Repositório RCAAP

O refluxo gastroesofágico (RGE) e a asma são ambas doenças prevalentes, que frequentemente coexistem. Há mais de um século que foi inicialmente proposta a existência de uma relação entre as duas patologias, sendo que apesar dos inúmeros estudos realizados nesta área, até à data, a natureza desta relação causa-efeito não está completamente esclarecida. Este artigo de revisão visa a apresentação de um ponto de situação actual relativamente a esta temática. Estudos epidemiológicos mostram que a doença do refluxo gastroesofágico (DRGE) é mais prevalente em pacientes asmáticos do que na população em geral. Os mecanismos que levam a que asma promova o aparecimento e/ou o agravamento da DRGE carecem de melhor elucidação. A literatura disponível aponta para o refluxo gastroesofágico como um potencial trigger para a asma, sendo que os mecanismos propostos neste sentido, envolvem a microaspiração de refluxo gástrico e respostas neurológicas com componente vagal associada. Dados de diversos estudos demonstram que a introdução de terapêuticas anti-refluxo, como os inibidores da bomba de protões (IBPs) e a fundoplicatura de Nissen, têm resultados positivos no outcome da asma, mas com uma eficácia muito variável de estudo para estudo. Sugerindo-se a aplicação empírica de tratamento com IBPs em pacientes com asma grave ou mal controlada e/ou suspeita de DRGE (a alternativa cirúrgica mais exclusiva a casos altamente selectivos ). Tem-se enfatizado também a existência provável de um relação entre a DRGE e a gravidade da asma. Possivelmente, a realização de estudos de larga escala, nos quais se proceda à análise e classificação de diferentes subgrupos de pacientes asmáticos com DRGE, poderá proporcionar uma compreensão mais aprofundada desta temática. Este ponto, por sua vez, poderá assim promover o desenvolvimento consensual de critérios específicos de selecção de pacientes, nos quais haja uma resposta mais consistente à terapêutica.

The lack of access to safe drinking water causes important health problems, mainly in developing countries. In the West African country Guinea-Bissau, waterborne diseases are recognised by WHO as major infectious diseases. This study analysed the microbiological and physicochemical parameters of drinking water in the capital Bissau and its surroundings. Twenty-two sites belonging to different water sources (piped water, tubewells and shallow wells) were surveyed twice a day for three weeks, in both dry and wet seasons. Most of the microbiological parameters were out of the acceptable ranges in all types of water and both seasons and tended to worsen in the wet season. Moreover, in Bissau, the levels of faecal contamination in piped water increased from the holes to the consumer (tap/fountain). Several physicochemical variables showed values out of the internationally accepted ranges. Both well sources showed low-pH water (4.87-5.59), with high nitrite and iron levels in the wet season and high hexavalent chromium concentration in the dry season. The residual chlorine never reached the minimum recommended level in any of the water sources or seasons, suggesting a high risk of contamination. Results reveal a lack of quality in the three water sources analysed, coherent with the high number of diarrheal cases in the country. There is an urgent need to improve sanitarian conditions to reduce the disease burden caused by these waterborne illnesses.

African ecosystems comprise a wealthy repository of biodiversity with a high proportion of native and endemic plant species, which makes them biologically unique and providers of a wide range of ecosystem services. A large part of African populations, in both rural and urban areas, depends on plants for their survival and welfare, but many ecosystems are being degraded, mostly due to the growing impacts of climate change and other anthropogenic actions and environmental problems. Loss of habitat and biodiversity a ects livelihoods, water supply and food security, and reduces the resilience of ecosystems in the African continent. Knowledge of the huge African plant and ecosystem diversity, and on the structure, composition and processes involved in vegetation dynamics, is crucial to promote their sustainable use and to preserve one of the most understudied regions in the world. This Special Issue aimed to gather contributions that update and improve such knowledge.

African ecosystems comprise a wealthy repository of biodiversity with a high proportion of native and endemic plant species, which makes them biologically unique and providers of a wide range of ecosystem services. A large part of African populations, in both rural and urban areas, depends on plants for their survival and welfare, but many ecosystems are being degraded, mostly due to the growing impacts of climate change and other anthropogenic actions and environmental problems. Loss of habitat and biodiversity affects livelihoods, water supply and food security, and reduces the resilience of ecosystems in the African continent. Knowledge of the huge African plant and ecosystem diversity, and on the structure, composition and processes involved in vegetation dynamics, is crucial to promote their sustainable use and to preserve one of the most understudied regions in the world. This Special Issue aimed to gather contributions that update and improve such knowledge.

Objectives: The objective of this study was to evaluate the effect of simulation-based training on the accuracy of fetal head position determination by junior residents during the second stage of labour. Study design: This prospective study was conducted in a tertiary care university hospital. During an initial period of 12 weeks, 13 junior residents were asked to routinely evaluate fetal head position by digital examination during the second stage of labour, in women with term singletons in cephalic presentation. Digital examination was followed immediately by transabdominal ultrasound to confirm fetal head position, performed by an experienced physician. Following this initial period, all participants attended a workshop where simulation-based training of fetal head position determination was provided. A second 12-week period was subsequently completed, with similar characteristics to the initial one. The accuracy of clinical evaluations was assessed by the percentage of exact evaluations, the percentage of correct evaluations within a 45° error margin, and by Cohen's kappa coefficient of agreement. Results: A total of 83 observations were performed in the initial period of the study and 74 observations were performed in the second period. The accuracy of fetal head position determination during the first period of the study was 59.0% (95% CI 47.7-69.7), k = 0.517 (95%CI 0.391 - 0.635), corresponding to a moderate agreement. Considering a 45° margin of error, accuracy was 71.1% (95% CI 60.1-80.5), k = 0.656 (95% CI 0.538 - 0.763), corresponding to substantial agreement. Following simulation-based training, the accuracy of fetal head position determination was 70.3% (95% CI 58.5-80.3), k = 0.651 (95% CI 0.526 - 0.785), corresponding to a substantial agreement. Considering a 45° margin of error, accuracy was 78.4% (95% CI 67.3-87.1), k = 0.745 (95% CI 0.631 - 0.854), corresponding to a substantial agreement. Conclusions: Although a trend towards increased accuracy in fetal head position determination was observed after simulation-based training, the difference was not statistically significant. Further studies are needed to clarify the role of simulation-based training for fetal head position determination during residency.

In a country of great literary traditions, the writers and their work have been, throughout history, one of the main vehicles for social and political change. Literature is perhaps the most precious asset of Portuguese culture. No wonder therefore that the authors of such a vast literary spoil have been, over time, often honored in public sculpture in Lisbon. Through the study of the monuments that evoke them in the city of Lisbon we may establish an overview of its iconography that, despite variations due to different approaches of each sculptor, follows a common denominator. The present study proposes a discovery journey of this referential that makes the sculpture of a poet or a writer in a meticulous work of refection about literature, about society and about live

Objectives: Etonogestrel subdermal implant is a highly effective, reversible and safe form of contraception. Immediate placement during abortion visit could increase contraception use in women at high risk for unintended pregnancy. Our purpose was to evaluate patient acceptability, user continuation rate and efficacy of medical termination of pregnancy when the implant is inserted during medical termination of pregnancy. Study design: Prospective observational study comparing patients who chose the subdermal implant for post-abortion contraception, inserted at the time of administration of mifepristone, with patients who chose delayed placement after the termination was complete. Results: After contraceptive counseling 119 women chose the implant as their post-abortion contraceptive method. In the intra-abortion implant insertion group the user continuation rate after 6 months was 73.7% (42/57). In the delayed placement group 59.7% (37/62) missed the follow-up after abortion visit, 24.2% (15/62) chose another method and only 16.1% (10/62) had the implant inserted. The efficacy of medical termination was 96.5% in the group of intra-abortion implant insertion and 98.4% in the delayed placement group. Conclusions: Intra-abortion subdermal implant insertion significantly increases the likelihood of effective long-acting contraception use following abortion. The efficacy of medical termination was not significantly changed by intra-abortion implant insertion.

We realize that the restless legs syndrome (RLS) is underdiagnosed in pregnancy, despite being an important cause of insomnia and impaired sleep. Our objective is to report the case of a pregnant woman with RLS surveilled at our Department and briefly review the main points of this disorder, to alert obstetricians, neurologists and family doctors to this entity.

Objective: To compare knowledge and practices surrounding third trimester screening of fetal growth restriction (FGR) in low risk pregnancies among Portuguese Gynecologists/Obstetricians (GOs) and General Practitioners (GPs). Primary outcome was to compare the proportion of GOs that consider the need of a third trimester ultrasound (estimation of fetal weight) for screening of FGR in low risk pregnancies and the best time to perform it with the corresponding proportion of GPs. Study design: We have conducted a prospective, observational cohort study based on application of surveys to GOs and GPs. Questionnaires were sent by e-mail to physicians and they filled them online. A second reminder e-mail was sent 7 days later. Recruitment was also done personally at scientific meetings. A total of 573 surveys were available for analysis, 298 corresponded to GOs and 275 to GPs. We used χ2 test to compare dichotomous variables and Kruskal-Wallis test for the comparison of ordinal variables. P values <0.05 were considered statistically significant. Results: The vast majority of GOs and GPs (93%) considered that third trimester ultrasound is useful and needed for surveillance of low risk pregnancy. A higher proportion of GOs (38%) selected 35th-37th weeks as the best time to perform the ultrasound compared to GPs (10%) (p < 0.001). GOs (51%) consider that symphysis-fundus distance is a measurement with moderate accuracy for screening of FGR while GPs (61%) attribute a low accuracy (p < 0.001). Fifty percent (50%) of GOs consider that performing a third trimester ultrasound will have no impact on cesarean delivery rate for fetal distress, while 41% of GPs consider that routine ultrasound will contribute to increase this rate (p < 0.001). The majority of GPs (52%) consider that routine ultrasound will contribute to diminish the admission rate to neonatal intensive care unit while GOs revealed a dichotomy with 43% of respondents reporting that it will diminish the rate and 40% that it will have no impact. Conclusion: Varied opinions among the clinicians included in our sample reflect the controversy that remains on the best screening of FGR in low risk pregnancies.

Introduction: Anemia and iron deficiency during pregnancy are a worldwide concern and are more frequent among women of reproductive age, pregnant women, and young children. The aim of this study was to assess the prevalence of iron deficiency anemia and the risk factors for iron depletion during the first half of pregnancy, in a Portuguese population. Material and Methods: A prospective study was conducted at a tertiary hospital and included pregnant women, until the 20th week of gestation. Data was collected regarding demographic and pregnancy features and hemoglobin and serum ferritin concentrations were determined. A multivariate logistic regression was performed to identify potential risk factors for iron deficiency. Results: Two hundred and one women were included, from which five (2.49%) presented anemia. Additionally, 77 (38.3%) exhibited iron deficiency and 22 (10.9%) revealed severe iron depletion. Maternal age was the only risk factor identified. The odds ratio (OR) was equal to 12.99 (95% CI 2.41 - 70.0) for women under twenty years of age and 2.09 (95% CI 1.05 - 4.14) for women older than thirty years of age. Discussion and Conclusion: The prevalence of maternal anemia in the first half of pregnancy was lower than in other studies. However, more than one-third of the women exhibited iron deficiency. With the exception of maternal age, no other risk factors were identified.

Introduction: External cephalic version is a procedure of fetal rotation to a cephalic presentation through manoeuvres applied to the maternal abdomen. There are several prognostic factors described in literature for external cephalic version success and prediction scores have been proposed, but their true implication in clinical practice is controversial. We aim to identify possible factors that could contribute to the success of an external cephalic version attempt in our population. Material and methods: We retrospectively examined 207 consecutive external cephalic version attempts under tocolysis conducted between January 1997 and July 2012. We consulted the department's database for the following variables: race, age, parity, maternal body mass index, gestational age, estimated fetal weight, breech category, placental location and amniotic fluid index. We performed descriptive and analytical statistics for each variable and binary logistic regression. Results: External cephalic version was successful in 46.9% of cases (97/207). None of the included variables was associated with the outcome of external cephalic version attempts after adjustment for confounding factors. Discussion: We present a success rate similar to what has been previously described in literature. However, in contrast to previous authors, we could not associate any of the analysed variables with success of the external cephalic version attempt. We believe this discrepancy is partly related to the type of statistical analysis performed. Conclusions: Even though there are numerous prognostic factors identified for the success in external cephalic version, care must be taken when counselling and selecting patients for this procedure. The data obtained suggests that external cephalic version should continue being offered to all eligible patients regardless of prognostic factors for success.

Acute effects of maternal cigarette smoking on fetal heart rate (FHR) and fetal body movements felt by the mother (FM) were studied in 51 pregnant volunteers. Thirty four were chronic smokers (6 or more cigarettes per day, with an average of 14 cigarettes/day) and 17 were sporadic smokers (1 to 5 cigarettes per day, with an averaged of 3 cigarettes/day). In both groups the number of FM, fetal reactivity and short-term FHR variability decreased significantly in the 20 minutes following cigarette smoking; a sustained FHR rise of 10 or more beats/min was also found after the cigarette in more than 50% of the cases in the 2 groups. No statistically significant differences were found among the 2 groups when the post-cigarette data were compared. We conclude that maternal cigarette smoking produces important acute effects upon FM and FHR regardless the average daily number of cigarettes smoked by the mother.

Marfan syndrome is an autosomal dominant connective tissue disease with an estimated incidence of 1 in 5000 individuals. In 90% of cases it is caused by mutations in the gene for fibrillin-1, the main constituent of extracellular microfibrils. Studies on animal models of Marfan syndrome have revealed that fibrillin-1 mutations interfere with local TGF-β signaling, in addition to impairing tissue integrity. The cardinal features involve the cardiovascular, ocular and skeletal systems. The diagnosis of Marfan syndrome is made according to the revised Ghent nosology. Early identification and appropriate management are critical for patients with Marfan syndrome, who are prone to the life-threatening cardiovascular complications of aortic aneurysms and aortic dissection. The standard treatment includes prophylactic beta-blockers in order to slow down dilation of the ascending aorta, and prophylactic aortic surgery. The success of current medical and surgical treatment of aortic disease in Marfan syndrome has substantially improved mean life expectancy, extending it above 72 years. This review aims to provide an overview of this hereditary disorder.

Introduction: We report the case of a patient with classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency who presented with unusual anatomical and biochemical features, namely massively enlarged adrenal glands, adrenogenital rest tissue and an unexpected endocrine profile. The contribution of the adrenocortical cells in the adrenals and testicles was determined by a cosyntropin stimulation test before and after adrenalectomy. To the best of our knowledge this is the first report of such a case in the literature. Case presentation: A 35-year-old Caucasian man was admitted to the emergency room with an Addisonian crisis. He had been diagnosed with congenital adrenal hyperplasia in the neonatal period. He acknowledged poor adherence to treatment and irregular medical assistance. Physical examination revealed marked cutaneous and gingival hyperpigmentation, hypotension, and hard nodules in the upper pole of both testicles. Blood analysis showed mild anemia and hyponatremia and no evidence of acute infection. Endocrine evaluation showed very low cortisol levels, low dehydroepiandrosterone-sulfate and elevated corticotropin, 11-deoxycortisol and delta-4-androstenedione. The concentration of 17-hydroxyprogesterone was 20,400ng/dL. After the cosyntropin stimulation test the pattern was similar and there was no significant increase in cortisol or 17-hydroxyprogesterone. The abdominal computed tomography scan revealed grossly enlarged and heterogeneous adrenal glands (left, 12cm; and right, six cm). A bilateral adrenalectomy was performed and pathologic examination revealed adrenal myelolipomas with nodular cortical hyperplasia. The sonogram showed bilateral heterogeneous masses on the upper pole of both testes which corresponded to the nodular hyperplasia of adrenal rest tissues. The genetic study revealed compound heterozigoty (mutations R124H and R356W), suggestive of a phenotypically moderate disease. We performed a cosyntropin stimulation test after adrenalectomy. The steroidogenic profile displayed the same unusual features, indicating an important contribution from the adrenogenital cells. Conclusion: This case illustrates that congenital adrenal hyperplasia due to 21-hydroxylase deficiency can progress to severe acute and chronic complications. The masses in the patient’s adrenal glands and testicles resulted from chronically elevated adrenocorticotropic hormone and growth of adrenocortical cells. The basal and stimulated steroid profile, before and after adrenalectomy, revealed an unexpected pattern, suggesting significant contribution of the testicular adrenal cells to the steroidogenesis.

Introduction. Adrenal glands play a major role in the control of blood pressure and mild defects of steroidogenesis and/or inappropriate control of mineralocorticoid production have been reported in high blood pressure (HBP). Patients and Methods. We used a specific protocol for the evaluation of 100 consecutive patients with inappropriate or recent onset HBP. Specific methods were used to confirm HBP and to diagnose secondary forms of HBP. In addition we tested adrenal steroidogenesis with the common cosyntropin test, modified to include the simultaneous measurement of renin and aldosterone besides 17-hydroxyprogesterone (17OHP) and 11-deoxycortisol (S). Results. Secondary forms of HBP were diagnosed in 32 patients, including 14 patients with primary hyperaldosteronism (PA) (14%) and 10 patients with pheochromocytoma (10%). Mild defects of the 21-hydroxylase (21OHD) and 11-hydroxylase (11OHD) enzymes were common (42%). ACTH-dependent aldosterone secretion was found in most patients (54%) and characteristically in those with mild defects of adrenal steroidogenesis (>60%), PA (>75%), and otherwise in patients with apparent essential HBP (EHBP) (32%). Discussion. Mild defects of adrenal steroidogenesis are common in patients with HBP, occurring in almost half of the patients. In those patients as well as in patients with apparent EHBP, aldosterone secretion is commonly dependent on ACTH.

O setor do turismo apresenta-se como um fenómeno social, cultural e económico, que abrange um conjunto de atividades ligadas à circulação de pessoas para lugares que vão para além do seu local habitual de residência. O crescimento visível do turismo em Portugal, do qual decorre o aumento do número de turistas e o prolongamento das respetivas estadas, exige uma resposta diversificada, eficiente e qualificada por parte da hotelaria de forma a poder dar resposta à intensa procura que se tem verificado nos últimos anos. Sendo a satisfação pessoal a principal motivação para a mobilidade das pessoas, existem, no entanto, dificuldades/problemas de natureza ambiental, social e económica, com que o turismo se depara. O presente relatório retrata a forma como a consultoria se apresenta como uma excelente colaboradora para o desenvolvimento da oferta turística, face à concorrência, abarcando os múltiplos segmentos de mercado. Como se trata de um relatório de estágio, terei oportunidade de descrever uma empresa de consultoria, na área do turismo, bem como explicar as tarefas por mim desenvolvidas durante o período que aí permaneci. Partindo da experiência de estágio, e do enquadramento teórico, deseja-se dar a conhecer as formas como uma consultora dá resposta às necessidades crescentes deste mercado emergente que é o Turismo, nomeadamente no setor hoteleiro.

Hoje em dia a partilha de informação é uma característica cada vez mais intrínseca na sociedade em que vivemos. A crescente necessidade em haver um acesso rápido, intuitivo e seguro a uma grande quantidade e variedade de informação, leva a que sejam criados vários mecanismos que a satisfaçam. A Wikipédia baseada no conceito Wiki é um exemplo de um caso de sucesso nesta área e tem desempenhado um papel fundamental quanto à promoção deste conceito de informação colaborativa. No actual clima empresarial e de negócio, as empresas estão a apostar também nesta política de partilha de informação de forma a agilizar o processo de cooperação entre os vários colaboradores que as integram, resultando num melhoramento do processo e execuçao de tarefas. Assim sendo, o conceito de informação colaborativa tem-se traduzido como um objectivo estratégico de qualquer empresa. Este projecto teve como objectivo desenvolver um sistema de pesquisa e de publicação automática de informação inerente à gestão de projectos da Empresa EF Tecnologias de Software, S.A. numa ferramenta Wiki, de forma a facilitar aos seus colaboradores o acesso a este tipo de informação e a oferecer aos gestores de projecto uma melhor perspectiva de gestão dos mesmos.

Background: Adverse reactions associated to anti-thyroid drugs include fever, rash, arthralgia, agranulocytosis and hepatitis that are thought to be hypersensitivity reactions. Five cases of pleural effusion associated to thionamides have also been reported, two with propylthiouracil and three with carbimazole. Case presentation: We report here a case of a 75-year-old man admitted because of unilateral pleural effusion. The patient had a recent diagnosis of hyperthyroidism and 6 days after starting methimazole complained of pleuritic chest pain. He had elevated C-reactive protein and erythrocyte sedimentation rate and normal white blood cell count and liver enzymes. Chest radiography showed a moderate right pleural effusion and the ultrasound revealed a loculated effusion that was shown to be an eosinophilic exudate. Conclusions: The temporal relationship between methimazole intake and the development of pleural effusion combined with the extensive exclusion of alternative causes, namely infectious, neoplastic and primary auto-immune diseases, led to the diagnosis of hypersensitivity reaction to methimazole. The thionamide was stopped and corticosteroid was started with complete resolution of the pleural effusion in 3 months. Awareness of this rare adverse reaction of anti-thyroid drugs is important and methimazole can be added to the list of possible etiologies of drug-induced eosinophilic pleural effusion.

Background: Nowadays, dislocated intraocular lenses (IOLs) and inadequate capsular support are becoming a challenge for every ophthalmic surgeon. Explantation of dislocated IOL and iris claw IOL (ICIOL) are the techniques that have been used in our ophthalmic department. The aim of this study is to report our technique for retropupillar ICIOL. Methods: This study is a retrospective case series. A total of 105 eyes with dislocated IOL from the patients at the Department of Ophthalmology in Santa Maria Hospital, a tertiary reference hospital in Lisbon, Portugal, from January 2012 until January 2016, had been analyzed. Of these 105 eyes, 66 eyes had dislocated one-piece IOL and 39 eyes had dislocated three-piece IOL. The latter underwent iris suture of the same IOL and were excluded from this study. The remaining 66 eyes with dislocated one-piece IOL underwent pars plana vitrectomy, that is, explantation of dislocated IOL through corneal incision and an implantation of retropupillary ICIOL. Operative data and postoperative outcomes included best corrected visual acuity, IOL position, intraocular pressure, pigment dispersion, clinical signs of endothelial cell loss, and anterior chamber depth. Results: The mean follow-up was 23 months (range: 6–48 months). The mean preoperative best corrected visual acuity was 1.260±0.771 logMAR, and postoperative best corrected visual acuity was 0.352±0.400 logMAR units. Mean vision gain was 0.909 logMar units. The patients had the following complications: 1) retinal detachment was found in one patient, 2) corneal edema was found in three patients, 3) high intraocular pressure was observed in twelve patients, 4) subluxation of the IOL was observed in one patient, and 5) macular edema was found in three eyes. Conclusion: The results demonstrate that retropupillary ICIOL is an easy and effective method for the correction of aphakia in patients not receiving capsule support. The safety of this procedure must be interpreted in the context of a surgery usually indicated in complicated cases.

Este estudo procura conhecer a comunicação na aula de Matemática do 3 ° ciclo, analisando os problemas que isso coloca à prática profissional do professor. Assim, pretende responder às seguintes questões: Que importância atribuem os professores à comunicação matemática na aprendizagem dos alunos? Como se desenvolvem as suas práticas de comunicação na sala de aula? Que modos de comunicação e que formas de promover a comunicação estão subjacentes à actividade matemática na sala de aula? O enquadramento teórico discute a importância da comunicação e as funções da linguagem na aula de Matemática e analisa as perspectivas teóricas sobre a comunicação em educação matemática, incluindo as formas e modos de comunicação. A metodologia de investigação segue o paradigma qualitativo de cunho interpretativo apoiado em dois estudos de caso. A recolha de dados foi realizada durante o ano lectivo de 2005/06 através de observação de aulas, entrevistas e análise documental. Os resultados deste estudo mostram o gosto dos dois professores em reflectir sobre a prática, nomeadamente sobre a comunicação na sala de aula. Ambos relacionam o ensino da Matemática com a transmissão de conteúdos matemáticos e o desenvolvimento da capacidade dos alunos para reflectirem sobre os conceitos. Nas suas práticas de comunicação, os professores incentivam a comunicação oral e escrita de modo a compreenderem o raciocínio dos alunos. As principais formas de comunicação que ambos os professores recorrem durante as suas práticas são o questionamento para o esclarecimento de dúvidas e a exposição para explicação dos conceitos. Relativamente aos modos de comunicação, destaca-se em ambos o modo contributivo.