Repositório RCAAP

O objectivo da Newsletter do Instituto de Saúde Baseado na Evidência (ISBE) é a disponibilização de informação sobre áreas relevantes para a prática clínica, baseada na melhor evidência científica. São localizados estudos relevantes e de alta qualidade, criticamente avaliados pela sua validade, importância dos resultados e aplicabilidade prática e resumidos numa óptica de suporte à decisão clínica. É dada prioridade aos estudos de causalidade – revisões sistemáticas, ensaios clínicos, estudos de coorte prospectivos/retrospectivos, estudos seccionais cruzados e caso‐controlo – incluindo‐se ainda, quando justificado, estudos qualitativos considerados de elevada qualidade metodológica e importância clínica.

The One Health context considers health based on three pillars: humans, animals, and environment. This approach is a strong ally in the surveillance of infectious diseases and in the development of prevention strategies. Aspergillus spp. are fungi that fit substantially in this context, in view of their ubiquity, as well as their importance as plant pathogens, and potentially fatal pathogens for, particularly, humans and avian species. In addition, the emergence of azole resistance, mainly in Aspergillus fumigatus sensu stricto, and the proven role of fungicides widely used on crops, reinforces the need for a multidisciplinary approach to this problem. Avian species are involved in short and long distance travel between different types of landscapes, such as agricultural fields, natural environments and urban environments. Thus, birds can play an important role in the dispersion of Aspergillus, and of special concern, azole-resistant strains. In addition, some bird species are particularly susceptible to aspergillosis. Therefore, avian aspergillosis could be considered as an environmental health indicator. In this review, aspergillosis in humans and birds will be discussed, with focus on the presence of Aspergillus in the environment. We will relate these issues with the emergence of azole resistance on Aspergillus. These topics will be therefore considered and reviewed from the “One Health” perspective.

As the global COVID-19 pandemic advances, it increasingly impacts those vulnerable populations who already bear a heavy burden of neglected tropical disease. Chagas disease (CD), a neglected parasitic infection, is of particular concern because of its potential to cause cardiac, gastrointestinal, and other complications which could increase susceptibility to COVID-19. The over one million people worldwide with chronic Chagas cardiomyopathy require special consideration because of COVID-19's potential impact on the heart, yet the pandemic also affects treatment provision to people with acute or chronic indeterminate CD. In this document, a follow-up to the WHF-IASC Roadmap on CD, we assess the implications of coinfection with SARS-CoV-2 and Trypanosoma cruzi, the etiological agent of CD. Based on the limited evidence available, we provide preliminary guidance for testing, treatment, and management of patients affected by both diseases, while highlighting emerging healthcare access challenges and future research needs.

Urban green spaces (UGS) provide multiple benefits, and public parks in particular have a key role in supporting ecological and social sustainability in cities, contributing to human-nature interactions. We studied the interrelationships between uses, experiences and the environment by adopting a novel concept of urban biocultural diversity (BCD). The concept identifies three interlinked spheres of urban BCD: materialised, lived and stewardship. We conducted place-based research in 33 parks located in four European capitals: Helsinki, Berlin, Bucharest and Lisbon. A total of 1474 visitors were interviewed concerning their motivations to use the park and their experiences during the visit. Using an open-ended survey, we revealed more than 50 motivations for park use and over 100 features people enjoyed during their visits. On the other hand, visitors mentioned far fewer things that disturbed them (60). We revealed that despite the fact motivations to use parks were strongly human-oriented, visitors widely enjoyed the environmental characteristics of parks, and especially nature. We found that parks located in neighbourhoods with low socio-economic status and outside the central area of the city were structurally less diverse than parks located in the city core. The structurally diverse parks enhanced motivations to use them, and increased overall enjoyments of the environment. We revealed clear differences in motivations and enjoyments between cities, implying that the day-to-day practices of people using and experiencing nature varies between cities.

A investigação em Didática da Matemática é um campo científico relativamente recente, que se apoia em teorias e metodologias de outros campos das ciências sociais e humanas, mas lida com os seus problemas próprios, que resultam do seu objeto de estudo – o ensino-aprendizagem da Matemática e a formação dos respetivos professores. As suas questões assumem em cada país especificidades próprias, mas muitos conceitos e modelos desenvolvidos internacionalmente têm grande relevância para Portugal e, certamente, também para o Brasil. Este artigo revisita contributos fundamentais da investigação neste campo, cruzando ideias de autores internacionais com projetos e realizações portuguesas. Aborda também o modo como estes contributos influenciam em Portugal as práticas profissionais dos professores e os seus processos de formação e desenvolvimento profissional. Finalmente, discute o modo como pode evoluir a relação entre a investigação e o ensino, para que os professores se sintam mais capacitados na sua atividade profissional e, em conjunto com os investigadores (muitos dos quais são também professores ou formadores de professores), tenham mais condições para gerar conhecimento relevante e robusto para a melhoria do ensino da Matemática para todos os alunos.

O presente artigo apresenta os resultados de uma pesquisa inserida em um ciclo de intervenção de uma Investigação Baseada em Design (IBD) sobre o desenvolvimento do conhecimento didático de professores de Matemática, nomeadamente no que diz respeito à Estatística. Tem por objetivo compreender de que forma a articulação de um conjunto de princípios de design no contexto de uma experiência de formação pode contribuir para promover o conhecimento didático dos participantes. A análise de dados tem por base os seguintes princípios de design: utilização de tarefas de natureza exploratória; uso de situações autênticas de sala de aula; e uso da tecnologia. Os resultados sugerem que os princípios de design assumidos na experiência de formação contribuíram para o desenvolvimento do conhecimento dos professores no que se refere às potencialidades da abordagem exploratória da Estatística, de modo a expandir o seu conhecimento sobre as tarefas que possam subsidiar este ensino.

A 61-year-old male, former smoker and diabetic patient with a previous medical history noted for an inferior myocardial infarction complicated with left ventricular free wall rupture that had been surgically corrected 6 years prior, presented to the cardiology unit complaining of a new-onset dyspnoea, orthopnoea and fatigue which had started over the month prior to presenting.

Introduction: The understanding of the social representations about the functions of deliberate self-harm can be an important factor for the comprehension of this phenomenon. Nonetheless, only a few studies focused on this topic and specifically on the social representations from adolescents with and without a history of deliberate self-harm and their parents. Methods: This article presents two studies that analysed these representations. Study 1 compared the social representations from 411 Portuguese adolescents (219 females and 192 males, aged 12–19 years), from which 109 reported having a history of deliberate self-harm. Study 2 focused on the comparison of the social representations from 471 parents (265 mothers and 206 fathers, aged 33–62 years) of Portuguese adolescents. Of the parents in Study 2, 120 had children with a history of deliberate self-harm. Results: In Study 1, adolescents without a history of deliberate self-harm perceived most interpersonal functions as more relevant than adolescents with a history of these behaviours, while adolescents with a history of deliberate self-harm emphasized one intrapersonal function. In Study 2, no differences were found between parents of adolescents with and without a history of deliberate self-harm. However, results revealed differences between the representations of mothers and fathers in several intrapersonal functions. Conclusions: This research provides important insight regarding the social representations about the functions of deliberate self-harm from adolescents with and without a reported history of these behaviours and their parents. The impact for clinical intervention and prevention programs is discussed.

With the increased awareness about deliberate self-harm, the understanding of its social representations can be important for clinical intervention and prevention. However, there is still a lack of instruments to assess the social representations of the functions of these behaviors. This research focuses on the validation of the Questionnaire of Representations of the Functions of Deliberate Self-Harm for adolescents with and without a history of these behaviors. The basis for this questionnaire was the translation and adaptation of the Inventory of Statements About Self-Injury. To access adolescents' social representations, we conducted semidirective interviews and an analysis of the Portuguese written press, which complemented the questionnaire with new items and functions. Study 1 consisted of an exploratory factor analysis with a sample of 434 adolescents. Results revealed a 2-factor structure of interpersonal and intrapersonal dimensions. After item reduction, the factorial analysis of the independent functions showed acceptable psychometric values. This structure was corroborated in Study 2 by a confirmatory factor analysis with a new sample of 405 adolescents, which revealed an acceptable model fit. This questionnaire presents a relatively solid structure and is based on acceptable psychometric properties, which allows its use in future research.

Background: A transient postoperative drop in platelet count is an expected finding after aortic valve replacement using extracorporeal circulation. The implantation of the Perceval valve has been associated with a more intense drop of platelet count compared to other bio-prostheses. This study analyses and compares the platelets progression associated with the Perceval and Intuity valves. Methods: The data was collected retrospectively for patients submitted to isolated aortic valve replacement with the Perceval valve (80 patients) and the Intuity valve (141 patients) in our institution between March 2014 and December 2018. The groups were further divided into those who receive platelet transfusion and those who did not. Results: The minimum values of platelet count were 54% and 67% of the preoperative platelet count in the patients treated with a Perceval and an Intuity valves, respectively (p<0.001). In the patients transfused with platelets, the minimum values were 52% and 79% of the preoperative platelet count, respectively (p<0.01). Recovery of the count was faster in the patients treated with an Intuity valve. Abnormal bleeding and transfusion of packed red blood cells were not significantly different between groups (without platelet transfusion: p=0.71 and p=0.99, respectively; with platelet transfusion: p=0.58 and p=0.99, respectively). Conclusion: Compared to the Intuity valve, the Perceval valve is associated with a transient, but significant, drop in platelet count. This drop was not associated to an increased risk of bleeding. Platelet transfusion, in this setting, should be judicious and not only ruled by absolute values.

Estudo da sociedade portuguesa nos alvores da Época Moderna, a partir da análise, na sua totalidade, da obra do grande dramaturgo português Gil Vicente, aprofundando-se a explicação de perspectivas com base tanto na observação das suas estratégias discursivas quanto no confronto com outros testemunhos epocais. Prefaciado por Luís de Albuquerque (UC). Divulga-se no Repositório um excerto, com autorização da Autora e do Editor.

Background and purpose: Pregnancy and puerperium are associated with an increased risk of venous thrombotic events (VTEs), including cerebral venous thrombosis (CVT). We aimed to systematically review, in pregnant woman with previous CVT, (1) the risk of recurrence of CVT or other VTE; (2) the result of pregnancy; and (3) the association of antithrombotic prophylaxis with these outcomes. Methods: We searched MEDLINE, Cochrane Database of Systematic Reviews, clinicaltrials.gov (from inception to July 2015), and reference lists of included studies and review articles. We considered observational studies reporting original data on the frequency of CVT or other VTE associated with pregnancy or puerperium in women with history of CVT. Results: Thirteen studies were included. A simple pooled analysis of individual patient data and meta-analysis of proportions using a random effect model were performed. (1) 1 CVT recurrences/217 pregnancies (9 per 1000; 95% confidence interval, 3-33) and 5 noncerebral VTE/186 pregnancies (27 per 1000; 95% confidence interval, 12-61). (2) Pregnancy outcome: 33 spontaneous abortions/186 pregnancies (17.7%; 95% confidence interval, 13-24). (3) Data on the risk of CVT/extracerebral VTE according to antithrombotic prophylaxis was limited. Miscarriage did not differ significantly in women undergoing antithrombotic therapy or not (11.3% versus 18.8%; P=0.34). Conclusions: In women with previous CVT, the absolute risk of pregnancy-related venous thrombosis is low but the relative risk of noncerebral VTE is 16-fold higher and the recurrence of CVT is 80-fold higher than the baseline risk described in general population studies. The rate of miscarriage is not significantly different from that estimated for the general population.

Objective: To identify characteristics, predictors, and outcomes of acute symptomatic seizures (ASS) in cerebral venous thrombosis (CVT), we investigated 1,281 consecutive adult patients with CVT included from 12 hospitals within the International CVT Consortium. Methods: We defined ASS as any seizure between symptom onset and 7 days after diagnosis of CVT. We stratified ASS into prediagnosis and solely postdiagnosis ASS. Status epilepticus (SE) was also analyzed separately. We analyzed predictors for ASS and the association between ASS and clinical outcome (modified Rankin Scale) with multivariable logistic regression. Results: Of 1,281 eligible patients, 441 (34%) had ASS. Baseline predictors for ASS were intracerebral hemorrhage (ICH; adjusted odds ratio [aOR] 4.1, 95% confidence interval [CI] 3.0-5.5), cerebral edema/infarction without ICH (aOR 2.8, 95% CI 2.0-4.0), cortical vein thrombosis (aOR 2.1, 95% CI 1.5-2.9), superior sagittal sinus thrombosis (aOR 2.0, 95% CI 1.5-2.6), focal neurologic deficit (aOR 1.9, 95% CI 1.4-2.6), sulcal subarachnoid hemorrhage (aOR 1.6, 95% CI 1.1-2.5), and female-specific risk factors (aOR 1.5, 95% CI 1.1-2.1). Ninety-three (7%) patients had solely postdiagnosis ASS, best predicted by cortical vein thrombosis (positive/negative predictive value 22%/92%). Eighty (6%) patients had SE, independently predicted by ICH, focal neurologic deficits, and cerebral edema/infarction. Neither ASS nor SE was independently associated with outcome. Conclusion: ASS occurred in one-third of patients with CVT and was associated with brain parenchymal lesions and thrombosis of the superficial system. In the absence of prediagnosis ASS, no subgroup was identified with sufficient risk of postdiagnosis ASS to justify prophylactic antiepileptic drug treatment. We found no association between ASS and outcome.

Herpes simplex virus 2 (HSV-2) is a very rare cause of central nervous system (CNS) infections. We report a case of a young woman with a left middle cerebral artery (MCA) ischemic stroke. The patient had history of HIV-1 infection, with periods of therapeutic non-compliance. Initial computed tomography (CT) imaging studies showed stenosis of the M1 segment of the left MCA, and magnetic resonance imaging (MRI) confirmed infarction of the MCA territory. Serial transcranial Doppler ultrasound revealed progressive occlusion of the MCA and stenosis of the left anterior cerebral artery. Systemic investigation for other causes of stroke was normal. Lumbar puncture revealed a mildly inflammatory cerebrospinal fluid, and HSV-2 DNA was identified by PCR, with a positive viral load in favor of active replication. No other viral or microbiological infections were identified. MRI angiography confirmed a vasculitic process involving the left carotid artery, and a HSV-2 vasculitis diagnosis was assumed. The patient started acyclovir with improvement of clinical features and imaging abnormalities. In the HIV-infected patient, stroke is a multifactorial common cause of morbidity. The physician should take into account a broad differential diagnosis including rare causes and atypical presentations of common etiologies, including HSV-1 and HSV-2 CNS infection.

As a medical student, I have now almost 6 years of academic studies and clinical interaction with numerous patients, though sometimes brief and superficial. I have found that sometimes it is truly hard to grasp how humane a person is behind their sickness. Fortunately, I have been hitherto able to avoid the almost natural desensitization our degree imposes upon us, either through my own process of thought or through a kind warning of some of "my" patients. Having been particularly thrown aback by the keen eye of a patient I had the opportunity to meet in an Oncology ward, I realized that I had much more to consider when studying a clinical case and that rarely a cancer (or a disease whatever it may be) is but a cancer. In fact, a disease needs a patient to be diagnosed upon and that patient has most often a life besides their disease.

Cardiac rhythm abnormalities are a possibly serious manifestation of epilepsy and seizures. We present a 36-year-old woman with episodes of altered mental status and loss of muscle tone for 20-30 seconds, preceded by déjà vu, bilateral tinnitus and generalized coldness.

Objective: Electroencephalography (EEG) can identify biomarkers of epileptogenesis and ictogenesis. However, few studies have used EEG in the prediction of poststroke seizures. Our primary aim was to evaluate whether early EEG abnormalities can predict poststroke epilepsy. Methods: A prospective study of consecutive acute anterior circulation ischemic stroke patients, without previous epileptic seizures, who were admitted to a stroke unit over 24 months and followed for 1 year. All patients underwent standardized clinical and diagnostic assessment during the hospital stay and after discharge. Video-EEG was performed in the first 72 h (first EEG), daily for the first 7 days, in case of neurological deterioration, at discharge, and at 12 months after stroke. The occurrence of epileptic seizures in the first year after stroke (primary outcome) was evaluated clinically and neurophysiologically during the hospital stay and at 12 months. A telephone interview was also performed at 6 months. The primary outcome was the occurrence of at least one unprovoked seizure (poststroke epilepsy). Secondary outcomes were the occurrence of at least one acute symptomatic seizure and (interictal and/or ictal) epileptiform activity on at least one EEG during the hospital stay for acute stroke. The first EEG variables were defined using international criteria/terminology. Bivariate and multivariate analyses with adjustment for age, admission National Institutes of Health Stroke Scale (NIHSS) score, and Alberta Stroke Program Early CT Score (ASPECTS) were performed. Results: A total of 151 patients were included; 38 patients (25.2%) had an acute symptomatic seizure and 23 (16%) had an unprovoked seizure.The first EEG background activity asymmetry and first EEG with interictal epileptiform activity were independent predictors of poststroke epilepsy during the first year after stroke (P = 0.043 and P = 0.043, respectively). No EEG abnormality independently predicted acute symptomatic seizures. However, the presence of periodic discharges on the first EEG was an independent predictor of epileptiform activity (p = 0.009) during the hospital stay. Significance: An early poststroke EEG can predict epilepsy in the first year after stroke, independently from clinical and imaging-based infarct severity.

This study aimed to characterize, clinically and neurophysiologically, a series of patients with gelastic seizures (GS), including both adults and children. We retrospectively collected patients with GS from epilepsy clinics of five tertiary hospital centres within a single country. Patients were selected through relatives'/caregivers' descriptions, home video and/or video-EEG monitoring. GS were identified through ictal semiology. Thirty-five patients were enrolled; 62.9% had initial GS in infancy, 14.3% in adolescence and 22.8% at adult age. Twenty-six had abnormal MRI: eight presented with hypothalamic hamartoma (HH) and 16 non-HH lesions that included different structural aetiologies and genetic, metabolic and immune aetiologies. All patients with HH had their first GS in infancy or adolescence. For the remaining aetiologies, GS started in infancy in 59.3%, in adolescence in 11.1% and at adult age in 29.6%. Video-EEG data was available for analysis in 11 patients, including seven patients with a non-HH MRI lesion. The ictal onset topography on scalp video-EEG was usually concordant with the MRI lesion (in 6/7 patients) and the most frequent ictal onset was fronto-temporal. In two patients, both video-EEG and MRI suggested a parietal and occipital epileptogenic zone. Aetiologies and patterns of affected topography unrelated to HH are common in patients with GS, and all age groups may manifest with this type of ictal semiology. This ictal manifestation has no lateralizing value and, despite a clear preponderance for hypothalamic, frontal and temporal lobe origins, other brain areas, namely the parietal and occipital lobes, should be considered.

O mundo contemporâneo da comunicação massiva traduz a necessidade de compreender os meios de comunicação e as suas imagens. Aliada à televisão, a publicidade comunica com um grande número de pessoas, procura conhecer os seus estilos de vida, sonhos, desejos e cativa-as para uma identificação pessoal e social. Os mais jovens reconhecem na publicidade televisiva formas de ser, aprender e estar em cidadania, que se reflectem nas suas atitudes perante o consumo. À luz da educação do consumidor e do cidadão, a finalidade deste estudo procura compreender a relação entre o grupo de alunos investigado e a recepção da imagem publicitária televisiva, enquanto representação da realidade. Como objectivos, importa entender o modo como a publicidade é entendida e recebida pelos sujeitos de investigação, como interpretam as suas alterações e os desejos que lhes provoca. Para atingir esses objectivos, instituíram-se como instrumentos de investigação o registo de observação da sessão de visionamento de uma compilação de anúncios publicitários televisivos, o texto livre, escrito pelos alunos, e a entrevista semi-estruturada. O grupo de alunos investigado é composto por 20 elementos do 2º ciclo do ensino básico, na faixa etária entre os 9 e 13 anos, residentes na cidade de Sines. Estes dados foram compreendidos através de uma análise qualitativa de conteúdo e orientados pelos objectivos inerentes às questões das entrevistas, em esquemas interpretativos. O grupo de alunos investigado, na relação com a imagem de publicidade televisiva, revelou três atitudes-padrão: de participação no seu pensamento e comportamento; de consciência sócio-moral e afectiva e de poder sobre as escolhas de compra. As conclusões do presente estudo são ambivalentes. O grupo de investigação considera a publicidade televisiva e valoriza as suas imagens, sem lhes atribuir relevância perante o consumo massivo. Reconhece-a como humorística, descontraída e criativa, embora lhe atribua um teor persuasivo e, em certos casos, fraudulento. Para a construção dos conhecimentos e interpretação das experiências dos mais jovens, considera-se importante o papel dos adultos na sua vida cívica e a ajuda na análise crítica do mundo visual em que vive.

Purpose: Periodic discharges (PDs) are common in acute structural or metabolic brain lesions, but their occurrence during follow-up of epileptic patients in an outpatient setting is rare. Aim of this article was to study whether PDs on the routine outpatient scalp EEG of patients with epilepsy, as compared with nonperiodic epileptiform discharges, are associated with drug refractoriness and the decompensation of epilepsy and particular etiologies. Methods: A retrospective case–control study. EEG reports were screened for PDs and their variants. The inclusion criteria were as follows: a diagnosis of epilepsy, epileptogenic lesion on imaging, or a normal 3-T MRI. Inpatient EEGs or EEGs performed in patients with acute cerebral lesions were excluded. Age- and sex-matched controls presenting with other epileptiform EEG abnormalities were selected, and similar selection criteria were applied. Results: Forty-one patients with PDs and 82 controls were selected. There were no significant differences between the cases and controls in the rates of epilepsy decompensation at the time of EEG collection or drug refractoriness. Stroke, hippocampal sclerosis, and malformations of cortical development were the most frequent etiologies, without significant differences between the groups. Conclusions: By performing a case–control study, the authors have shown that PDs are not a marker of epilepsy decompensation and drug refractoriness and that the finding of PDs is not suggestive of particular epilepsy etiologies, when compared with other epileptiform abnormalities.