurrent CDI for a willingness to pay threshold of 30.000 €. Conclusions: In the Portuguese health system context, fidaxomicin presents good cost-effectiveness and cost-utility results, representing a valuable addition to the therapeutic arsenal for the treatment of CDI.Objetivos: A fidaxomicina é um antibiótico pertencente à classe macrocíclica de antibacterianos, com indicação para o tratamento de infeções por Clostridium difficile (ICD). O objetivo deste estudo foi avaliar, na perspetiva da sociedade, o custo-efetividade e o custo-utilidade da fidaxomicina no tratamento de ICD graves ou recorrentes, comparativamente à alternativa terapêutica recomendada, a vancomicina. Métodos: As estimativas de eficácia da fidaxomicina e vancomicina, provenientes de dois ensaios clínicos em conjunto com dados de outros estudos, foram extrapoladas para ciclos de dez dias e um horizonte temporal de um ano, recorrendo a um modelo de Markov. Os custos considerados no estudo incluem os custos da medicação, do internamento, das complicações e das consultas. Não foram considerados os custos indiretos derivados da perda da produtividade por absentismo, quer por falta de evidência direta relevante para a realidade portuguesa quer porque a população afetada pelas ICD tende maioritariamente a já não estar ativa no mercado de trabalho. Resultados: Ao longo de um ano, e comparativamente com tratamento com vancomicina, no cená- rio de base o tratamento com fidaxomicina em doentes com ICD grave está associado a um ganho de 0,010 AVAQ e a um incremento dos custos em € 138. No tratamento de doentes com ICD recorrente, a fidaxomicina está associada a um ganho de 0,019 AVAQ e a um decréscimo de custos de € 626. O tratamento com fidaxomicina corresponde assim a um valor aceitável de custo-efetividade em doentes com ICD grave (ICUR: € 13,245/AVAQ) e é dominante em doentes com ICD recorrente (ICUR: -€ 33,701/AVAQ). O tratamento com fidaxomicina em doentes com ICD grave e doentes com ICD recorrente está também associado a uma redução do número de recorrências (ICER: € 321/recorrência evitada em doentes com ICD grave e ICER: -€ 828/ recorrência evitada em doentes com ICD recorrente). Estes resultados são sensíveis ao custo do internamento, diminuindo com o aumento do custo do internamento. Na análise de sensibilidade probabilística, o modelo prevê que, para um limiar de aceitabilidade de € 30 mil, a probabilidade da fidaxomicina ser custo-efetiva é de 44,9 por cento no caso de ICD grave e de 58 por cento no caso de ICD recorrente. Conclusões: A fidaxomicina tem uma boa relação custo-utilidade no contexto do sistema de saúde português, representando um adicionamento importante ao arsenal terapêutico para o tratamento das ICD.info:eu-repo/semantics/publishedVersio

Clinical trials in palliative care : a systematic review of their methodological characteristics and of the quality of their reporting

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: Over the past decades there has been a significant increase in the number of published clinical trials in palliative care. However, empirical evidence suggests that there are methodological problems in the design and conduct of studies, which raises questions about the validity and generalisability of the results and of the strength of the available evidence. We sought to evaluate the methodological characteristics and assess the quality of reporting of clinical trials in palliative care. Methods: We performed a systematic review of published clinical trials assessing therapeutic interventions in palliative care. Trials were identified using MEDLINE (from its inception to February 2015). We assessed methodological characteristics and describe the quality of reporting using the Cochrane Risk of Bias tool. Results: We retrieved 107 studies. The most common medical field studied was oncology, and 43.9% of trials evaluated pharmacological interventions. Symptom control and physical dimensions (e.g. intervention on pain, breathlessness, nausea) were the palliative care-specific issues most studied. We found under-reporting of key information in particular on random sequence generation, allocation concealment, and blinding. Conclusions: While the number of clinical trials in palliative care has increased over time, methodological quality remains suboptimal. This compromises the quality of studies. Therefore, a greater effort is needed to enable the appropriate performance of future studies and increase the robustness of evidence-based medicine in this important field.info:eu-repo/semantics/publishedVersio

Active aging awareness and well-being among older adults in Portugal

Funding Information: This study is part of the research program of the General Foundation of the University of Salamanca, through the International Centre on Aging (CENIE), within the framework of the Programme for a Longevity Society (0551_PSL_6_E), a project co-financed by the European Regional Development Fund (ERDF) through the Interreg VA Spain-Portugal Programme (POCTEP) 2014–2020. Publisher Copyright: Copyright © 2023 Costa, Henriques, Alarcão, Henriques, Madeira, Virgolino, Sousa, Feteira-Santos, Arriaga, Rocha and Nogueira.Objective: This study aims to assess the active aging awareness of older adults in mainland Portugal and their levels of overall well-being and to identify social and health-related factors. Methods: A cross-sectional study was conducted with a representative sample of 613 older adults, aged 65 or older, who participated in the PROKnos – Knowing Social Prescribing needs of the elderly study in Portugal. The questionnaire consisted of the Active Ageing Awareness Questionnaire and the World Health Organization – Five Well-Being Index, as well as sociodemographic, economic, and health status questions. Correlation coefficients, t-tests for independent samples, and one-way ANOVA were used to explore potential associations between variables. Results: The active aging awareness levels were significantly higher for women (p = 0.031), and those who were younger (p = 0.011), more educated (p < 0.001), had a better financial situation (p < 0.001), and had better health (p < 0.001). The same pattern was found for well-being, except in relation to gender, as men had higher levels (p = 0.016). These variables were found to be correlated. Discussion: Even though active aging is an important strategy to implement, it is indispensable to consider the perceptions and conditions that need to be in place before that. This study reveals that several social and health-related factors are associated with well-being and active aging awareness, as well as the differences between groups that exist in mainland Portugal in relation to that. This emphasizes how vital it is to address social inequalities in active aging efforts, which are not necessarily uncovered when only considering actual active aging measures.publishersversionpublishe

Prescrição off-label : análise científica tendo como exemplo a utilização de Bevacizumab em oftalmologia

Off-label prescribing poses specific technical/scientific, professional and ethical problems. In this study we carry out a technical and scientific analysis of the off-label prescribing using a current, clinical and economically relevant example: the paradigmatic case of the use of bevacizumab in ophthalmologic pathologies for which it has no formal indication. We conducted a systematic review of the literature on the efficacy and safety of this drug, as well as ranibizumab - which has approved ophthalmologic indications, in order to qualitatively analyze the available evidence on the two interventions. This is a typical case for technical and scientific analysis of the off-label prescribing problems. According to the results of the systematic review, the use of bevacizumab in this context has in fact scientific evidence of appreciable size, including clinical trials head-to-head with ranibizumab. However, the identified safety issues raise the question of the use of this drug in ophthalmologic pathologies. The different players involved in the treatment decisions (physicians, patients and institutional decision makers) should be adequately informed about the existing evidence that supports off-label prescribing which, by definition, must always be on an exceptional basis and properly justified.info:eu-repo/semantics/publishedVersio

Off-label prescribing : scientific analysis taking the use of bevacizumab in ophthalmology as an example

Copyright © Ordem dos Médicos 2013Off-label prescribing poses specific technical/scientific, professional and ethical problems. In this study we carry out a technical and scientific analysis of the off-label prescribing using a current, clinical and economically relevant example: the paradigmatic case of the use of bevacizumab in ophthalmologic pathologies for which it has no formal indication. We conducted a systematic review of the literature on the efficacy and safety of this drug, as well as ranibizumab - which has approved ophthalmologic indications, in order to qualitatively analyze the available evidence on the two interventions. This is a typical case for technical and scientific analysis of the off-label prescribing problems. According to the results of the systematic review, the use of bevacizumab in this context has in fact scientific evidence of appreciable size, including clinical trials head-to-head with ranibizumab. However, the identified safety issues raise the question of the use of this drug in ophthalmologic pathologies. The different players involved in the treatment decisions (physicians, patients and institutional decision makers) should be adequately informed about the existing evidence that supports off-label prescribing which, by definition, must always be on an exceptional basis and properly justified.A prescrição off-label levanta problemas técnicos/científicos, profissionais e éticos específicos. No presente trabalho, procurámos realizar uma análise técnico-científica da prescrição off-label recorrendo a um exemplo atual, clinica e economicamente relevante: o caso paradigmático da utilização de bevacizumab em patologias do foro oftalmológico para as quais não tem indicação formal aprovada. Para tal realizámos uma revisão sistemática da literatura sobre a eficácia e segurança deste medicamento, assim como de ranibizumab – o qual tem indicações oftalmológicas aprovadas, no sentido de analisar qualitativamente a evidência científica disponível sobre as duas intervenções. Este caso é exemplar para análise técnico-científica dos problemas da prescrição off-label, já que, de acordo com os resultados da revisão sistemática realizada, o uso do bevacizumab neste contexto possui, de facto, evidência científica de dimensão apreciável, incluindo ensaios clínicos head-to-head com ranibizumab. No entanto, os problemas de segurança identificados levantam a questão da utilização deste fármaco nas patologias oftalmológicas. Os diferentes agentes que participam no processo de decisão terapêutica (médicos, doentes e decisores institucionais) devem estar adequadamente informados sobre a evidência existente que suporta a prescrição off-label, a qual, por definição, deve ser sempre de caracter excecional e devidamente justificada.info:eu-repo/semantics/publishedVersio

PCV141 Atherosclerosis : real-world insights from a Portuguese primary care database

Copyright © 2019 Published by Elsevier Inc.Objectives: Cardiovascular disease remains the leading cause of death in Portugal and across the world. Atherosclerosis is the most common pathophysiologic process underlying CVD. Its clinical manifestations include coronary artery disease (CAD), cerebrovascular disease (CVD) and peripheral artery disease (PAD). This study aims to determine the clinical and demographic characteristics of adult patients with atherosclerosis in a Portuguese primary care comprehensive administrative database.info:eu-repo/semantics/publishedVersio

EFICÁCIA E SEGURANÇA DE MEBUTATO DE INGENOL NO TRATAMENTO DA QUERATOSE ACTÍNICA − REVISÃO SISTEMÁTICA E META-ANÁLISE

Introduction: Actinic keratosis is the most common premalignant lesion. The therapeutic approach to patients with multiple lesions involves field-directed treatment.Objective: To evaluate the efficacy and safety of ingenol mebutato, a new drug treatment for topical field-directed treatment of actinic keratosis.Design: Systematic review and meta-analysis of randomized controlled trials (RCTs) trials.Data sources: Medline and Cochrane Library (June 2014).Study selection: Two reviewers independently searched for studies and retrieved their characteristics and data estimates.Data synthesis: Random-effects meta-analysis. Heterogeneity was assessed with the I2 test.Results: Six trials (n = 1,492) versus placebo were included. The odds of a patient experiencing complete removal of the lesions was 17 (95%CI: 9 to 31, I2 = 0%) and 8.5 (95% CI: 5 to 15, I2 = 0%) times higher, compared to placebo, in the face/scalp and trunk/extremities, respectively. The incidence of adverse events related to treatment was higher in the group of mebutato ingenol (+23%, 95%CI: 11 to 35%), with no differences between groups in the discontinuation rate due to adverse events.Conclusions: Mebutato of ingenol is efficacious in the treatment of actinic keratosis. Compared to other field-directed treatments available in Portugal, its therapeutic value comes from the favourable safety profile and tolerability, simplicity and short duration of the treatment regimen and the possibility of different treatment to injuries according to anatomical location (individualization of therapy). Future studies should directly compare the different therapeutic options and evaluate the effectiveness of the same in the real world.Introdução: A queratose actínica é a lesão pré-maligna mais frequente. A abordagem terapêutica dos doentes com múltiplas lesões envolve terapêuticas de campo.Objetivo: Avaliar a eficácia e segurança de mebutato de ingenol, um novo medicamento destinado à terapêutica tópica de campo.Desenho: Revisão sistemática e meta-análise dos ensaios clínicos controlados e aleatorizados (RCTs).Fontes bibliográficas: Medline e Cochrane Library (junho 2014).Seleção dos estudos: A seleção e avaliação dos RCTs foram feitas de forma independente.Análise quantitativa: Meta-análise de efeitos aleatórios. A heterogeneidade foi avaliada com o teste I2.Resultados: Foram incluídos 6 ensaios (n=1.492) versus placebo. Mebutato de ingenol esteve associado a uma possibilidade de um doente ter remoção completa das lesões 17 (IC95%: 9 a 31; I2=0%) e 8,5 (IC95%: 5 a 15; I2=0%) vezes superior, comparativamente ao placebo, no rosto/couro cabeludo e no tronco/extremidades, respetivamente. A incidência de eventos adversos relacionados com o tratamento foi superior no grupo mebutato de ingenol (+23%, IC95%: 11 a 35%), sem diferenças entre grupos na taxa de abandono por eventos adversos.Conclusões: Mebutato de ingenol é eficaz no tratamento da queratose actínica. Comparativamente às restantes terapêuticas de campo disponíveis em Portugal, o seu valor terapêutico advém do favorável perfil de segurança e tolerabilidade, da simplicidade e curta duração do esquema terapêutico e da possibilidade de tratar de forma diferenciada as lesões de acordo com a localização anatómica (individualização da terapêutica). Estudos futuros deveriam comparar diretamente as diferentes opções terapêuticas e avaliar a efetividade das mesmas no mundo real