The burden of chronic low back pain in the adult Portuguese population : an epidemiological population-based study under the scope of Epireumapt

RESUMO: Nos países desenvolvidos a lombalgia é a condição músculo-­‐esquelética mais prevalente. Quando evolui para um quadro crónico é responsável por um encargo económico bastante considerável, não só em relação aos indivíduos, mas também para a sociedade. A lombalgia crónica é por isso uma das principais causas de perda de produtividade e de perda de independência económica, nomeadamente através do absenteísmo (ausência do trabalho), do presenteísmo (perda de produtividade no trabalho, devido à capacidade diminuída provocada pela lombalgia) e da incapacidade para trabalhar (invalidez permanente, total ou parcial). Até à data, em Portugal, a prevalência e carga social da lombalgia crónica eram desconhecidas. Até agora não existiam estudos populacionais de grande dimensão sobre este tema. O objetivo principal desta tese foi determinar a prevalência de lombalgia crónica, e também avaliar a carga social que esta tem na população adulta Portuguesa. O trabalho de investigação foi desenvolvido no âmbito do Estudo Epidemiológico de Doenças Reumáticas em Portugal (EpiReumaPt). Este foi o primeiro estudo de larga escala e de base populacional, que determinou a prevalência de doenças reumáticas e músculo-­‐ esqueléticas na população adulta portuguesa. Foi realizado numa amostra aleatória e representativa, de 10.661 indivíduos do Continente, da Região Autónoma dos Açores e da Região Autónoma da Madeira, entre Setembro de 2011 e Dezembro de 2013. Esta tese foi dividida em duas secções. A primeira secção incluiu o detalhe das questões relativas ao desenvolvimento e gestão do EpiReumaPt, constituindo-­‐se como um guia prático sobre como realizar um estudo de base populacional de larga escala, em Portugal. A metodologia detalhada do EpiReumaPt foi também descrita nesta secção e incluiu os objectivos, o desenho do estudo, as características de recrutamento e a preparação de dados para análise. Nesta secção foram ainda descritos os principais resultados do EpiReumaPt. Estes evidenciaram que a lombalgia foi a condição músculo-­‐esquelética com maior prevalência na população adulta portuguesa.A segunda secção desta tese estimou a prevalência da lombalgia crónica ativa na população adulta Portuguesa, e avaliou a carga social esta condição. A lombalgia ativa foi definida com base na dor auto-­‐relatada no dia da entrevista e que persistia há pelo menos 90 dias (independentemente da causa). A lombalgia foi definida como dor na área definida entre a margem inferior das décimas segundas costelas até às pregas glúteas inferiores, com ou sem dor nos membros inferiores. A carga social foi medida tendo em conta os seguintes parâmetros: qualidade de vida, função, consumo de recursos de saúde, consumo de analgésicos e outros fármacos usados no alívio da dor, sintomas de ansiedade e sintomas de depressão. Os resultados mostraram que o consumo de recursos em saúde e a carga social da lombalgia crónica na população adulta Português é significativa. Também a incapacidade causada pela lombalgia crónica,nos indivíduos com idade ativa, é responsável por elevadas taxas de absenteísmo e má qualidade de vida, aos quais acresce o consequente ónus socioeconómico. Esta tese também concluiu que o consumo de analgésicos e outros medicamentos para alívio da dor, na população adulta portuguesa com lombalgia crónica ativa, é relativamente baixa. A maioria destes indivíduos não tomava nenhum medicamento analgésico, independentemente da intensidade da dor. Mesmo os indivíduos que reportaram dor intensa, apenas 4.0% estavam no primeiro degrau da escada analgésica da Organização Mundial de Saúde; 2.3% usavam opióides fracos e 0.03% usavam opióides fortes para controlar a dor (segundo e terceiro degrau da escada analgésica da Organização Mundial da Saúde). O trabalho de investigação também confirmou que a prevalência de sintomas de ansiedade e depressão entre os indivíduos adultos portugueses com lombalgia crónica ativa é elevada. Nestes indivíduos, registou-­‐se um consumo mais elevado de analgésicos e outros medicamentos para alívio da dor, quando comparados com os indivíduos com lombalgia crónica activa sem esses sintomas psicológicos. Os grupos terapêuticos mais utilizados foram os ansiolíticos, sedativos e hipnóticos, os antidepressivos e os anti-­‐inflamatórios não esteróides. A intensidade média da dor reportada foi também maior entre os indivíduos com lombalgia ativa e sintomas de ansiedade e/ou depressão. Também nestes, foi reportada pior função e pior estado de saúde. Em relação ao consumo de recursos de saúde foram encontradas diferenças significativas entre as duas populações: os indivíduos com lombalgia ativa e sintomas psicológicos concomitantes registaram maior número de consultas de psiquiatria de outras especialidades médicas, assim como precisaram de mais apoio domiciliário nos 12 meses prévios à entrevista do EpiReumaPt. Foram também identificados os fatores associados a sintomas isolados de ansiedade, a sintomas isolados de depressão e a sintomas de ansiedade e depressão. Resumindo,esta tese permitiu concluir que a lombalgia crónica é um problema de saúde comum na população adulta portuguesa, contribuindo para um elevado grau de incapacidade e que consequentemente afeta o desempenho laboral e o bem-­‐estar dos indivíduos. A lombalgia crónica é também responsável por um consumo considerável de recursos de saúde. Acresce ainda que os sintomas de ansiedade e depressão são comuns, entre os indivíduos com lombalgia crónica, contribuindo com uma carga social adicional.---------------------------------- ABSTRACT:Low Back Pain(LBP) is the most prevalent of musculoskeletal condition in developed countries.When it becomes chronic, LBP causesan enormous economic burden on individuals and society -­‐ it is one of the leading causes of loss of productivity and economic independence through absenteeism (time off work), presenteeism (lost productivity because of diminished capacity while at work) and work disability (permanent, partial or complete disablement for work purposes). In Portugal the prevalence and burden of LBP and chronic LBP (CLBP) were poorly defined. Until now no large population-­‐based studies have focused on this. The main aim of this thesis was to determine the prevalence of LBP and CLBP, and also to assess the burden of CLBP in the adult rtuguese population. The research work was developed under the scope of EpiReumaPt (the Portuguese Epidemiologic Study of Rheumatic Diseases). EpiReumaPt was the first national large population-­‐based and prevalence study of rheumatic and musculoskeletal diseases (RMD). It was performed among a randomized and representative sample of 10,661 adult Portuguese subjects recruited in Mainland, Azores and Madeira Islands, from September 2011 to December 2013. The first section of this thesis included detailed issues regarding the development and management of EpiReumaPt, and provided a practical guide on how to set-­‐up a large population-­‐based study in Portugal. The detailed methodology of EpiReumaPt, including its objectives,study design,recruitment features,and data preparation for analyses were also described. The main results from EpiReumaPt study were provided in this section and showed that LBP was the musculoskeletal condition with highest prevalence among Portuguese population. The second section of this thesis estimated the prevalence of active CLBP among adult Portuguese population, and assessed the social burden of this condition. Active CLBP was defined based on self-­‐reported pain on the day of the interview, and for most of the time for at least 90 days (independently from cause). LBP was defined as pain in the back area from the lower margin of the twelfth ribs to he lower gluteal folds, with or without pain referred to the lower limbs. Social burden was measured taking into account the following outcomes: quality of life, function, healthcare resources consumption, analgesic and other pain relief drugs intake, anxiety and depression symptoms. Results showed that the healthcare consumption and social burden of CLBP among adult Portuguese population were enormous, and the disability caused by CLBP among subjects in a working age provides high rates of absenteeism (work loss) and poor quality of life, with a consequent socioeconomic burden. This thesis also concluded that analgesic and other pain relief drugs untake among adult Portuguese population with active CLBP was very low. Most of the subjects with active CLBP did not take any analgesic drug regardless pain severity. Even when subjects self-­‐reported severe pain, only 24.0% were in the 1st step of the analgesic ladder,2.3% used weak analgesic opioids and 0.03% used strong opioids (2nd and 3rd step of WHO analgesic ladder, respectively) to control pain . The research work also confirmed that the prevalence of anxiety and depression symptoms among adult Portuguese subjects with active CLBP was high. Regarding pharmacological therapy, the intake of analgesic and other pain relief drugs was higher among subjects with anxiety and/or depression symptoms, when compared with subjects without these psychological symptoms. Anxiolytics, sedatives and hypnotics, antidepressants and NSAIDs intake had higher usage rates among these subjects. The pain severity mean was also higher among this subjects and function and health status was worse. Regarding healthcare resources consumption,significant differences between the two populations were found. Subjects with ctive CLBP and concomitant psychological symptoms had a higher number of psychiatrist and other physician visits. They also needed more home care in the previous 12 months. Factors associated with isolated symptoms of anxiety, depression,and concomitant anxiety and depression symptoms were also identified. Summarizing, we concluded that CLBP is a common health problem among adult Portuguese population contributing to disability and affecting labor performance, and the well being of subjects. it is also responsible for considerable healthcare resource consumption. Anxiety and depression symptoms are common among subjects with CLBP and provided an additional burden among them

Vivências dos cuidadores informais na mobilidade do idoso com dependência

Mestrado , Enfermagem de Reabilitação, 2013, Escola Superior de Enfermagem de LisboaNa atualidade as famílias continuam a ser os principais recursos informais que proporcionam cuidados aos idosos dependentes. Estes cuidadores familiares deparam-se com exigências, decorrentes do processo de cuidar que englobam desde os aspetos emocionais aos instrumentais. Neste sentido, assumimos o desafio de conhecer as vivências dos cuidadores familiares na mobilização do idoso dependente, identificar as estratégias utilizadas na mobilização do idoso dependente e ainda descrever as necessidades do cuidador familiar na mobilização do idoso dependente. Para respondermos a estes objetivos realizamos um estudo de paradigma qualitativo do tipo descritivo, com abordagem fenomenológica, recorrendo ao método de Giorgi. Atendendo à natureza do fenómeno, realizamos dez entrevistas semiestruturadas a dez familiares que cuidam de idosos dependentes no domicílio. Da análise efetuada aos dados obtidos identificaram-se dois contextos essenciais do fenómeno da experiência vivida, um relativo às “vivências no cuidar” e outro ao “cuidar na dimensão da mobilização”, cujos constituintes chave dos dois contextos se influenciam mutuamente. No contexto “vivências no cuidar”, evidenciaram-se, quatro constituintes chave: assunção do papel de cuidador; fatores facilitadores; fatores inibidores e repercussões da assunção do papel de cuidador; As vivências dos cuidadores familiares na mobilização do idoso dependente, passam pela aplicação de intervenções direcionadas para a promoção da autonomia, da independência, do conforto e da qualidade de vida, atendendo à evolução clínica de cada idoso. Para mobilizar adequadamente cada idoso, os cuidadores familiares recorreram à observação, à experiência de vida, à procura de informação, à educação pelos profissionais, à tentativa erro e ao treino de habilidades. De um modo geral, a falta de preparação para assumir o papel de cuidador familiar, surge como uma necessidade que deve ser colmatada com formação iminentemente prática, de modo a capacitar os cuidadores familiares para mobilizarem os idosos com o mínimo de riscos para estes e para o cuidador

Watchful waiting? Portuguese approach to otitis media with effusion

Vera-Cruz, P., Larroudé, A., Gouveia, N., Mendes, J., & Coelho, P. S. (2021). Watchful waiting? Portuguese approach to otitis media with effusion. Nascer e Crescer: Birth and Grwoth Medical Journal, 30(1), 143-151. https://doi.org/10.25753/BirthGrowthMJ.v30.i3.19192Otitis media with effusion (OME) is an important public health problem. Several clinical practice guidelines for diagnosis and treatment of OME are in place, including from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). This study aimed to evaluate the clinical practice of OME diagnosis and treatment among the Otolaryngology medical community working in Portugal. Material and methods: A questionnaire was developed based on AAO-HNS guidelines regarding placement of tympanostomy tubes in children. Each directive was transformed into a question, and further questions were added to improve the characterization of the population and its practices. Results: Answers provided agreed with “recommendations” and “recommendations against” enunciated in the guidelines. The exceptions were recommendations regarding the adoption of measures to prevent water from entering the external ear canal of children with tympanostomy tubes and the use of drugs. Questions asked outside guidelines scope revealed that 96.7% of doctors consider children’s age and 49.1% wait for the end of summer when deciding about surgery for tube placement, 68% recommend bathing in beaches, and 21.9% recommend mineral water treatment.publishersversionpublishe

Differences in Industry and Investigator Initiated Trials

INTRODUCTION: The aim of this study was to investigate the Portuguese authorship in publications resulting from trials initiated by the industry or investigators and run in Portugal. MATERIAL AND METHODS: Clinical trials with Portuguese institutions as sponsor or recruiting centers, and registered in four clinical trial registries, in the last 14 years, were assessed. Publications of completed trials, from both the initiative of the industry and investigatorswere screened and compared. RESULTS: The percentage of published trials initiated by industry and investigators was similar (28.0%). However, the percentage of completed investigator-initiated trials (43.6%) was lower when compared to industry trials (69.7%). There was a higher percentage of Portuguese authorship in published investigator-initiated trials when compared with industry-initiated trials (47.1% vs 8.5%, respectively). Moreover, industry-initiated trials with Portuguese authors were published in journals with lower journal impact factor when compared with those published without authorship of Portuguese investigators. Oncology was the therapeutic area with the highest number of clinical trial registrations and publications. However, in publications with Portuguese authors, industry Initiated trials mainly focused on neurology while investigator-initiated trials had a higher number of papers in the fields of gastroenterology and infection diseases. Published trials with Portuguese authorship, initiated by the industry or investigators, also targeted different populations and had different purposes. In both cases, no significant differences were observed in terms of the journal impact factor or in the alignment of the published randomized trials with the respective reporting guidelines. DISCUSSION: When compared with previous publications, this study showed an increasing trend in the number of clinical trials in Portugal, published within similar timeframes, after trial conclusion. Even though both industry and investigator trials are published within the standards for reporting trials, the low number of Portuguese authorships in industry publications might underline the need for invigorating these independent clinical trials in Portugal by capacitating and empowering national clinical research teams. CONCLUSION: This study confirmed that even though all registered trials had the involvement of Portuguese institutions as a recruiting center, not all the published trials had Portuguese investigators as authors, mainly those initiated by the industry.publishersversionpublishe

Is the reason to switch relevant?

57763]. AS is supported by a doctoral grant from “Fundação para a Ciência e Tecnologia” (SFRH/BD/108246/2015).Background: To investigate whether the reason to discontinue the first TNF inhibitor (TNFi) affects the response to the second TNFi in axial spondyloarthritis (axSpA). Methods: Patients with axSpA from the Rheumatic Diseases Portuguese Register (ReumaPt), who discontinued their first TNFi and started the second TNFi between June 2008 and May 2018, were included. Response was assessed by the Ankylosing Spondylitis Disease Activity Score (ASDAS) clinically important improvement (ASDAS-CII), major important improvement (ASDAS-MI), low disease activity (ASDAS-LDA), and inactive disease (ASDAS-ID). The reason for discontinuation of the first TNFi was defined, according to ASDAS-CII as primary failure (no response ≤ 6 months), secondary failure (response ≤ 6 months but lost thereafter), adverse events, and others. The association between the reason for discontinuation of the first TNFi and response to the second TNFi over time was assessed in multivariable generalized equation (GEE) models. Results: In total, 193 patients were included. The reason for discontinuation of the first TNFi did not influence the response to the second TNFi, according to the ASDAS-CII. However, a difference was found with more stringent outcomes, e.g., there was a higher likelihood to achieve ASDAS-ID with the second TNFi for patients discontinuing the first TNFi due to secondary failure (OR 7.3 [95%CI 1.9; 27.7]), adverse events (OR 9.1 [2.5; 33.3]), or other reasons (OR 7.7 [1.6; 37.9]) compared to primary failure. Conclusion: Patients with axSpA with secondary failure to their first TNFi, compared to those with primary failure, have a better response to the second TNFi according to stringent outcomes.publishersversionpublishe

going beyond BASDAI

This work was supported by a Research Grant from the InvestigatorInitiated Studies program of Merck Sharp & Dohme (Grant No. 56078). The sponsor did not interfere with the study question, analysis or interpretation of results. AS is supported by a doctoral grant from Fundação para a Ciência e Tecnologia (Foundation for Science and Technology) (SFRH/BD/108246/2015).OBJECTIVES: To compare definitions of high disease activity of the Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in selecting patients for treatment with biologic disease-modifying antirheumatic drugs (bDMARDs). METHODS: Patients from Rheumatic Diseases Portuguese Register (Reuma.pt) with a clinical diagnosis of axial spondyloarthritis (axSpA) were included. Four subgroups (cross-tabulation between ASDAS (≥2.1) and BASDAI (≥4) definitions of high disease activity) were compared regarding baseline characteristics and response to bDMARDs at 3 and 6 months estimated in multivariable regression models. RESULTS: Of the 594 patients included, the majority (82%) had both BASDAI≥4 and ASDAS ≥2.1. The frequency of ASDAS ≥2.1, if BASDAI<4 was much larger than the opposite (ie, ASDAS <2.1, if BASDAI≥4): 62% vs 0.8%. Compared to patients fulfilling both definitions, those with ASDAS ≥2.1 only were more likely to be male (77% vs 51%), human leucocyte antigen B27 positive (79% vs 65%) and have a higher C reactive protein (2.9 (SD 3.5) vs 2.1 (2.9)). Among bDMARD-treated patients (n=359), responses across subgroups were globally overlapping, except for the most 'stringent' outcomes. Patients captured only by ASDAS responded better compared to patients fulfilling both definitions (eg, ASDAS inactive disease at 3 months: 61% vs 25% and at 6 months: 42% vs 25%). CONCLUSION: The ASDAS definition of high disease activity is more inclusive than the BASDAI definition in selecting patients with axSpA for bDMARD treatment. The additionally 'captured' patients respond better and have higher likelihood of predictors thereof. These results support using ASDAS≥2.1 as a criterion for treatment decisions.publishersversionpublishe

a detailed view of the methodology

Rheumatic and musculoskeletal diseases (RMD) are prevalent and leading causes of disability and consumption of healthcare and social resources. EpiReumaPt is a national population-based survey developed by the Portuguese Society of Rheumatology that aimed to estimate the prevalence of RMDs and determine their impact on function, quality of life, mental health and use of healthcare resources. This article describes in detail the design, methodology and planned analyses of EpiReumaPt. Recruitment started in September 2011 and finished in December 2013. This study involved a three-stage approach. The first step was a face-to-face survey performed by trained interviewers at the household of 10,661 subjects who where randomly selected by a stratified multistage sampling. A highly sensitive screening questionnaire for RMDs was used. Secondly, participants who screened positive (64%) for at least one RMD as well as 20% of individuals with a negative screening were invited for assessment by a rheumatologist. In total, 3,877 subjects participated in this second phase, where they were also invited to donate a blood sample to be stored at the Biobanco-IMM. History and physical examination, followed by appropriate laboratory and imaging tests were performed. At the end of the visit, the rheumatologist established a diagnosis. Finally, a team of three experienced rheumatologists reviewed all the clinical data and defined the diagnoses according to previously validated criteria. The EpiReumaPt dataset, containing data from several questionnaires, various clinical measurements and information from laboratory and imaging tests, comprises an invaluable asset for research. The large amount of information collected from each participant and the large number of participants, with a wide age range covering and being representative of the adults from the entire country, makes EpiReumaPt the largest study of RMDs performed in Portugal.publishersversionpublishe

Ipomoea batatas (L.) Lam.: a rich source of lipophilic phytochemicals

The lipophilic extracts from the storage root of 13 cultivars of sweet potato (Ipomoea batatas (L.) Lam.) were evaluated by gas chromatography-mass spectrometry with the aim to valorize them and offer information on their nutritional properties and potential health benefits. The amount of lipophilic extractives ranged from 0.87 to 1.32% dry weight. Fatty acids and sterols were the major families of compounds identified. The most abundant saturated and unsaturated fatty acids were hexadecanoic acid (182-428 mg/kg) and octadeca-9,12-dienoic acid (133-554 mg/kg), respectively. β-Sitosterol was the principal phytosterol, representing 55.2-77.6% of this family, followed by campesterol. Long-chain aliphatic alcohols and α-tocopherol were also detected but in smaller amounts. The results suggest that sweet potato should be considered as an important dietary source of lipophilic phytochemicals.info:eu-repo/semantics/publishedVersio

Farmacogenómica/farmacogenética : realidades e perspectivas na prática clínica

Dissertação de mestrado em Tecnologias do Medicamento na especialidade de Farmacologia, apresentada à Faculdade de Farmácia da Universidade de CoimbraA saúde pública abrange várias preocupações actuais, entre elas, o uso racional do medicamento com a consequente optimização das terapêuticas. Esta optimização assenta em dois grandes focos: a segurança e a efectividade, sendo intervenções prioritárias a anulação de problemas relacionados com a segurança (reacções adversas) e a maximização de questões relacionadas com a efectividade. Neste contexto, a Farmacogenómica é hoje uma área em expansão e poderá deter as ferramentas necessárias que possibilitam a construção de respostas terapêuticas dirigidas ao perfil genético dos indivíduos, permitindo respeitar a variabilidade intra e inter-individual. Este trabalho tem como objectivos: avaliar a utilização da Farmacogenómica na prática clínica hospitalar em Portugal Continental; identificar as competências necessárias a desenvolver para aplicação de técnicas de Farmacogenómica - Médico/Farmacêutico; analisar quais as futuras áreas potenciais de aplicação da Farmacogenómica na prática clínica. Para dar resposta aos objectivos definidos foram realizados dois sub-estudos distintos. O sub-estudo 1, um estudo transversal descritivo, cuja informação foi recolhida junto de serviços hospitalares previamente definidos; e o sub-estudo 2, que se baseou numa técnica de consenso – Painel Delphi. No sub-estudo 1 obteve-se informação de 4 serviços do IPO de Lisboa, 1 serviço do IPO do Coimbra e 4 serviços do IPO do Porto, e nestes serviços maioritariamente a utilização da genética nas decisões terapêuticas, quando se verifica, não é numa perspectiva farmacogenómica, mas sim numa perspectiva de caracterização da doença ou do seu estadio. No sub-estudo 2, das instituições identificadas para a indicação dos peritos, as poucas respostas recepcionadas foram maioritariamente via telefone, (uma vez que foi feito um reforço telefónico para maior brevidade na resposta), foram todas negativas, argumentando que não havia peritos na área de estudo identificada. Da pesquisa e das informações recolhidas a farmacogenómica/farmacogenética parece ser um campo de investigação que apresenta ainda algumas fragilidades. Podem ser identificados nichos de potencial interesse na utilização da Farmacogenómica, nomeadamente nas áreas da genética, oncologia e doenças infecciosas, em que os fármacos manuseados são aqueles que se encaixam exactamente na utilidade da farmacogenómica/farmacogenética: fármacos com margem terapêutica estreita. Na perspectiva de concretizar o estado da arte da utilização da farmacogenómica/farmacogenética numa área clínica em particular optou-se por realizar uma revisão bibliográfica sobre esta matéria em doentes que fazem terapêutica com varfarina

Relatório estágio profissional

Relatório final do estágio profissionalizante do 6.º an